Box 4 Lessons for implementing a successful mentorship intervention to strengthen surgical services in low-resource settings

Intervention design

• A multimodal mentorship intervention design using both in-person and virtual platforms can support different types of learning (e.g., tacit or explicit). The different platforms complement and reinforce each other, contributing to continuous and deeper learning

• Mentorship is optimized when it is part of a multicomponent intervention. Training mentees and mentors on evidence-based practices before mentorship ensures that everyone is working to implement the same standards for safe surgery

• A team-based approach to mentorship can provide discipline-specific mentorship (e.g., nurses mentoring other nurses), and reinforce a culture of shared learning

• To improve the intervention, there should be opportunities for reflection and learning. Incorporating time for bi-directional feedback, such as debriefing after each visit, at annual meetings, and evaluations can strengthen future intervention design

Mentors

• Selecting the right mentors is key. Subject matter expertise and strong interpersonal and communication skills are crucial. Selecting local mentors can facilitate cultural congruence and an understanding of context, relatability, and language. Local mentors can also train new surgical providers more frequently and engage in peer-to-peer learning to diffuse knowledge quickly and continuously

• Preparation of mentors should cover subject matter expertise, change management skills, and mentorship skills, such as relationship-building, communication and feedback, and effective teaching. Pairing junior mentors with experienced mentors can also be considered to strengthen mentorship skills and confidence

• Mentorship requires resources. Mentors need protected time away from clinical work to prepare and conduct mentorship visits as well as resources for coordination, training, and support. Options for incentivizing mentors through compensation, continuing education credits or other incentives like certification should be considered

Implementation

• A Quality Improvement Action Plan can facilitate a shared understanding about the overall improvement goals of the intervention. An action plan can lay out a clear strategy (e.g., specific actions, responsibilities, timing and means of verification) and can provide a framework for assessing progress and setting goals for the next visit

• Buy-in from the surgical team is essential before starting the mentorship intervention; they must understand the goals. It is especially important to address those who are less ready to change. Whole-site orientation and training and engaging facility leaders in mentorship can increase buy-in

• Leadership support and engagement from facilities, district and regional leaders is necessary for success. Leaders can support staff in implementing mentoring activities, release staff time, and assist in setting up QI systems. Furthermore, leadership support is crucial in sustaining surgical quality improvement. Mentorship cannot work if leadership is not receptive to it

• Time constraints must be considered for mentees and mentors. Health facilities in low-resource settings are often faced with staff shortages. Mentors also have competing work and personal demands. Therefore, implementation must consider providing surgical providers the time to learn and improve, timing of sessions, lowering work burden, and revamping tools for efficiency for both mentees and mentors

Sustainability

• Building a culture of mentorship is necessary for sustainability. Mentorship is a promising approach for scaling surgical quality and requires policy support to institutionalize it. Mentorship should be incorporated in the safe surgery space, linked to continuing professional development systems, and should be incorporated in the District plans and budget. Training a pool of local multidisciplinary mentors is critical for cost effectiveness and sustainability