ihar nurse Mobile Mentoring PrograMMe 66 | MAkING A Difference : Good, Replicable and Innovative Practices
ProbleM stateMent In the c<strong>on</strong>text of the maternity-benefits-driven rapid increase in the utilizati<strong>on</strong> of public facilities for childbirth in Bihar (current estimate ~65% of all deliveries), these facilities must sustain minimum standards of quality of care for safe birth outcomes to be ensured. Most deliveries in public facilities are c<strong>on</strong>ducted by ANM and GNM nurses. Pre-service training and SBA training have proven insufficient in improving the quality of intra-partum care to desirable standards, obstetric skill deficits of nurses are identified as serious and the numbers of nurses in positi<strong>on</strong> are too small to permit drawing them out of their places of work for prol<strong>on</strong>ged offsite training. The likelihood of recruiting skilled nurses in sufficient numbers in the foreseeable future is small, and without in-service training of available nurses, intra-partum care is unlikely to result in reducing preventable perinatal deaths. PrograMMe DescriPti<strong>on</strong> This programme is an in-service, <strong>on</strong>site mentoring of available nurses in public facilities by qualified mobile nurse mentors has been implemented in three phases: Phase 1: Pilot in 32 designated BEmONC level facilities in 8 districts (2012-2013). Phase 2: 48 more facilities (including 8 CEmONC level facilities) in the same districts (2013-2014). Phase 3: (Ongoing) 320 more BEmONC facilities and 56 more CEmONC level facilities (2015-2017). All nurse mentoring is embedded in the Quality Improvement process of the State and is implemented by the Bihar Technical Support Program (BTSP). The current model exposes 6-8 selected staff nurses in each facility (typically, a combinati<strong>on</strong> of all available GNMs and additi<strong>on</strong>al ANMs to make up this number, selected by the c<strong>on</strong>cerned block/district hospital) to a pair of mobile nurse mentors (typically, BSc nurses, with some experience in obstetric nursing) for <strong>on</strong>e week a m<strong>on</strong>th for a total of 6-8 m<strong>on</strong>ths. A carefully planned but flexibly implemented curriculum defines learning goals for each week and m<strong>on</strong>th, and seeks to incrementally improve functi<strong>on</strong>ality every m<strong>on</strong>th until desired functi<strong>on</strong>ality is achieved in the facility. The mobile nurse mentors are overseen by master nurse mentors (typically, <strong>on</strong>e MSc in obstetric nursing oversees 2 pairs of nurse mentors). The nurse mentors use a combinati<strong>on</strong> of bedside teaching (in the labor room <strong>on</strong> actual delivery cases), simulati<strong>on</strong>s (using inexpensive equipment, for teaching complex skills such as managing maternal and ne<strong>on</strong>atal emergencies), and theory to emphasize the rati<strong>on</strong>ale for each protocol and process. The mentoring interventi<strong>on</strong> seeks to ensure that all basic practices - infecti<strong>on</strong> c<strong>on</strong>trol, intra-partum and postpartum maternal and ne<strong>on</strong>atal care services, as well as quality of FP procedures provided at these facilities c<strong>on</strong>form to acceptable standards of quality, and result in c<strong>on</strong>sistently predictable and positive clinical outcomes. The progress of facilities and individual student nurses is measured and m<strong>on</strong>itored regularly. evaluati<strong>on</strong> Although no third party evaluati<strong>on</strong> has been carried out, programme data showed significant improvement in practices. For instance, Oxytocin for AMTSL improved from 8.6% to 58.5%, initiati<strong>on</strong> of Kangaroo Mother Care increased from 30.9% to 62.5% and use of sterile instruments increased from 13% to 43.5%. financial investMent Besides routine Government of Bihar finances and PIP support from NHM for infrastructure and supplies, <strong>on</strong>ly the direct costs of recruiting, deploying and managing the nurse mentors have been borne by CARE/SRU budgets and is estimated to cost Rs. 1300* per trainee per day. scalability This programme has already g<strong>on</strong>e to scale in Bihar starting from 80 facilities and to complete 320 facilities by next year. The GOI has also accepted as a programme and allocated a FMR A9.1.4 for Onsite Mentoring at Delivery Points under the Skill Labs comp<strong>on</strong>ent within the PIPs for the Nati<strong>on</strong>al <strong>Health</strong> Missi<strong>on</strong>. c<strong>on</strong>clusi<strong>on</strong>s/less<strong>on</strong>s learnt Sustaining and diffusing quality of care is inbuilt in the current model through identifying and training 2-3 staff nurses in each facility to be mentors for others, and through a separate programme for doctor mentoring. The model is effective in improving all aspects of quality of care, but needs complete ownership by the leadership at the block and district level to sustain. reference BTSP is a programme c<strong>on</strong>ceptualized by State Quality Assurance Committee and NHSRC, planned and implemented by CARE India with financial support from the Bill and Melinda Gates Foundati<strong>on</strong> (BMGF). C<strong>on</strong>tact SPO Nursing, GoB: shsbnursingdivisi<strong>on</strong>@gmail.com Director, SRU hshah@careindia.org and Dy. Director, SRU, skaul@careindia.org *Assuming 8 trainees per facility and 7 weeks training per trainee. Programme has been scaled up from 80 facilities to 320 facilities. Oxytocin for AMTSL improved from 8.6% to 58.5%, initiati<strong>on</strong> of Kangaroo Mother Care increased from 30.9% to 62.5% and use of sterile instruments increased from 13% to 43.5%