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Beyond Didactic Trainings: Structured Mentorship to Improve Antenatal Care Delivery in Rwanda

By: Manzi Anatole, Director of Mentorship and Quality Improvement, Partners In Health

This post is part of our “Continuum of Care” blog series hosted by the Maternal Health Task Force

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MESH-QI mentor conducting training on neonatal resuscitation at health center level

Partners In Health, in collaboration with the Rwandan Ministry of Health, implemented a program entitled Mentorship and Enhanced Supervision at Health Centers and Quality Improvement (MESH-QI) to address inefficiencies in current health center training and clinical practice of nurses.  MESH-QI improves care delivery through:

  1. Decentralized pre-service training at the district level
  2. Building capacity of the existing district supervisory structure
  3. Initiation of a systems focus on clinical mentoring and coaching of health center teams
  4. Use of data for continuous quality improvement
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Figure 1: Pillars of Mentorship, Enhanced Supervision and Quality Improvement Program

Current health center training for nurses consists of centralized pre-service training and limited in-service supervision. The pre-service training includes emergency obstetrics and newborn care (EmONC) and focused antenatal care (FANC), but periodic supervision visits by district hospital supervisors are largely consumed with data collection and reporting, with limited opportunities for on-site clinical mentoring and re-training.

To address this gap in training, MESH-QI mentors make routine intensive visits to health centers, lasting at least two days, in which they provide on-site case management observation; support for higher level problem-solving, diagnostic, and decision-making skills; lead case discussions; and address quality improvement issues (see Figure 1). By routinely capturing valuable data on nurses’ clinical skills, facility conditions, and clinical indicators, clinical supervisors also enhance the feedback loop for quality improvement.

Key lessons learned

Mentorship catalyzes translation of theory to practice

Clinicians expressed this as one of the positive aspects of MESH-QI interventions. Mentors use various adult learning techniques to support nurses to address the “knowledge-practice gap.” This facilitates the implementation of FANC at MESH-QI supported sites.

Mentorship improves clinicians’ confidence, motivation and adherence to MCH protocols

Prior to the implementation of MESH-QI, there were challenges in learning how to effectively integrate and utilize national protocols, guidelines, and tools. One nurse mentee mentioned: “They built my confidence not only in screening and case management, but also in general nursing care I provide every day. I feel proud of the work when I can handle even the complicated cases that I could not manage before… their support.”

Mentoring checklists enable evidence-based feedback and continuous QI

Using mentoring and coaching tools, such as checklists for case management, facility, and systems observations, enables mentors to provide objective and constructive feedback and regular monitoring of ANC delivery.

MESH-QI is an effective strategy to improve the quality of antenatal care

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Figure 2: Quality of ANC Assessments at Baseline and Post-mentoring

With mentoring, uniform improvement was observed regardless of baseline EmONC/FANC-training status (Figure 2). This demonstrated that mentorship is a promising intervention to help improve the quality of FANC regardless of baseline training status. Mentoring, therefore, is particularly applicable to resource-limited healthcare settings facing human resources challenges. While EmONC and other didactic trainings are still costly—particularly in developing countries—on-site mentorship is an option to mitigate these challenges.

MESH-QI integrates in-service training and systems improvement into routine care delivery

In-service training bypasses the challenge of extracting nurses from their health centers to attend workshops in main cities, which could be hours away. Mentorship and coaching sessions take place at the health facility level, which avoids worsening staff shortages, an already significant challenge in resource-limited settings.

In Summary

The MESH-QI approach is also proving successful in several other health domains, including neonatal care and integrated management of childhood illness (IMCI), by strengthening the entire spectrum of care for families. The Ministry of Health of Rwanda has a number of efforts underway to replicate and scale this mentorship approach.

To learn more about mentorship, enhanced supervision and quality improvement in Rwanda, please see the following:

–          Description of the mentorship program in rural Rwanda
–          Perceptions and acceptability of health care workers
–          Mentorship and quality improvement strengthened the quality of pediatric care
–          Integrated mentorship and quality improvement to improves antenatal care

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