Session 8 - Pediatric Clinical Mentoring Overview

Clinical Mentorship: Taking the Pediatric Agenda into the Field: Robin Flam, MD, DrPH, Clinical Officer, began the clinical mentoring overview by presenting a new definition of clinical mentorship, as a system of practical guidance that fosters sustainable high-quality patient outcomes through attention to what occurs on three levels: the provider level, team level, and site level.  She noted that clinical mentoring is time-sensitive and occurs on two dimensions: program components and levels of the programmatic system.  She then laid out a plan for clinical mentoring sessions upcoming throughout the workshop.

Working with Providers: Robin outlined provider mentee needs (e.g. a knowledge base in content and models of care) and mentor’s needs (e.g. dedicated time to observe and feedback; interpersonal and communication skills; and clinical expertise).  Robin described the precepting process and tools needed, such as provider self-assessments and structured patient interviews; and described case-based learning processes (e.g. asking not telling; effective prompting; and fostering appropriate confidence), content (e.g. case investigation via chart review and accumulating lab/study results) and tools (e.g. case templates and a case-based curriculum).

Working with Teams: Robin next described the necessary components for a multidisciplinary team, including how to create a team, what makes a good team leader, what is involved in team meetings, and how to deal with dysfunctional teams.  She outlined the uses of task shifting, case studies, cross-training and cataloguing, as well as issues related to family and PLWHA involvement.

Working at the Site Level: For the last clinical mentoring session of the workshop, Robin described the assessment and enhancement of site program quality, including use of standards of care and capacity building.  Robin emphasized that we cannot always rely on training as solutions to staffing/provider problems, and outlined the overlap between supportive supervision and clinical mentoring.  She then discussed the mentoring of mentors (such as on-site supervisors) and the creation and training of networks.

Issues raised during Question & Answer session:

  • Two months ago, ICAP South Africa began a formal nursing training program, which is based on WHO IMAI Levels 1 and 2 competencies, includes identification of physical abnormalities, and has an HIV specialty.  8 people are currently enrolled, and East London will soon start training a few more.  This is an important training program that gets HIV away from vertical programming; HIV is still considered a specialty, despite the high prevalence in South Africa.
  • ICAP Rwanda has been able to expand care in the context of a great staff shortage by using pediatric clinical mentoring with on-site trainings.
  • As an observer and a preceptor, how does one ensure that the patient doesn’t feel awkward about the provider being observed for competency?  The most conservative approach is to ask for patient permission before the appointment, explaining that the mentor is a “visitor”, avoiding hierarchical terms like “preceptor.”  It might be helpful to set aside time for the preceptor to talk privately with the provider before the patient leaves, especially if the provider is doing something really wrong.  It may helpful to set up some other ground rules.  Precepting does slow the provider down, and it can be a difficult process, so some providers can only accept a bit of precepting at a time.  Eventually you get to know each other well enough to know each other’s boundaries. 
  • An important take-home message is that every place is different, so the appropriate approach may vary.  In Nigeria, it would be very unusual to have an attending physician mentoring you while you are seeing a patient.  Sometimes mentoring can be done from a distance.  This lack of mentoring creates a tough situation, because soon after a doctor’s training, they begin treating children with HIV, etc. 
  • There was some interest in ICAP developing online mentorship such that country teams could communicate with the New York team, explaining cases and obtaining clinical assistance electronically.  Difficulties may arise depending on phone and internet reliability.  Country teams might start by building their own hard copy case libraries, even if there is not yet an online library. 

Session 9: Open Space Technology

In order to allow for some creativity and natural discussion development, suggestions were solicited throughout the workshop for topics that participants wanted to discuss in depth on the last workshop day.  On the last day, participants self-selected discussions to join, created the agenda themselves, and ran their own meetings.  Discussion areas included:

  • Adolescents and adherence
  • Early infant diagnosis and exposed infant follow-up
  • Improving pediatric adherence to HAART
  • Involving men
  • Infant feeding
  • INH prophylaxis and TB/HIV co-infection

Session 10: Transforming Strategy into Action in the Field

Review of Key Learning Points: As a large group, participants reviewed the key points they felt they would find most useful from the workshop. 

Country Presentation on Workplanning for One Program Element: Each country team presented a summary of workplan activities agreed upon for a specific workshop session, and answered brief questions from the audience.

Next Steps

In the coming months, country teams will:

  • Immediately report back on the pediatric workshop proceedings, key learning points and tools, to the rest of their country team.
  • Continue to craft their pediatric workplans, producing final versions during summer 2007.
  • Translate the workplans into measurable outcomes with the expectation of reporting on progress at the ICAP annual meeting. 

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