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Using Clinical Mentorship to build the capacity and confidence of Zimbabwean nurses to initiate ART

Dr. Tafara MogaCare & Treatment Technical Advisor

EGPAF

29 August 2014

Outline

• Background• Setup and Implementation• Results • Recommendations• Acknowledgements• Opportunities for Private practitioners

Background

• National PMTCT program was started in 1999 and the ART program was launched in 2004

• Despite decentralization efforts, only 15% of ANC facilities were ART initiating sites by December 2012 (MOHCC, 2013)

• ART initiation for pregnant women and children were largely doctor-led

• This contributed to;– Low ART coverage for HIV+ pregnant women eligible for

ART – 40% as of Dec 2012 (MOHCC, 2012)– Low pediatric ART coverage - 43% as of December 2012

(MOHCC, 2014)

The “knowledge – practice gap”

Didactic in-service training

Clinical Practice,

Competency & Proficiency

Despite in-service trainings, nurses cite lack of confidence as a key barrier to initiating ART

Unclear mechanism to close this

gap

Definition of Clinical Mentorship

• Clinical mentorship is a system of practical training and consultation that fosters on-going professional development to yield sustainable high-quality clinical care outcomes. (WHO)

Key Operational Definitions

• Mentee: nurse who received training in HIV management and working at the mentee site.

• Mentor: a practicing clinician with considerable expertise or experience in HIV management (OI/ART)

• Mentee site: a site with functional MNCH unit which was not offering ART initiation services before CM

Objectives

• Primary Objective – To build a pool of nurses equipped with skills

and confidence in initiating HIV positive pregnant women and pediatric patients on ART

• Secondary Objectives– To improve the motivation of nurses by

providing effective technical support.– To increase the number of sites accredited

to initiate clients on ART

Steps taken in Setting up the Clinical Mentorship Program

Sensitization of provincial & district managers

Identification of mentee sites

& mentees

Identification of mentors

Identification of Centers for Attachment

Training of Mentors

Clinical Attachment of

Mentees

Clinical Mentorship(visits, telephonic)

The roles of a mentor

• To provide ongoing coaching and mentoring to less-experienced HIV clinical providers (nurses) by assisting in case management responding to questions reviewing clinical casesproviding feedback

Composition and Functions of mentor teams.

• Doctor – Clinical case management (drug regimens,

when to initiate ART, when to stop therapy or refer patients, possible drug side effects etc)

• OI-nurse – Counseling (adherence preparation and

support), ART M&E tools • Pharmacy technician – Stock management (pharmacy ART register,

drug storage, the CR form and good pharmacy practice).

Methodology

• MDT of mentors visited mentee sites fortnightly for a 3 month period.

• Two mentee sites per district covered per period.– As mentors have other roles to play at their

stations.• Mentors were supported with fuel,

allowances for meals and airtime.

Activities during a Clinical Mentorship visit

• Mentorship visit is one full day by the whole team per site.

• In between visits mentorship continued telephonically

Observe Case management and reinforce

skills

Review patient

monitoring cards and registers

Clinical case

review meeting

Document work

including recommend

ations

Mentorship Tools

• Clinical mentorship was guided by 5 tools– Tool 1: Clinical competency assessment (pre-

mentorship)– Tool 2: Mentee’s Log book– Tool 3: Mentors’ monthly report– Tool 4: Mentee’s Evaluation of the mentors– Tool 5: Clinical competency assessment

(post-mentorship)

Expected Outcomes

• Primary outcome A pool of nurses equipped with skills and confidence to appropriately initiate, manage and follow up patients on ART within MNCH settings.

• Secondary Outcomesi. Increased ART coverage for eligible PMTCT mothersii. Increased pediatric ART coverage iii. Reduction in lead time from eligibility to ART initiation iv. Increased number of sites accredited to initiate ARTv. A family centered approach to ART services within MNCHvi. Increased retention in care & reduced LTFU

Sustainability and Continuity

• After the 3months of intensive mentoring, we recommend that mentorship be incorporated into routine/ scheduled site support by the DHE.

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Results

Distribution of mentee sites

Province Number of Districts

Number of Mentee sites

Number of Mentees

Mash. East 9 17 33Manicaland 7 14 30Mat. North 7 14 23Midlands 8 16 37Masvingo 7 14 44Mash. West 7 14 35Mat. South 7 14 28Total 52 103 230

ART uptake among pregnant women at mentee sites by province: 2012

and 2013 Comparison

Mat South Masvingo Mat North Mash West Midlands Manicaland Mash East

9%

18%

27%

6%

17% 16% 17%

39% 39%

57%

16%

37%

64%

54%

Jan-Dec 2012 Jan-Dec 2013

Province Source: EGPAF PMTCT Program data

Comparison of Trends in uptake of ART Initiation in ANC between Mentee and

Non-mentee sites

Oct- Dec 2012 Jan-Mar 2013 Apr- Jun 2013 Jul-Sept 2013 Oct-Dec 2013

25%27%

48%

58%

67%

19%21%

30%

36%

52%

Mentee Sites

Non mentee sites

Time (months)

%in

itiat

ed o

n A

RT

Pre- mentorship phase

Mentorship phase Post- mentorship phase

Comparison of mean ART uptake in mentee and non-

mentee sites Period ART Uptake in ANC (%)

Non-mentee sites (n = 447)

Mentee sites (n = 103)

Difference

Pre- mentorship 21 27 6

Post- mentorship 36 58 22

Difference 15 31 16*

*p- value= 0.048

Results

• 94% of mentees reported having confidence to manage all types of patients on ART

• 168 Children <2years old were appropriately initiated on ART at the mentee sites during the intervention period

• Clients initiated on ART by mentees include pregnant and lactating women, general ART clients and children < 2years

• 92% of the 103 mentee sites had been accredited as stand alone ART initiating sites by December 2013

Results

• Mentees reported a decrease in lead time to ART initiation for all types of patients.

Conclusions

• Clinical mentorship is a feasible way of bridging the gap between didactic training and clinical practice.

• Clinical mentorship in HIV management is effective in building the confidence of trained nurses to initiate pregnant women and children on ART

Recommendations to the MOHCC

• To consider accelerating the roll out of clinical mentorship to support decentralization and expedite the roll out of 2013 HIV management guidelines.

• To consider adopting an integrated clinical mentorship approach (across programs) as an effective way to transfer knowledge into practice.

Opportunities for Private practitioners

• May be a source of mentors for HCW in the public sector– Volunteer your time at any local clinic

• May need mentoring as – Some are less experienced with adherence

counselling (seen as less profitable) – Some may not be familiar with the latest

national guidelines on HIV management• Opportunity to get mentorship from

central hospitals and other private places

Acknowledgements

• Ministry of Health and Child Care• UK Department for International

Development (DFID)• Children’s Investment Fund Foundation

(CIFF)

Towards virtual elimination of Pediatric HIV

• “Tell me and I forget, teach me and I may remember, involve me and I learn.”– Benjamin Franklin