Study setting

Malawi is a low-income country in sub-Saharan Africa with approximately 18.9 million people projected in 2021 including approximately three million children under 5 years. Injuries and trauma account for an estimated 19% of all non-communicable diseases and injuries (NCDIs) disability-adjusted life years (DALYs) in Malawi and contribute to 6.4% of all deaths [26–28]. Neno is located in the southwest of Malawi and is one of the hardest to reach as the last district without a paved road to its district hospital. It is one of the most impoverished areas of the country with only 3.7% of the population having access to electricity and >70% living in poverty [29]. In the district, there are two secondary level care hospitals; Neno District Hospital (NDH) and Lisungwi Community Hospital (LCH) along with 13 primary health facilities and a robust community health worker program (Fig 1).

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Fig 1. Map of Neno District, Malawi: Republished from partners In Health under a CC BY 4.0 license, with permission from Ermyas Birru, original copyright 2014.

https://doi.org/10.1371/journal.pone.0280454.g001

Study design

This was a mixed-methods analysis that included mentor and participant surveys, mentorship quantification, and participant examination results. The mentor and participant surveys and participant examinations were completed before and after the BEC course and one year following the BEC course intervention. This study received ethical approval from the National Health Science Research Committee (NHSRC) in Malawi with protocol number 1059 titled “Lessons Learned from Monitoring and Evaluation of Community Health Initiatives in Neno District, Malawi." In addition, ethical approval was received from UCSF Committee for Human Research with protocol #19–28037 titled “Piloting the WHO Basic Emergency Care Course and Trauma Checklist in Neno District, Malawi.”

BEC course and participants

Two BEC courses were completed from September to October 2019 at the two hospitals in the district, Neno District Hospital and Lisungwi Community Hospital, as all emergent or urgent patients in the district either seek direct care or are referred to these facilities for treatment. All course materials were delivered in English and formally hosted by local and National MOH and PIH/APZU.

Master trainers from UCSF and the Africa Federation for Emergency Medicine (AFEM) conducted a two-day training of trainers (ToT) on teaching methodology and delivery mechanisms for key BEC concepts, after which the newly trained facilitators and the master trainers taught the course to local participants. Two local district-based mentors were selected by hospital leadership based on leadership ability, level of commitment, and interest in clinical care to provide ongoing mentoring on BEC practices in the district. Neither one had prior formal emergency care training or primarily worked in acute care. The goal of the ToT was to develop BEC facilitators who could then train and mentor additional staff using the BEC curriculum.

Following the ToT, two BEC courses (one at each hospital) were taught over five days in September and October 2019 by two master BEC trainers and the newly-trained facilitators with supervision. Participants of mid-level providers and nurses were selected by hospital leadership with no prior formal emergency care training and never primarily worked in trauma and/or acutely ill patient settings, but all care for these patients as part of their daily job. The topics comprised didactic lectures, interactive workbook questions, case scenarios, and hands-on skills sessions. Each lecture had small group sessions where students practiced case scenarios and discussed how to manage acutely ill patients. Hands-on skills stations allowed participants to learn and practice skills using available supplies. Examples of hands-on skills taught in this course included: airway skills like inserting oropharyngeal airways and how to perform airway maneuvers to open an airway; breathing skills such as what oxygen delivery device to use, and emergency needle decompression; and circulation skills such as controlling bleeding and uterine massage. To complete the course, participants had to complete all activities in their workbooks, pass all skills tests through the performance of all critical actions, successfully outline the management of one case scenario, pass a post-test with a score of >75% and attend all sessions. Assessments included pre-and post-course content-based evaluations covering course contents, skills assessments, workbook completion checks, and a post-course survey. Written consent was obtained from each participant, trainer, and mentor after explanation from the facilitator prior to the course for use of generated data.

Mentorship

The healthcare workers who completed the BEC course were given six months of formal follow-up mentorship completed by the two BEC facilitators, with one located at Neno District Hospital and Lisungwi Community Hospital respectively. Immediately following the BEC course completion in October 2019, on-site mentorship was initiated. Mentors were expected to be in the outpatient department or hospital wards mentoring for at least two to three days a week for 5 hours a day over six months. Additionally, mentors were available for staff to call when there were emergencies or acute care. The mentorship specifically included observation and assistance with emergency cases along with consultation, teaching, and meetings. Mentors’ activities included compiling and maintaining an emergency supply box that would be easily accessible to staff, assisting and educating both BEC trained and untrained staff during emergency cases, planning skills or case scenario teaching throughout the wards and outpatient departments, and participating in meetings surrounding emergency care in the district. They also collected data on their mentorship with monthly reporting for the six months following the training in the two hospitals using CommCare application. Data was reviewed with monthly check-ins with a BEC master trainer as a supportive supervisor for coaching and guidance as well as surveys on perceptions of the mentorship.

Data collection

Data analysis

Data from pre, post-course, and one-year post-course examinations and survey data were analyzed in R version 4.0.2 [31] using Rstudio Integrated Development Environment Version 1.4.1103 [32]. A suite of “Tidyverse” packages was used to clean, manage, and analyze the data. Simple descriptive statistics and visuals (boxplot) were used to describe participant demographics and course scores. A Wilcoxon signed-rank test was used to evaluate the difference in the median between pre-and post-test scores for Lisungwi Community Hospital, Neno District Hospital, and combined. Simple counts were used to demonstrate mentorship characteristics and the total number of mentorship activities, hours of mentorship, and the number of emergency patients.

Responses from the pre, post-course and one-year post-course surveys as well as the mentor surveys and monthly qualitative feedback were uploaded into Dedoose version 8.3.17 for data management. The data was analyzed using qualitative content analysis by three authors with immersion and active reading of transcripts. To ensure the reliability of coding and consistency, three authors independently read the transcripts line by line to inductively assign codes to similar concepts that repeatedly emerged from the data in line with study objectives. The codebook was generated through iterative review with the final codebook agreed upon by joint consensus. We identified relationships between these codes, repeatedly identified codes were merged and themes around facilitators and challenges to execution of the basic emergency clinical care were generated. We chose quotes for each theme summarizing main points established from the qualitative data.

Participant and mentor survey results

Following the course, all the participants who responded to the post-course survey (N = 27) agreed the course content was “very appropriate”, and 89% (N = 24/27) felt that the course content was “very appropriate” to the setting and context. All of the respondents to the course survey either “agreed” or “strongly agreed” that the BEC was a productive use of their time and would recommend the course to other healthcare providers. When asked what they would change about the course, just under half of the participants felt the course should be longer or follow up with refresher training.

Participant and mentor qualitative feedback

Through examination of the survey responses and feedback, findings were deductively identified around facilitators and challenges in use of basic emergency care enabled by the BEC training and mentorship (Fig 3). Themes of facilitators included i) teaching skills of instructors and mentors, ii) availability of supportive mentorship; iii) knowledge gain, and iv) professional development. The themes of challenges were i) the need for additional training or mentorship, ii) enhancement of training or mentorship; and iii) lack of time or commitment to the use of basic emergency skills.

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Fig 3. Mapping themes of facilitators and challenges of basic emergency skill use in Neno District.

https://doi.org/10.1371/journal.pone.0280454.g003

Facilitators in use of basic emergency skills

The teaching and inviting nature of the BEC instructors and mentors, along with hands on skills sessions were key enablers to use of basic emergency skills and comfort in use for participants. Participants shared that the instructor encouragement and ability to approach them were vital for engagement and learning. Participants remarked “[They were] clear, and skilled with making everyone comfortable,” “They were flexible which made us comfortable to ask questions and clarifications” and “They were good, very clear on mentioning things to be done, very friendly and loving. Could answer any questions we asked, and we love that.” The instructors also enhanced confidence in skills through teaching. One participant responded that the course “Necessitated the acquisition of the necessary skills, confidence in handling emergencies and improved morale” and another noted “[Instructors] involved participants to enhance participation.” Use of hands-on skills were valued as well with one participant stating, “Knowing how to manage trauma and cervical spine immobilization were possible with skills sessions.”

Increased knowledge and skills gained was a fundamental enabler for participants to use basic emergency skills for their patients. One participant remarked that “knowledge gained during the BEC course is being applied on my patients with good outcomes” and another responded, “I managed and helped poly-trauma patient from a road trauma accident using the knowledge and skills gained.” Due to the training and mentorship, participants felt confidence and pride in patient management. One respondent offered “before this course I used to run away from emergency patients but now I am able to manage them.”

The availability of supportive mentorship following the BEC course was an enabler for continued learning and correct use of basic emergency skills. Reminding participants of key concepts was a key theme with one respondent offering “[the] mentor helped with clarifying the concepts I missed during the training” and another remarked “[Mentors] helped with sharpening skills attained and created more time for practice”. From the mentorship, improved quality of care was noted–“[Mentors] improved quality of care through presence and reminders,” “Mentorship assisted in my weak areas,” and “Mentor was always present when needed during emergencies. Mentors remind when one forgets.”

Over the six months of mentorship, the mentors also shared that their work improved knowledge and skills in the participants. One mentor stated, “The mentorship program is of paramount importance in our field…In my setting, it [mentorship] was particularly beneficial to those who were new and not trained as they were eager to be equipped with knowledge and skills.” Both mentors shared that they observed improvements in participants. One shared, “[The] provider was able to adjust management quickly as the child was deteriorating very fast and managed to save him,” and another stated, “[The] mentee used BEC skills to save life by calculating and giving appropriate amount of fluids to a baby in shock.”

Furthermore, and most important, the mentors gave feedback frequently on how longitudinal hands-on mentorship allowed them to constructively correct practice of mentees to improve use of basic emergency skills and quality of care delivered to patients. One mentor gave an example, “provider forgot to check pulse rate, sensation and capillary refill. She was mentored and reminded how to do splints. Finally, she checked everything correctly,” and another mentor noted “provider was able to resuscitate baby successfully after being reminded of the right way to provide bag mask valve [resuscitation] that was age appropriate, commenced baby on oxygen therapy then sent them for proper management.”

Lastly, the instruction and mentorship of the BEC course allowed mentors and participants to build their professional attributes. One mentor shared “I would say I feel great and motivated to have participated in [the] BEC and mostly to be a mentor of the project. Personally, the trainings and mentorships were great. They have improved my skills, knowledge and my CV.” A participant noted the BEC training and mentorship “updated/refreshed my attitude, knowledge and skills for emergency care.”

Challenges to use basic emergency skills

A challenge that was voiced clearly by the participants was the need for additional and refresher training, and continued mentorship. One participant remarked “duration of course was too short with a lot of content to cover” and another offered “would suggest a refresher course and course review meetings”. In appreciation of the knowledge gained during the training, all participants felt that all healthcare providers could benefit from the BEC course and mentorship. Several respondents recommended increasing the number of participants in the course; “train everyone at the facility so cases always find trained personnel.” Overwhelmingly the participants recommended more mentorship availability. One stated “more time needed with mentor especially at night” and another asked that “[the] mentor should have a schedule to follow up on all mentees”. One participant even suggested avoiding overwhelming mentors with the requests “do more group mentorship if time constraints.”

In addition to extended training and mentorship, there were participant and mentor calls for enhancement of the training and mentorship. With acknowledgment of the knowledge and skills the BEC program had provided. Suggestions for enhancement of the training focused on further resources and more skills training, for example “Need more case scenarios as their use bring an idea of how to approach different patients with different presentations,” and “make some resources available like mannequins for continued and updating skills.” One adjustment that was noted by several participants was for the master trainers to be Malawian or aware of local guidelines with statements including, “there was a need to have some local facilitators to give local scenarios” and “lecturers to be aware of national guidelines so as to be able to deliver real situations and management according to the setting.” Participants did not have specific areas for refreshing training but rather several noted it was needed to maintain knowledge and update participants to current recommendations.

For enhanced mentorship there were calls for more interface and additional mentors with participants requesting, “Add drills for one-on-one mentorship for the team” and “more mentors at departmental level would make the program better.” Some participants expressed a desire for additional structure to the mentorship with noting, “Mentors should have a schedule to cover/follow up on all mentees, “and “[there is] need to draw action plans with mentors to assess progress over time.”

Even though the mentorship was appreciated by both mentors and mentees with numerous examples of improved patient care, challenges for the mentors included the time mentorship took that was in addition to their other duties. One stated, “the time given to us to work is unrealistic and it was not working. We were still being called to attend emergencies day and night even if we were not supposed to handle emergencies on that particular day or when we were off duty.” Additionally, the limitation of staff shortage and loss of trained providers limited the reach of the mentors. One noted “shortage of staff doesn’t help much either because only a few were trained; we have one person on duty most of the time giving less time for mentorship as they are always busy with other cases that may not be emergencies.” In addition to staff shortage, a limitation noted was lack of motivation by mentees with one mentor remarking “there is need for motivation and mentoring of nurses to do the right things at the right time.” Another mentor suggested that the participants for the BEC course should be carefully chosen so that they are assigned to the outpatient department and wards where BEC skills are utilized and plan on remaining working in the Ministry of Health in the district. The mentor explained, “…[There was a] lack of availability and commitment of trained providers. This happen because inappropriate people were trained and they were mostly busy attending their usual duties neglecting BEC.”

Limitations

This study is limited in generalizability by its geographical small footprint in one district in Malawi and a small number of participants practicing only in hospitals along with staff turnover during the course of the study. However, these challenges are not unlike other rural settings across sub-Saharan Africa and Asia representing the environment of work. The other limitation is that the study could not follow patient level outcomes since it would be difficult to attribute the outcomes to the course and mentorship alone. The future studies should be designed to follow the effect of the BEC training and mentorship on patient level outcomes as well as sub-analysis by health worker cadre with larger number of participants. The study was completed in a district with a non-governmental organization (NGO) partner who provided support to mentors in forms of transport, laptops, airtime et cetera that may not be possible for other resource-limited settings in and out of Malawi. Further BEC training and longitudinal mentorship with a larger cohort of providers from diverse geographic and care settings, and a control group with no mentorship will be critical to support and expand on the findings from this paper.