Table 2 Illustrative quotations on factors that support and challenge the mentorship intervention and perceived impact

Factors supporting implementation

 Intervention characteristics

  Systems focus of the mentorship intervention

The goals are to improve surgical outcomes and to practice safe surgery. So in that work there are different things, like improving surgical techniques, surgical site infections, safe anesthesia, and safe instrument handling, and also increasing surgical volume. (Hospital 4, Surgical Team Leader)

  Multidisciplinary mentorship team

So, we went there but after a couple of visits, we modified it. We saw that there was a very big gap that we couldn't fill… We thought that it's not fair to only involve the surgeons and scrub nurses. It's good to have a team which involves a gynecologist, orthopedic surgeon, anesthesiologist, and scrub nurses. (Mentor)​​

  Psychological safety

They are not judging. They try to make sure we don’t repeat [mistakes]. There is no blame. There is no shame. Even though we have some mistakes, they don’t want to show us. They just told us, ‘See what will be the next outcome.’ Directly they tell us the next outcome will be bad. That means we are missing something. So just we understood them clearly without any trauma for us. (Hospital 5, Surgical Team Leader)

They are easy, safe to communicate with …even if you do wrong…This is why I like it. They teach like friends. (Hospital 1, Nurse)

 Mentor characteristics

  -Generosity

X-ray, ultrasound, one mentor privately helped us, 17,000 birr. Out of [their] own pocket. And if we have any problem with an operation, we’ll contact with phone. (Hospital 5, IESO)

  -Accessibility

One is the team approach because we are consulting them at night, during the day, on holiday, at any time. If we find any challenge, if we need to contact them, they are ready. Even if they are in a meeting or unable to speak with us, they text us a message. (Hospital 1, IESO)

  -Understanding of local context

We shouldn’t say “You have to do this, you don’t have to do this”, but understand why they do it. Is it because of the lack of knowledge, skills, experience, infrastructure? … So, we were trying to understand their challenges, their gaps, and their reasons for doing things. (Mentor)

  -Interpersonal skills

We trust them. They come, they are open, they are honest, they speak frankly. (Hospital 4, Surgical Team Leader)

 Organizational context

 Receptive implementation climate

In our hospital mentorship is so good. We [leaders] are so eager to be mentored too because we [also] get support from this, and improvement. So, there is good support by hospital management, there is good support and willingness to be mentored by the surgical team. (Hospital 4, Medical Director & Obstetrician/Gynecologist)

Challenges to implementation

 Intervention characteristics

  Insufficient clinical training

OR nurses [should] be trained as OR nurses. Clinical training. Some of them are lacking surgical knowledge. There is no surgery without surgical nurses. (Hospital 2, IESO)

  Inadequate mentor support

Engagement, ownership of mentorship by Regional Health Bureaus, by people in the Ministry that needs to really improve. There is a perception that mentorship is an extracurricular activity provided by senior physicians for free, so this attitude about mentorship has really to change. (Key Stakeholder)

 Organizational context

 Challenging implementation context

Training is not enough. There are also some supplies which [are not available]. There are many interruptions due to many problems. They are aiming to increase surgical volume, but they have a single anesthetist, which sometimes gets sick and can't work. (Hospital 4, Surgical Team leader)

 Lack of clear understanding of the intervention

The mentees expect a lot of things from us. We cannot say that we met their needs. There are a lot of things, equipment, even their engagement in higher education, even in referral hospitals. Because of the financial constraints here, we cannot access these things. (Mentor)

Perceived impact of mentorship program

 Safer and more frequent provision of surgical care

The checklist was not filled before, and now they fill it after the mentorship, and surgical site infections – they did not have a uniform way of registering it. It was haphazard but now they have registers in the wards for the surgical site infections. (Hospital 4, Nurse)

 Establishment of collegial bonds between mentees and mentors

If they have challenge, or problem in the OR theatre, they call, and they [mentors] will solve their problems. I remember one very complicated surgery, so they called Dr. [name], a known gynaecologist from [site]. So, we were calling [them and they were] guiding us by phone. They were directing us. (Hospital 1, Medical Officer)

 Empowered mentees

Previously [the mentees] tended to externalize things, “So because we don’t have this, we don’t have this, and we don’t have this”, – something like that. So, by visiting them frequently and giving them their presentations, they realize that the majority of the things can be done within their sphere. So, I think that’s the impact we found out. They realize that they can solve by themselves, and most of the things can be done by simple interventions by themselves. (Mentor)

 Inculcation of a culture of continuous learning

A surgical site infection was not considered as a problem before—just patients are treated for surgical site infection but there was not any reason to describe how the infection was happening. But currently, we discuss if a patient post operatively will have a surgical site infection, just what is the reason. Is it from the surgeon? From the sterility technique? From the patient themselves? Or from the OR materials? We are discussing so we are saving patients from dying by infection or by sepsis. (Hospital 5, Surgical Team Leader)​