Elsevier

Nursing Outlook

Volume 61, Issue 3, May–June 2013, Pages 137-144
Nursing Outlook

Article
Workforce and Collaboration: International Perspective
Nurse mentorship to improve the quality of health care delivery in rural Rwanda

https://doi.org/10.1016/j.outlook.2012.10.003Get rights and content

Abstract

Quality of care at rural health centers in Rwanda is often limited by gaps in individual nurses’ knowledge and skills, as well as systems-level issues, such as supply and human resource management. Typically, nurse training is largely didactic and supervision infrequent. Partners In Health and the Rwandan Ministry of Health (MOH) collaborated to implement the nurse-focused Mentoring and Enhanced Supervision at Health Centers (MESH) program. Rwandan nurse-mentors trained in quality improvement and mentoring techniques were integrated into the MOH’s district supervisory team to provide ongoing, on-site individual mentorship to health center nurses and to drive systems-level quality improvement activities. The program targeted 21 health centers in two rural districts and supported implementation of MOH evidence-based protocols. Initial results demonstrate significant improvement in a number of quality-of-care indicators. Emphasis on individual provider and systems-level issues, integration within MOH systems, and continuous monitoring efforts were instrumental to these early successes.

Section snippets

Background on HCs in Rwanda

In Rwanda, HCs provide a range of outpatient preventative and curative services, as well as more limited in-patient care, including uncomplicated deliveries. Each MESH-supported HC covers an average population varying between about 20,000 (Southern Kayonza district) and 24,900 (Kirehe district) and encompasses an average area of 48 km2 in both districts. There are eight HCs in Southern Kayonza District and 13 in Kirehe District (see Figure 1). The mean distance between the district hospital and

Program Progress

Program implementation began in November 2010, with program initiation at four HCs at a time, achieving full-district coverage within five months. During initial visits, mentors conducted baseline assessments of service delivery through case observation and facility evaluation. Mentoring visits started approximately one month after baseline assessments.

Discussion

We have encountered a number of challenges in our early stages of program implementation. Frequent turnover of HC nurses was a challenge to the MESH program, as it resulted in the loss of trained and mentored nurses. Turnover of HC staff is a problem across the country and is related to a number of reasons, including individual nurse decisions to transfer from rural to urban areas, seek positions with higher salaries, or pursue further formal education opportunities. This loss of trained staff

Conclusion

Despite these challenges, the MESH program has helped to bridge the gap between traditional didactic training and clinical practice using locally trained nurse mentors to start to improve the quality of care delivered at rural HCs in Rwanda. Through ongoing, direct observation of nurse practices and HC operations, nurse-mentors can effectively identify and intervene in quality of care issues, reinforce didactic nurse training, and facilitate systems-level improvements. MESH’s integration within

Acknowledgments

We thank the MESH mentors, technical advisors, and the M & E team for their dedication to improving care at HCs in Kirehe and Southern Kayonza districts and Dr. Corrado Cancedda for his vision and leadership in training. We are grateful to Fabien Munyaneza for providing the map in Figure 1 and to Catherine Mezzacappa for her statistical support. This work could not have been accomplished without the ongoing support of the district hospital supervision teams, PIH, and the Rwandan MOH.

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The Mentoring and Enhanced Supervision at Health Centers (MESH) program is funded in part by the Doris Duke Charitable Foundation Population Health Implementation and Training Partnership.

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