In today's post-COVID-19 world, the impact of the pandemic on global healthcare systems has resulted in them operating under substantial pressure, and this is expected to continue for the foreseeable future (Page et al, 2023). This inevitably impacts on the prioritisation of resources, which include health professionals.
International health partnerships are reliant on health professionals sharing and exchanging knowledge and expertise either virtually or through in-country visits. However, in the current climate, health professionals may feel they are already overstretched, and therefore finding the time to commit to working with an international project may be difficult. In consequence, virtual projects and activities may offer a solution. This is increasingly possible because the COVID-19 pandemic led to rapid transition to, and acceptance of, virtual activities for partnerships (Tropical Health and Education Trust (THET), 2021; 2023).
A virtual partnership
Birmingham City University's health partnership with emergency, trauma and critical care nurses in Zambia is no exception and we have had several successful virtual volunteering projects. We have recently commenced a new partnership project on virtual mentorship. In preparation for the project, the partnership team reviewed the published literature to check if our approach was appropriate and based on current evidence. In previous projects, activities have been co-ordinated using a ‘hub-and-spoke’ model, in which the university acted as the hub. The spokes of the model are made up of emergency, trauma and critical care nurses working in acute NHS hospitals who provide their Zambian peers with virtual and in-country expertise, as requested. This provides a forum through which nurses can volunteer on different levels, both virtually and/or in-country. Also, with hospitals under pressure, this model of volunteering maximises effectiveness by increasing the pool of volunteers available and also increases opportunities for nurses who may not be able to travel overseas.
This approach has been described as good practice (THET, 2023), it has enabled a team of internationally based volunteers who have been able to continuously offer support both in-country and through virtual activities.
Examples of previous virtual projects have included the delivery of regular virtual lectures for students on post-basic emergency, trauma and critical care nursing courses and masterclasses for nurse lecturers. During our recent Nursing Now Challenge Fellowship project, we were able to create a virtual community of practice. International mentors worked with local mentors to support emerging leaders, as they completed their quality improvement projects in emergency, trauma, critical care, and operating theatre nursing in five hospitals in Zambia (Notter et al, 2022).
Benefits and limitations
The benefits of virtual partnerships include reduced costs spent on national and international travel. Making fewer international flights also reduces the environmental impact and increases the opportunities to engage more participants across a wider geographical area. However, there are several limitations, including the cost of using the internet and problems with access to laptops. In addition, evidence has shown that nurses may have limited digital e-health literacy, which may be a barrier to engaging in virtual activities (Shiferaw et al, 2020).
Although the perception may be that this is only an issue for nurses in low-income countries (LIC), it is also an identified challenge for nurses in high income countries (HIC) (Booth et al, 2021). Another key issue identified in our research, which fits with Lin et al's (2023) findings, is that productive partnerships who only use remote collaborations are less likely to integrate knowledge and generate new ideas, despite the advantages of digital technology. Therefore, taking a blended approach to activities subsumes the benefits of each individual approach.
Our new project is totally virtual from the UK side. Recognising the importance of face-to-face opportunities, a learning summit on completion of the project has been included. This event will provide an opportunity for mentees to meet and discuss what they have learnt and how they will take this back to their respective organisations throughout Zambia.
An equal relationship
Mentoring is globally accepted as an important approach to developing nursing practice and careers (Kulik and Nguyen, 2017). The term mentorship has different meanings and is often used interchangeably with other terms such as coaching (Manzi et al, 2017). This confusion has been referred to by Setati and Nkosi (2017) as a ‘mentoring chameleon’ due to the different roles mentors and mentees undertake. It is important to note that mentorship definitions often focus on a relationship between a novice and an expert (Bain et al, 2013; Kulik and Nguyen, 2017). However, we dispute this viewpoint and tried to find a term that accepted the expertise of all parties and have adopted the Intensive Care Society (2020) term ‘peer support’. This recognises that everyone's views and experiences are equal, rather than one person being seen more as an expert than others. This fits with the partnership ethos that all project activities need to address any potential power imbalances, which may affect bi-directional learning between Zambian and UK participants (Plamondon et al, 2021).
The importance of mentorship for nurse leaders has been recognised for over a century, from the early days of Florence Nightingale to the development of ‘restorative supervision’ as an alternative system to use in today's ever-changing NHS and other healthcare systems (Lorentzon and Brown, 2003; Wallbank, 2013; Carter, 2022). However, for nurses in LICs, as Hamid and Rasheed (2022) pointed out, there is very little discussion and evidence on mentorship to develop future leaders.
Therefore, in response to this, the approach taken in the new project is designed to start to address the imbalance, as only that way can specialist critical care nurse leaders develop the leadership and management skills and expertise to successfully lead nursing in their country through the 21st century. Our partnership has a strong track record in supporting emergency, trauma, and critical care nursing, and recognises the need for leadership development of senior critical care nurses. Therefore, this new project will focus on mentoring critical care nurse leaders in five provinces in Zambia. The partnership chose this group of nurses because, due to the critical shortage of critical care nurses, they often work in isolation and have few opportunities for development.
Mentorship is a complex relationship between mentors, mentees, and external factors such as donor and funding requirements, organisational and cultural challenges. However, for this project it is important that all participants, regardless of whether they are a mentee or mentor, are seen as equal professionals. This challenges the traditional power imbalance between HIC and LIC, as well as mentor and mentees. We recognise the importance of matching mentees and mentors, a two-way process that enables mentees and mentors to consider whether the suggested match is appropriate (Hamid and Rasheed, 2022). This approach is based on the principles of bi-directional learning and our previous projects have shown that all participants report increased knowledge and understanding of each other's roles. This leads to each individual reflecting on their own roles, identifying similarities and differences with their peers.
An international team has co-designed and co-created partnership training packages and activities for our new virtual mentorship programme. This has allowed for a ‘train the trainer’ element to be included in the project, which will enable the current participants to develop the skills to become mentors/peer supporters themselves. Therefore, this project provides a unique opportunity to initiate training that will be owned by participants and cascaded to others, thereby sustaining the principles of mentorship for critical care nurses. This aligns to strategic priorities to strengthen nurse leadership and the work in progress by the Critical Care Nurses Association of Zambia (CCNAZ) to raise the profile of critical care nurses in Zambia.
A focus on leadership
The authors' review of the literature has confirmed the approach of focusing on leaders is appropriate, as is the need to challenge the terminology used to provide a more balanced and equitable approach. We also recognise that international health partnerships are heterogeneous and a ‘one size fits all’ approach may not be appropriate. We are fortunate that we are an established partnership, which has consistently worked to facilitate activities that enable both sides of the partnership to grow together and understand similarities and differences in nurse education and practice. However, as Kulik and Nguyen (2017) argued, whatever we chose to call it, at its core, mentoring is about acknowledging that there is someone who cares and is willing to share. This is an important concept that, in today's current healthcare challenges, has increasing importance and must not be lost.