I-TECH’s Approach to Clinical Mentoring

1. I-TECH’s Approach to Clinical Mentoring

2. Overview of This Presentation • Definition of and Rationale for Clinical Mentoring • How Adults Learn • Strategies for Clinical Mentoring • Models of Clinical Mentoring

3. What Is Clinical Mentoring? A sustained, collaborative relationship in which a highly experienced health care provider guides improvement in the quality of care delivered by other providers and the health care systems in which they work.

4. Clinical Mentoring Rationale • Decentralization of HIV care and antiretroviral therapy (ART) • Strengthening district health systems • Task-shifting • Transitioning to chronic HIV care • Standardized content and care pathways • Continuing education

5. Mentoring vs. Supportive Supervision Supportive supervision • Space, equipment, forms • Supply chain management • Training, staffing, other human resource issues • Entry points • Patient satisfaction • Patient flow and triage • Clinic organization • Patient monitoring and record-keeping • Case management observation • Team meetings • Review of referral decisions • Clinical mentoring • Clinical case review • Bedside teaching • Journal club • Morbidity and mortality rounds • Assist with care and referral of complicated cases • Available via distance communication

6. Mentor Guides mentee through entire course of training: physical exam to advanced, complex, end-of-life care Two-way discussion with open-ended questions Teaches by modeling, not only intellectual skills but also empathy/ compassion Preceptor Works alongside student, directs his/her learning by telling him/her what to look for, how to look for it Telling, not showing Mentor ≠ Preceptor

7. Characteristics of a Good Mentor • Adept at physical diagnoses • Has working knowledge of possible diagnoses and issues that may need addressing • Enthusiastic and comfortable incorporating diverse situations/experiences into teaching • Takes a “back-seat” approach to teaching, avoiding extensive lectures • Allows mentor to explore and learn on his/her own • Good understanding of clinical systems helps to address systemic issues

8. Characteristics of Effective Mentorship Relationships • Both mentor and mentee want to be involved in mentoring relationship. • Relationship is warm, safe, respectful, trustful. • Mentor/mentee are able to process misunderstandings. • Continuity of the relationship over time. • Power is shared. • Learning is two-way; mentor is interested in learner’s ideas. • Mentor listens to learner and the learner knows it.

9. Positive Outcomes of Clinical Mentoring Besides improved patient care: • Improvements in organizational structure of busy clinics, including • Improved patient flow • Better systems for patient record-keeping • Greater communication across cadres with clinic staff • Leadership skills of mentees are encouraged and developed—possibly creating future mentors!

10. Mentoring Process • Mentors guide using a 5-stage process: • Building relationships • Identifying areas for improvement • Responsive coaching and modeling of best practices • Advocating for environments conducive to good patient care and provider development • Collecting and reporting on data

11. Components of Mentoring (1)

12. Components of Mentoring (2)

13. Components of Mentoring (3)

14. Components of Mentoring (4)

15. Components of Mentoring (5)

16. Components of Mentoring (6)

17. What Do Mentors Teach? Can teach about any aspect of service provision within the clinical setting: • Methodology or process of a counseling session or procedure • Background on disease pathophysiology • Patient rapport/interpersonal communication patterns • Building confidence as health care workers • Strategies for maintaining patient confidentiality within the clinic setting • Suggesting appropriate treatment options to health care workers

18. People Learn Differently I hear and I forget, I see and I remember, I do and I understand See one, do one, teach one

19. Three Basic Learning Styles • Visual: Learning through watching, observing, and reading • Demonstrations, visual examples • Auditory: Learning through listening • Case discussions, lectures • Kinesthetic: Learning through doing, practicing, and touching • Role plays, practice techniques (i.e., blood draws)

20. Principles of Adult Learning • Adults feel anxious if participating in a group makes them look weak, either professionally or personally. • Adults bring a great deal of experience and knowledge to any learning situation. • Adults are decision-makers and self-directed learners. • Adults are motivated by information or tasks that they find meaningful. • Adults have many responsibilities and can be impatient when their time is wasted.

21. When and Where Does Mentoring Occur? • In a variety of settings: • ART clinics, inpatient medical wards, labor and delivery wards, PMTCT*, ANC**, or TB*** clinics, etc. • Anytime: • While a patient is present in the room • Following a patient visit or during a chart review • Planned for the future

22. Mentoring Strategies • Bedside teaching • Side-by-side mentoring • Case Presentations

23. Bedside Teaching (1) • Teaching and reinforcing skills at patient’s bedside: • A common approach in medical education • Reinforces classroom learning • Allows mentor to model important clinical skills, attitudes, and communication in the context of patient care, as well as observe mentee’s skills

24. Bedside Teaching (2) Five steps: • Get a commitment • Probe for supporting evidence • Reinforce what was done well • Give guidance about errors and omissions • Summarize encounter with a general principle

25. Bedside Teaching: Benefits • Bedside teaching is an important part of the process of adult learning, as it reinforces classroom learning. • Strengths and weaknesses of mentees become clear at the bedside, because mentors can watch mentees interact with patients and experience firsthand what they do and how they act with patients.

26. Side-by-Side Teaching • As the name implies, this technique involves working alongside the mentee in clinic. • Mentor and mentee alternate duties of seeing and examining patients, writing relevant information in patients’ health records and ART files, and checking lab results.

27. Side-by-Side Teaching: Benefits • Mentor can observe mentee at work and identify and address challenges. • Mentor acts as a role model when he/she is performing physical exam. • Patients are seen more quickly than if the mentee sees the patients alone; visits are more comprehensive and thorough. • Mentors do not feel like they are being watched, but rather supported by a colleague.

28. Case Studies: Defined • A training methodology that provides learners with an opportunity to apply new skills and knowledge to a simulated “real-life” situation. • Allows exploration of various strategies to address complex issues. • Requires learners to analyze the scenario, problem solve, and apply what they know to work through the case, much like they would in a clinic setting.

29. Case Studies: Rationale • Case studies are one of the most effective ways to train health care workers on ART— particularly multidisciplinary teams. • Case studies can be used to role play best practices and effective health care worker behaviors. • Effective case studies include adequate patient details and specific decision points. • Discussion of options is central to case studies.

30. Models of Clinical Mentoring • Internal mentor • External mentor • Field-based mentoring teams • Mentoring as a component of a training package

31. Internal Mentor • Mentor is identified from among existing staff at a health care facility; already has clinical expertise, and receives training on how to mentor others • Benefits: Sustainable model, mentor already knows system and its issues and challenges, so little time needed for preparation • Challenges: Lack of appropriate human resources; perception of clinician as colleague, not mentor

32. External Mentor • Placement of an expert clinician identified from within or outside of the country for a designated period of time at a specific facility • Benefits: Draws from a larger pool of expert clinicians • Challenges: Significant resources may be required to recruit, relocate, and orient the mentor to their site

33. Field-Based Mentoring Teams • Multidisciplinary field-based teams provide ongoing clinical and systems mentoring to hospital sites and health care centers • Benefits: Allow for key groups of expert staff to regularly visit a select number of clinical sites and provide intensive site support and clinical mentoring

34. Mentoring as a Component of a Training Package • Classroom training followed by a preceptorship rotation at different sites, with follow-up evaluation completed at the trainees’ site several weeks later

35. In Summary Clinical mentors are experienced clinician-trainers who provide case review, problem solving, quality assurance, and continuing education. Mentoring: • Provides increased access to onsite training for health care workers in resource-limited settings. • Aims to increase the skills of clinic staff and the efficiency of the clinic for the well-being of the patients.