“Helping me, helping others, helping the nation”: Using the Consolidated Framework for Implementation Research to qualitatively assess a midwifery preceptor program in Sierra Leone

“Helping me, helping others, helping the nation”: Using the Consolidated Framework for Implementation Research to qualitatively assess a midwifery preceptor program in Sierra Leone | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “Helping me, helping others, helping the nation”: Using the Consolidated Framework for Implementation Research to qualitatively assess a midwifery preceptor program in Sierra Leone Nicholas Raposo, Olivia Yang, Alice Konyani, Chrisencia Owoko, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6320975/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Sierra Leone has the world’s third highest incidence of maternal mortality, with 443 deaths per 100,00 live births. With fewer than 500 midwives serving less than 15% of the nation’s population, strengthening the midwifery workforce is essential to reducing preventable perinatal mortality. In support of this goal, we implemented a novel midwifery preceptor program (MPP) to train experienced midwives to effectively mentor new and student midwives. This study applied the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to implementation of the MPP. Methods: Preceptors, facilitators, and academic and hospital leaders participated in individual virtual interviews. Using deductive content analysis, 26 interviews were coded according to constructs within the five CFIR domains: innovation, outer setting, inner setting, individuals, and process. Barriers and facilitators to MPP implementation were analyzed per domain. Results: Participants identified MPP strengths and opportunities across all five CFIR domains. They described the program as a comprehensive integration of theory and practice that was well-designed and effectively delivered. Facilitator support and stakeholder collaboration were key to successful implementation. Challenges included limited resources and time constraints, which made it difficult for some to balance professional responsibilities with program activities. Nonetheless, participants advocated for formalizing the MPP to sustain the program’s impact. Discussion: The findings indicate that the MPP is a valuable innovation for enhancing midwifery education and improving perinatal health in Sierra Leone. Participants expressed support for the MPP and were eager to expand it across and beyond Sierra Leone. In addition to enhancing future iterations of the MPP, addressing barriers and leveraging facilitators to program implementation are essential for scaling the MPP up and out. midwifery midwifery education preceptorship maternal health services health workforce capacity building qualitative research implementation science Sierra Leone Introduction Sierra Leone has one of the poorest maternal health indicators globally, with a maternal mortality rate of 443/100,000 live births. 1 Strengthening midwifery care, which can substantially reduce perinatal mortality in low- and medium-income countries, is integral to addressing high rates of preventable maternal mortality in Sierra Leone. 1,2 The government of Sierra Leone projects it needs 3,000 midwives to provide minimally adequate maternal health care services; however, the country has fewer than 500 midwives who collectively serve less than 15% of the population. 3 To address this critical workforce shortage, the national government and midwifery schools in Makeni and Bo have collaborated since 2010 to increase enrollment of midwifery students in Sierra Leone. 4 In addition to increasing the quantity of midwives, improving maternal health in Sierra Leone depends upon high-quality midwifery care aligned with the skills and competencies recommended by the International Confederation of Midwives. 2 According to educational standards set by the Nurses and Midwives Council of Sierra Leone, a novice student develops into a professional midwife through exposure to an academic program that consists of 40% theory and 60% clinical competence-building. 5 To produce a competent midwifery workforce that meets national and international standards, an effective clinical teaching program is vital. 5 In response to this need, Seed Global Health (Seed) developed a novel four step midwifery preceptor program (MPP) to facilitate the transfer of competencies for quality midwifery care. 6 In collaboration with the two schools of midwifery, Seed implemented the program in the Makeni and Bo districts of Sierra Leone. To understand barriers and facilitators to program implementation, we conducted qualitative interviews with individuals who participated in, facilitated, or were highly engaged with the first year of the program. Methods Setting Seed, a non-profit organization that supports healthcare workforce training in resource-limited countries, has been working to strengthen midwifery education in Sierra Leone since 2021. 7 Seed piloted the MPP at Makeni Regional Hospital and Bo Government Hospital. Makeni Regional Hospital is the referral hospital for the five Northern Districts of Sierra Leone and the primary training site for midwifery students from the School of Midwifery Makeni. Bo Government Hospital is the regional hospital in the Southern Province, where another school of midwifery is located. Both schools offer direct-entry diploma programs, as well as certificate programs for nurses seeking midwifery training. Students train at these regional hospitals, as well as other public health units and community health clinics. However, a lack of adequate and effective clinical supervision in the hospitals has negatively affected students’ skill acquisition. Program Design and Implementation Preceptorship is a globally accepted and common approach to achieving clinical competency. Seed developed the MPP as a one-year, low-dose, high-frequency program to train experienced midwives to instruct, advise, mentor, assess, and orient new and student midwives in peripartum care. Twenty preceptors – 10 each from Makeni and Bo – were selected following an application and interview process. The program included an opening retreat, 12 weeks of intensive skills- and team-building, 12 weeks of preceptor training in the clinical setting, and 7 weeks of supervised preceptorship. Pre- and post-program assessments measured changes in competence and confidence in clinical and teaching skills. Consolidated Framework for Implementation Research The Consolidated Framework for Implementation Research (CFIR) 2.0 guided our interviews, deductive content analysis, and systematic assessment of MPP implementation. 8 The framework comprises five domains: innovation, outer setting, inner setting, individuals, and process. Additionally, we followed the Standards for Reporting Qualitative Research. 9 Participants We invited all preceptors (n = 20), facilitators (n = 5), and stakeholders (n = 15) for in-depth individual interviews. Twenty-six individuals – 18 preceptors and eight facilitators and stakeholders – completed interviews (Table 1 ). Participants were compensated for their time. Table 1 Participant characteristics Characteristic n (%) or mean (SD) Age Preceptors (n = 18) 43.5 (7.0) Facilitators and stakeholders (n = 8) 41.6 (5.7) Sex (female) 28 (100) Occupation Seed educator 5 (19.2) Seed employee 2 (7.7) Midwife 6 (23.1) Midwife-in-charge (labor ward, triage, maternity theatre) 7 (26.9) Midwifery school principal 1 (3.8) Nursing officer 3 (11.5) Ministry of Health (unspecified) 1 (3.8) Post-operative nurse 1 (3.8) Years as a midwife (n = 18) 12.5 (5.8) Midwife with previous experience precepting or teaching Yes 15 (83.3) No 3 (16.7) Data Collection Interviews took place via Zoom between May and June 2024. We created an interview guide (Appendix A) using CFIR domains. We obtained written informed consent prior to audio recording and transcribing the interviews using Zoom functions. Two authors (NR and OY) conducted interviews in English, the official language in Sierra Leone, and lasted 30 to 60 minutes. Each interviewer reviewed and edited their corresponding transcripts for accuracy before uploading to Dedoose for coding. 10 Analysis Transcripts were coded in Dedoose according to the predetermined CFIR codebook. Each of the first 20% of transcripts (n = 5) was coded by two reviewers to ensure intercoder reliability. Reviewers engaged in discussion to ensure codes were used similarly and to achieve consensus regarding discrepancies. In these discussions and as supported by CFIR, one additional domain – future directions – was created to capture an emerging theme in the data. 8 The remaining interviews were independently coded by three authors (NR, OY, BvdW). The team reviewed coded excerpts to determine barriers and facilitators per CFIR domain. Ethics & Reflexivity The Boston College Institutional Review Board (#23.147.01) and Office of Sierra Leone Ethics and Scientific Review Committee (017/02/2023) provided ethical approval. This study involved a diverse research team, including nurses and midwives from the U.S. (NR, OY, JM, BvdW) and Sierra Leone (AK, CO, AD, JRV). Throughout the project, team members carefully considered personal, professional, academic, and sociocultural differences and power imbalances between one another and between researchers and participants. U.S.-based researchers continuously reflected on their positionality, consciously sought to mitigate power differentials, and worked to center the voices of Sierra Leonean authors and participants. Sierra Leonean researchers played a crucial role contextualizing the research, facilitating cross-cultural understanding, and ensuring fidelity to the perspectives of local midwives. Results Interviews with participants revealed strengths of the MPP across all five CFIR domains, as well as opportunities for future development. Tables 2 and 3 summarize illustrative quotes, as well as barriers and facilitators per CFIR domain. Table 2 Illustrative quotes with CFIR domain and construct codes Participant Illustrative quote CFIR domain: Construct Bo Preceptor #1 It's a full package that really instills all the competencies that a learner should have to be able to practice midwifery. Innovation: Evidence-base Facilitator #4 People remember about 5 or 10% of what they're told, but 90% of what they do, so having opportunities for simulation and debrief embedded throughout the entire program, and then mentorship opportunities throughout the workday – I think the combination of those two things in an ongoing way is the best educational opportunity that I think we could design for anyone, especially for clinical skills. Innovation: Design Bo Preceptor #5 The program – it's not easy, you know; one year is not just one month or one week. Every week, sometimes we go twice. They really take the program in detail. We touched every area of midwifery that we think is necessary and worth knowing. We have gaps there; we try to fill those gaps with some new things. Innovation: Complexity Makeni Preceptor #9 That was just my challenge, that balancing. How am I to balance work, balance precepting, or supervising, and going for class?... You have this document that you need to do, you have test tomorrow, you know, it was so stressful. Innovation: Complexity Facilitator #2 The previous programs were focusing on how to teach students but not enhancing the skills of the preceptors. While ours is both: the skills and how to teach. Innovation: Relative advantage Makeni Preceptor #2 This preceptor program has re-molded us. We should know how to talk to our subordinates, how to talk to our students, how to train them if somebody is doing something wrong – the manner in which you should correct them... It has really added leadership qualities to us as preceptors and as nurses. Innovation: Relative Advantage Stakeholder #1 We work through the partners. It’s a partnership program. So the partners that are in the facility, the school, they will come together. Then we decide, what do they want to achieve for the year? What is the problem that you want us to help them solve?... So that's how the program is developed: it’s purely based from the partners’ perspective. Outer setting: Partnerships & connections Makeni Preceptor #4 I'm just hoping that there will be resources.... After you people [Seed], maybe if there is no finance you left, then I'm not sure this country will be able to take up this venture to train preceptors.... I'm not foreseeing that when Seed will leave our country, there will be continuity. I’m not sure, but I am hoping for the better. Outer setting: Financing Makeni Preceptor #5 It should be a diploma program or maybe a degree program for me. Because considering the package – that, you know, it’s intense and every day you have a new topic to cover – considering how it’s covered – practicals, theory in the classroom – it is really, you know, a big – it should... be a diploma. Outer setting: Policies & laws Stakeholder #1 We are really advocating that the Ministry really recognize these people because that's the only way they will be encouraged to continue precepting other midwives, which will definitely have a profound impact on saving the lives of mothers. Outer setting: Policies & laws Bo Preceptor #3 I want to help my people out there. There are people suffering. We need to put hands together to reduce maternal and child mortality and morbidity. Outer setting: Performance-measurement pressure Bo Preceptor #7 This maternal and infant mortality has become a public health emergency in our country. I'm very sure preceptorship will be a key component to help us to reach that – to bridge that gap. Outer setting: Performance-measurement pressure Stakeholder #1 Communication [and] teamwork was a very big challenge. Inner setting: Communications; Relational connections Bo Preceptor #9 We have been practicing this archaic midwifery, and we have been seeing the results of our old practice. Inner setting: Tension for change Bo Preceptor #4 When we had classes here at the hospital, there is no space for us to get these classes... We are eager, we wanted to learn, we wanted these topics to be covered, but then there were no spaces. Inner setting: Space Facilitator #4 Gloves were often missing. You can't practice a skill if you can't touch a patient because you don't have gloves or you don't have a way to properly sanitize because you just don't have soap... There were days when we didn't have oxytocin available... or we didn't have needles or syringes available... How can you suture, you know, if you don't have suture kits? Inner setting: Materials & equipment Stakeholder #2 The hospital, the medical superintendent, the matron, the heads of the unit, they are very supportive... We are the educators doing the training and they are giving back up. Inner setting: Mission alignment Makeni Preceptor #7 The program was really valued to the hospital because it helps to mold staffs... They [preceptors] serve as a model; they lead and others follow. You don't take blame, you don't cast blame. That's what the preceptorship taught us... You have a way to reframe it, which was well accepted by the hospital. You can say ‘Where do you think you did well? And where do you think you need improvements? Can we discuss on this? Inner setting: Learner-centeredness Makeni Preceptor #6 I'm a woman, and I'm in my reproductive age, so in Sierra Leone, as long as you are within your reproductive age... you are at risk of dying whilst giving birth. So... to be competent and feel confident to reduce – to prevent – more women from dying from maternal death, and also being competent enough to teach others, that one was a very big incentive for all of us. Individuals: Motivation Bo Preceptor #1 Some of us really had passion for professional and even the teaching skills. If you have this goal, or this new title that you are a preceptor, you have more respect. Before this time, we are just midwives... But because of the title – preceptors – and we are the ones teaching, I think we had more respect, people listen to us. Individuals: Opinion leaders Bo Preceptor #6 When the preceptor program starts, I was angry because when they call for classes, at that time, I have my children to attend to, going for school…So at first, I was really… confused if I will able to continue with this preceptorship program. Individuals: Opportunity Makeni Preceptor #3 It [the program] has empowered me. It has helped me to build self-confidence… I have a strong inner feeling that I can do it... Now, as a midwife who has been empowered with tremendous knowledge, I can make plans, I can make decisions for a patient, then the outcome will be positive. Individuals: Motivation Makeni Preceptor #6 Students have been coming. As me being in-charge, I will sign for them, I will just ask them questions. But now [after the program] I have a different sense that I need to teach them. And I need to know what’s their objective of being posted to my unit. What are they supposed to cover? I need to assign them to roles. I need to debrief with them. I need to mentor them. I need to have time for them. Individuals: Innovation recipients Bo Preceptor #6 Each time we call on [the facilitators], they will respond. They will answer us. They will teach us. Anytime; day, night, whenever we call them; both practical and theory; they are ready for us. Individuals: Implementation facilitators Bo Preceptor #9 [Facilitators] are like parents to us; they guide us... [and] are with us whenever... [we] call them. Individuals: Implementation facilitators Makeni Preceptor #9 [The facilitator] was teaching us with respect and love. Individuals: Implementation facilitators Facilitator #2 When I just arrived at the hospital, you could see that the students were not being supported properly… [Now] the students will be put with the preceptors. As a result, they will meet their learning objectives, they will be able to achieve their competencies, and I feel – with the transition of the preceptors – our students will be far much better than the previous groups. Individuals: Need Bo Preceptor #1 [The] matron or the medical superintendent, they are very, very supportive. They give us the classroom or hall. And even the in-charges of the other units, when we go to the various units to precept our students, they are really supportive... So the leadership, they are very, very much supportive. Individuals: Mid-level leaders Makeni Preceptor #6 The CNMO [Chief Nursing and Midwifery Officer of Sierra Leone] attends the meetings and sees the presentations we make and what we are doing practically. Individuals: High-level leaders Facilitator #3 To gain that acceptance was the crucial point. So gaining that acceptance from the Ministry of Health side and bringing down the project to the school side – so the huge acceptance for the program to begin was, I mean, a huge success for its implementation. Process: Teaming Stakeholder #2 One of the huge barriers of the implementation of this preceptorship program is the fact that the [school] faculty staff are left behind. Yeah, they are not included in any of the implementation... If we are talking about sustainability, then we need to include the faculty who are training these midwives. We need to involve them fully. Process: Engaging Facilitator #3 As an implementer – educator implementing this program – we didn't have the support; like an orientation for us to know what we are supposed to do. So it was more like you understanding it on your own and delivering it. There wasn't that orientation for us. We were just given the documents. And then you go to the document, and you deliver it as you understand it. Process: Reflecting & evaluating implementation Makeni Preceptor #9 Being in this preceptorship program taught me that it's not just about knowledge, but it's about behavior... The preceptorship has taught me to be empathized with you... Not only for your patients, even for the people that you're working with, you need to listen to them; you need to see them and talk to them. Don't work in isolation. At first, I just took decisions as an in-charge. I don’t communicate. I don’t want to know what you feel... Now... anytime I want to take any decision or I want to implement anything, we'll sit together and talk... So it has really helped me to bond with my subordinates and empathize with them. Process: Reflecting & evaluating innovation Stakeholder #4 Yes, it's successful, because we are seeing the outcomes before even the completion of the program... The Seed educators assign [our] students to the preceptors and they're seeing what they have been doing. What they are teaching them is what they are applying, so it’s a success. Process: Reflecting & evaluating innovation Makeni Preceptor #2 Some people are already asking, 'When is the next cohort going to start? When is the next cohort going to start?’ So most of the midwives at the maternity units want to be preceptors as well. They want to be trained. They want to learn new things. They also want to start teaching these students that come for clinical placement. So, to me, I think it's a positive impact. Process: Engaging innovation recipients Makeni Preceptor #4 There are other hospitals that I think are still struggling with the skills and knowledge... so by the time they send patient to our hospital, it’s late. It’s [too] late for us to intervene. Future directions Makeni Preceptor #7 I want this program to be a continuous program because this program can help; it can help reduce maternal mortality rates in Sierra Leone, and not only the reduction of maternal mortality rate; the program can help mold the attitude of staffs, change their negative attitude to positive attitude. It can also help the health sector to understand quality care for patients, clients, and relatives, including other walks of life. Future directions Makeni Preceptor #6 [The Nursing Council and the Chief Nursing and Midwifery Officer of Sierra Leone] said, ‘No, this is good! So we need to adopt this, we need to cascade it to other institutions. It should not only stop at Makeni Regional Hospital and Bo Government Hospital. We need to expand. We need to own it, as a country, we need to borrow the curriculum, and we need to cascade. Future directions Bo Preceptor #5 If this program continues, it will benefit both the students, the patient, and even the colleagues or staff and to make the positive impact. Yes. So, we think this program is very necessary and we hope it will continue to be sustaining so other people can come on board. Future directions Facilitator #1 If those that are involved in decision-making know the impact and they're worked through how the program is and what is expected at the end of it, 99.99% [it] will be replicated. Any place. Future directions Table 3 Barriers and facilitators to MPP implementation per CFIR domain CFIR Domain Barriers Facilitators Innovation • Complexity, stress, and time commitment of MPP • Balancing MPP activities with other responsibilities • Comprehensive, structured, intuitive design • Low-dose, high-frequency learning and application Outer setting • Concerns regarding viability of MPP beyond Seed • Need for support, resources, and funding to sustain MPP • Strong partnerships between Seed, national government, schools, and hospitals • Shared goal of improving national perinatal health Inner setting • Limited space, materials, and infrastructure to properly conduct MPP • Alignment with hospital mission and values • Support from hospital leaders and peers • Tension for change in practice and unit culture Individuals • MPP demands time and dedication • Highly motivated preceptors • Supportive facilitators • Preceptors felt empowered with improved knowledge, skills, and attitudes • Preceptors felt highly esteemed by peers Process • Insufficient collaborations with school faculty • Inadequate support for facilitators • Strong teaming among most stakeholders • Adaptability of MPP Innovation Domain: “A whole package; simple but comprehensive” According to participants, the MPP was a novel and necessary innovation for midwifery clinical education. The blend of in-depth learning, skill building, and continuous mentorship seemed an intuitive approach to participants. Although some described the program as stressful, serious, or complex, participants felt well supported by program facilitators, who delivered the program in a way that was thoughtful and easy to follow. “It's a full package that really instills all the competencies that a learner should have to be able to practice midwifery.” (Bo Preceptor #1) “People remember about 5 or 10% of what they're told, but 90% of what they do, so having opportunities for simulation and debrief embedded throughout the entire program, and then mentorship opportunities throughout the workday – I think the combination of those two things in an ongoing way is the best educational opportunity that I think we could design for anyone, especially for clinical skills.” (Facilitator #4) Participants noted that the MPP was challenging but worthwhile. To minimize participant burden, the program was designed to be delivered in the hospitals where the midwives worked; however, several participants reported difficulties balancing class attendance or activities with patient care responsibilities. Additionally, some participants said the yearlong commitment was a significant demand on their time and emphasized the motivation necessary to see the program through to completion. “The program – it's not easy, you know; one year is not just one month or one week. Every week, sometimes we go twice. They really take the program in detail. We touched every area of midwifery that we think is necessary and worth knowing. We have gaps there; we try to fill those gaps with some new things.” (Bo Preceptor #5) “That was just my challenge, that balancing. How am I to balance work, balance precepting, or supervising, and going for class?... You have this document that you need to do, you have test tomorrow, you know, it was so stressful.” (Makeni Preceptor #9) Despite its challenges, the MPP was much more comprehensive than prior training models, which were often shorter in duration and narrower in scope. As a prerequisite to effective student teaching, facilitators helped midwives to recognize weaknesses in their own practice and offered a comprehensive, standards-based program to improve clinical mastery. Owing to the program’s rigor and timespan, participants felt empowered with the knowledge, skills, and attitudes necessary to precept effectively. “The previous programs were focusing on how to teach students but not enhancing the skills of the preceptors. While ours is both: the skills and how to teach.” (Facilitator #2) “This preceptor program has re-molded us. We should know how to talk to our subordinates, how to talk to our students, how to train them if somebody is doing something wrong – the manner in which you should correct them... It has really added leadership qualities to us as preceptors and as nurses.” (Makeni Preceptor #2) Outer Setting Domain: “Hands together to reduce maternal and child mortality” Participants identified several external environmental factors that impacted implementation of the MPP. Key among these were effective collaborations between Seed, the national government, the midwifery schools, and the regional hospitals. “We work through the partners. It’s a partnership program. So the partners that are in the facility, the school, they will come together. Then we decide, what do they want to achieve for the year? What is the problem that you want us to help them solve?... So that's how the program is developed: it’s purely based from the partners’ perspective.” (Stakeholder #1) Given Seed’s leading role in orchestrating key partnerships and leading the initiative, some participants voiced concern about the program’s viability in the absence of a partner like Seed. Specifically, they questioned who would oversee the program, and who would provide funding to sustain and scale the program after Seed. “I'm just hoping that there will be resources.... After you people [Seed], maybe if there is no finance you left, then I'm not sure this country will be able to take up this venture to train preceptors.... I'm not foreseeing that when Seed will leave our country, there will be continuity. I’m not sure, but I am hoping for the better.” (Makeni Preceptor #4) In response to this concern, many participants suggested the national government adopt the MPP. Some believed that formalizing the program via a national diploma or distinct career pathway would attract the interest of more midwives and help to cascade the program to other parts of the country. Others envisioned revising the scope of practice for nurses and midwives to explicate the unique role and responsibilities of the preceptor. “It should be a diploma program or maybe a degree program for me. Because considering the package – that, you know, it’s intense and every day you have a new topic to cover – considering how it’s covered – practicals, theory in the classroom – it is really, you know, a big – it should... be a diploma.” (Makeni Preceptor #5) “We are really advocating that the Ministry really recognize these people because that's the only way they will be encouraged to continue precepting other midwives, which will definitely have a profound impact on saving the lives of mothers.” (Stakeholder #1) Most participants were motivated to enroll in the MPP by a desire to improve perinatal health in Sierra Leone. Encouraged by anecdotal evidence of the program’s effectiveness in improving these outcomes, many were eager to sustain and scale the program to other parts of the country. “I want to help my people out there. There are people suffering. We need to put hands together to reduce maternal and child mortality and morbidity.” (Bo Preceptor #3) “This maternal and infant mortality has become a public health emergency in our country. I'm very sure preceptorship will be a key component to help us to reach that – to bridge that gap.” (Bo Preceptor #7) Inner Setting Domain: “We fight with everything we have: teamwork, passion, resources" Interviewees recalled characteristics of the inner setting that warranted implementation of the MPP, including negative workplace dynamics and outdated practices. One participant specified that “communication [and] teamwork was a very big challenge” (Stakeholder #1), while another said that “we have been practicing this archaic midwifery, and we have been seeing the results of our old practice” (Bo Preceptor #9). However, implementation of the MPP was constrained by a lack of space for preceptorship activities, insufficient material resources, and limited work infrastructure. “When we had classes here at the hospital, there is no space for us to get these classes... We are eager, we wanted to learn, we wanted these topics to be covered, but then there were no spaces.” (Bo Preceptor #4) “Gloves were often missing. You can't practice a skill if you can't touch a patient because you don't have gloves or you don't have a way to properly sanitize because you just don't have soap... There were days when we didn't have oxytocin available... or we didn't have needles or syringes available... How can you suture, you know, if you don't have suture kits?” (Facilitator #4) Nonetheless, other aspects of the inner setting facilitated implementation. According to several participants, the MPP aligned well with the broader mission and values of the hospital. They found that hospital administrators, supervisors, and peers were equally invested in improving unit culture and practice. As one shared, “The medical superintendent, the matron, the heads of the unit, they are very supportive... we are the educators doing the training and they are giving back up” (Stakeholder #2). Ultimately, participants felt that the program created a positive culture of learning, reflection, communication, and teamwork. “The program was really valued to the hospital because it helps to mold staffs... They [preceptors] serve as a model; they lead and others follow. You don't take blame, you don't cast blame. That's what the preceptorship taught us... You have a way to reframe it, which was well accepted by the hospital. You can say ‘Where do you think you did well? And where do you think you need improvements? Can we discuss on this?’” (Makeni Preceptor #7) Individuals Domain: “They are ready for us” Various stakeholders contributed to and benefited from implementation of the MPP. Participants were foremost among them. As previously mentioned, many saw the program as a contribution to improving perinatal health nationally. The opportunity for professional growth was also a primary motivation for joining the MPP. “I'm a woman, and I'm in my reproductive age, so in Sierra Leone, as long as you are within your reproductive age... you are at risk of dying whilst giving birth. So... to be competent and feel confident to reduce – to prevent – more women from dying from maternal death, and also being competent enough to teach others, that one was a very big incentive for all of us.” (Makeni Preceptor #6) “Some of us really had passion for professional and even the teaching skills. If you have this goal, or this new title that you are a preceptor, you have more respect. Before this time, we are just midwives... But because of the title – preceptors – and we are the ones teaching, I think we had more respect, people listen to us” (Bo Preceptor #1). However, participation in the program was not without its challenges. The program was time-consuming, and some participants struggled to balance their professional and personal commitments. One preceptor stated: “When the preceptor program starts, I was angry because when they call for classes, at that time, I have my children to attend to, going for school… so at first, I was really… confused if I will able to continue with this preceptorship program” (Bo Preceptor #6). Nonetheless, participants felt that the program empowered them with knowledge, confidence, and agency, transforming their approach to patient care and student mentorship. “It [the program] has empowered me. It has helped me to build self-confidence… I have a strong inner feeling that I can do it... Now, as a midwife who has been empowered with tremendous knowledge, I can make plans, I can make decisions for a patient, then the outcome will be positive.” (Makeni Preceptor #3) “Students have been coming. As me being in-charge, I will sign for them, I will just ask them questions. But now [after the program] I have a different sense that I need to teach them. And I need to know what’s their objective of being posted to my unit. What are they supposed to cover? I need to assign them to roles. I need to debrief with them. I need to mentor them. I need to have time for them.” (Makeni Preceptor #6) Many participants attributed the program’s success to its facilitators, who were described as knowledgeable, approachable, and always available for guidance, and who nurtured an enabling learning environment. “Each time we call on [the facilitators], they will respond. They will answer us. They will teach us. Anytime; day, night, whenever we call them; both practical and theory; they are ready for us.” (Bo Preceptor #6) “[Facilitators] are like parents to us; they guide us... [and] are with us whenever... [we] call them.” (Bo Preceptor #9) “[The facilitator] was teaching us with respect and love.” (Makeni Preceptor #9). Facilitators, for their part, believed that successful implementation was the result of mutual commitment from both facilitators and participants. In addition to supporting participants, facilitators played a pivotal role promoting the importance and value of the program for midwifery education. “When I just arrived at the hospital, you could see that the students were not being supported properly… [Now] the students will be put with the preceptors. As a result, they will meet their learning objectives, they will be able to achieve their competencies, and I feel – with the transition of the preceptors – our students will be far much better than the previous groups.” (Facilitator #2). Those interviewed also perceived dedicated support from other influential stakeholders. “The matron or the medical superintendent, they are very, very supportive. They give us the classroom or hall. And even the in-charges of the other units, when we go to the various units to precept our students, they are really supportive... So the leadership, they are very, very much supportive” (Bo Preceptor #1). “The CNMO [Chief Nursing and Midwifery Officer of Sierra Leone] attends the meetings and sees the presentations we make and what we are doing practically” (Makeni Preceptor #6). The collective efforts and commitment of all these individuals were instrumental in shaping the process and outcomes of program implementation. Process Domain: “People are already asking, 'When is the next cohort going to start?’” Prior to implementation, Seed collaborated with hospital, school, and government stakeholders to ensure the MPP aligned with their needs and goals and, in turn, to secure their buy-in to the program. As a result of this teaming, hospital leaders welcomed the MPP and supported preceptors in balancing class attendance with clinical duties. “To gain that acceptance was the crucial point. So gaining that acceptance from the Ministry of Health side and bringing down the project to the school side – so the huge acceptance for the program to begin was, I mean, a huge success for its implementation.” (Facilitator #3) However, some felt that better collaboration – with school faculty, in particular – could have benefited implementation and would be necessary to sustain the program. “One of the huge barriers of the implementation of this preceptorship program is the fact that the [school] faculty staff are left behind. Yeah, they are not included in any of the implementation... If we are talking about sustainability, then we need to include the faculty who are training these midwives. We need to involve them fully.” (Stakeholder #2) Several facilitators appreciated the adaptability of the program, which allowed them to tailor lesson plans and timelines based on participants' needs and abilities, or available resources. For example, one facilitator dedicated extra time to practicing fundamental peripartum skills. Others, however, expressed a desire for more structure and support to better prepare for and deliver the program. “As an implementer – educator implementing this program – we didn't have the support; like an orientation for us to know what we are supposed to do. So it was more like you understanding it on your own and delivering it. There wasn't that orientation for us. We were just given the documents. And then you go to the document, and you deliver it as you understand it.” (Facilitator #3) Reflecting on the success of implementation and innovation, preceptors highlighted positive changes in their clinical skills, patient care, and ability to mentor students and colleagues. Despite role conflicts previously discussed, integrating the MPP with midwifery practice was ultimately beneficial; it allowed preceptors to immediately apply new skills and reflect on challenges they encountered in the clinical setting. Reflecting on the process, many were excited by the opportunity for growth and felt the program was a worthwhile investment of their time and energy. “Being in this preceptorship program taught me that it's not just about knowledge, but it's about behavior... The preceptorship has taught me to be empathized with you... Not only for your patients, even for the people that you're working with, you need to listen to them; you need to see them and talk to them. Don't work in isolation. At first, I just took decisions as an in-charge. I don’t communicate. I don’t want to know what you feel... Now... anytime I want to take any decision or I want to implement anything, we'll sit together and talk... So it has really helped me to bond with my subordinates and empathize with them.” (Makeni Preceptor #9) “Yes, it's successful, because we are seeing the outcomes before even the completion of the program... The Seed educators assign [our] students to the preceptors and they're seeing what they have been doing. What they are teaching them is what they are applying, so it’s a success” (Stakeholder #4) “Some people are already asking, 'When is the next cohort going to start? When is the next cohort going to start?’ So most of the midwives at the maternity units want to be preceptors as well. They want to be trained. They want to learn new things. They also want to start teaching these students that come for clinical placement. So, to me, I think it's a positive impact.” (Makeni Preceptor #2) Future Directions Domain: “Let it cascade” Building on the successful implementation of the MPP in Makeni and Bo, participants advocated for expanding it nationally and internationally. Highlighting an urgent need to scale the program, one participant noted, “There are other hospitals that I think are still struggling with the skills and knowledge... so by the time they send patient to our hospital, it’s late. It’s [too] late for us to intervene.” (Makeni Preceptor #4) Several recommendations were made to enhance future iterations of the program. One participant recommended refresher training to maintain connections among cohorts and ensure the most up-to-date practices. Another suggested that reducing the frequency of meetings from weekly to monthly could improve sustainability and ease replication of the program. Overall, participants felt the intervention was highly adaptable and, with appropriate support and contextual adjustments, could be replicated in various settings. They also highlighted the multifaceted impact of the intervention, noting its direct influence on preceptors as well as the broader, indirect benefits for colleagues, students, and patients. “If this program continues, it will benefit both the students, the patient, and even the colleagues or staff and to make the positive impact. Yes. So, we think this program is very necessary and we hope it will continue to be sustaining so other people can come on board.” (Bo Preceptor #5) “If those that are involved in decision-making know the impact and they're worked through how the program is and what is expected at the end of it, 99.99% [it] will be replicated. Any place.” (Facilitator #1) Cascading the program would ensure its sustainability, with each cohort of preceptors training the next, thus exponentially increasing the number of preceptors, students, and patients who could benefit from the program’s impact. “I want this program to be a continuous program because this program can help; it can help reduce maternal mortality rates in Sierra Leone, and not only the reduction of maternal mortality rate; the program can help mold the attitude of staffs, change their negative attitude to positive attitude. It can also help the health sector to understand quality care for patients, clients, and relatives, including other walks of life.” (Makeni Preceptor #7) “[The Nursing Council and the Chief Nursing and Midwifery Officer of Sierra Leone] said, ‘No, this is good! So we need to adopt this, we need to cascade it to other institutions. It should not only stop at Makeni Regional Hospital and Bo Government Hospital. We need to expand. We need to own it, as a country, we need to borrow the curriculum, and we need to cascade.’” (Makeni Preceptor #6) Discussion Preceptors, facilitators, and stakeholders described the MPP as a comprehensive innovation that equipped participants with knowledge, skills, and attitudes to become effective midwifery preceptors. Participants discussed the influence of partnerships and connections, financing, policies and laws, and performance measurement pressures on implementation, sustainment, and scaling of the program. While the need for the program was evident in each setting, the people and resources within these settings were key to the program’s success. The support of leadership, the time and dedication of facilitators, and the commitment from preceptors were also critical to intervention fidelity and created a positive culture specific to the MPP. Despite the demands of the program, participants deemed it rigorous and worthwhile for professional development. Moving forward, most participants wanted to maintain the MPP in these facilities and expand the program across and beyond Sierra Leone. Barriers to Implementation One of the primary barriers to MPP implementation cited by interviewees related to the duration and scope of the program. Unlike prior professional development programs, which were brief and had little sustained follow-up, the MPP was higher-frequency and longer lasting, which demanded significant commitment from all parties. However, serial, targeted interventions combined with mentorship or supportive supervision have been shown to improve knowledge, clinical performance, skill retention, and health outcomes more effectively than isolated interventions delivered via traditional training approaches. 11 – 15 Competing professional and program demands were another salient barrier. As with the MPP, implementation of a midwifery educational program in Kenya was challenged by staffing shortages, heavy workloads, work infrastructure gaps, and inadequate clinical support. 16 A scoping review of nursing preceptorship programs across sub-Saharan Africa identified time constraints and conflicting priorities as primary barriers to implementation of programs in Namibia, Botswana, and Ghana. 17 Both articles highlighted the need for resources and policy directives to support high-quality education and professional development. Several participants raised concerns about the viability of the MPP without Seed and many believed that long-term sustainability would require local and national partners to take ownership of the program. Suggestions included embedding the MPP in the schools of midwifery and working with the Ministry of Health to develop the MPP into a national diploma program. One model for these efforts is the Nurse Education Partnership Initiative, a capacity-building program that was formally adopted by the Malawi Nurses and Midwives Council after garnering support from 19 nursing and midwifery schools. 18 Ultimately, adapting the MPP to overcome these barriers will be key to sustaining and scaling the program. Facilitators to Implementation Facilitators of MPP implementation included the design of the program, which participants described as comprehensive and well-organized. Preceptors valued the support and mentorship of their educators and appreciated that the program was implemented in their practice settings. Previous studies have described the importance of enabling learning environments to effective clinical training. 19 , 20 Evaluating facilitators of a similar preceptorship program in Kenya, Shikuku et al. (2024) noted that training in the clinical setting was feasible, effective, and particularly valuable for implementation work in resource-limited settings. 16 Regarding outcomes related to MPP implementation, participants shared that the program resulted in noticeable improvements in preceptors’ knowledge, competence, and confidence, as found with similar programs implemented in Kenya and Nigeria. 21 Although outcomes evaluations for this first iteration of the MPP are forthcoming, several preceptors believed that the program was already effecting positive changes in perinatal morbidity and mortality. Encouraged by the personal, professional, and public health benefits of the MPP, most participants were eager to leverage program facilitators to sustain and scale the MPP in settings across and beyond Sierra Leone. Limitations This study is not without limitations. Although English is the official language of Sierra Leone and the language used in all hospitals and universities, it is not the first language of many Sierra Leoneans; accordingly, nuances may have been missed in interviews with some participants. Additionally, the interview guide may have limited discussion of facilitators and barriers beyond the CFIR domains. Few participants responded substantively to the final, open-ended interview question, with was intended to mitigate this limitation. Finally, we cannot rule out selection bias among interview participants. We invited all individuals involved in program implementation to an interview; it is difficult to determine whether those who responded are significantly different, or have significantly different perspectives, than those who did not. Conclusions According to the preceptors, facilitators, and stakeholders involved in the first year of program implementation, the MPP is a valuable innovation for enhancing midwifery education and improving perinatal health in Sierra Leone. Participants strongly endorsed the MPP and were eager to expand it across and beyond Sierra Leone. Based on our findings, adaptations can be made to address barriers and leverage facilitators to program implementation, in turn enhancing the efficacy and effectiveness of future iterations of the MPP and facilitating efforts to scale the program up and out. Declarations Funding The Boston College Connell School of Nursing Innovation Grant (BvdW, JM) supported this study. Author Contribution NR and OY collected data. NR, OY, JM, and BvdW analyzed data. NR and BvdW drafted the manuscript. All authors made significant contributions and revisions, and all approved of this final manuscript. Acknowledgement We would like to thank the participants who generously shared their time and insights for this study.NR is a 2024-2026 Jonas Scholar who gratefully acknowledges Jonas Nursing for their support and encouragement. Data Availability The data supporting the conclusions of this article are included within the article. References World Health Organization. Trends in Maternal Mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Published online 2023. https://www.who.int/publications/i/item/9789240068759 Nove A, Friberg IK, de Bernis L, et al. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. Lancet Glob Health . 2021;9(1):e24-e32. doi:10.1016/S2214-109X(20)30397-1 UNFPA Sierra Leone. National Nursing and Midwifery Strategic Plan 2019- 2023. UNFPA Sierra Leone. November 1, 2018. Accessed October 16, 2022. https://sierraleone.unfpa.org/en/publications/national-nursing-and-midwifery-strategic-plan-2019-2023 Sonnie M, Kella F, Stern A, et al. A Sierra Leone 2021 Midwifery Clinical Training Needs Assessment: A Call to Action to Augment Clinical Precepting. Ann Glob Health . 2023;89(1):10. doi:10.5334/aogh.3970 UNFPA Sierra Leone. Preceptorship policy and implementation guidelines for clinical competency building of midwifery and nursing students and residents. Published online April 2020. https://sierraleone.unfpa.org/sites/default/files/pub-pdf/preceptorship_policy_final.pdf van de Water B, Renning K, Nyondo A, et al. Development and initiation of a preceptor program to improve midwifery and nursing clinical education in sub-saharan Africa: protocol for a mixed methods study. BMC Nursing . 2024;23(1):365. doi:10.1186/s12912-024-02036-2 Home. Seed Global Health. Accessed February 16, 2022. https://seedglobalhealth.org/ CFIR. The Consolidated Framework for Implementation Research (CFIR). CFIR. 2022. Accessed January 24, 2022. https://cfirguide.org/constructs/ O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine . 2014;89(9):1245. doi:10.1097/ACM.0000000000000388 Home | Dedoose. Accessed January 24, 2022. https://www.dedoose.com/ Ameh CA, van den Broek N. Making It Happen: Training health-care providers in emergency obstetric and newborn care. Best Pract Res Clin Obstet Gynaecol . 2015;29(8):1077-1091. doi:10.1016/j.bpobgyn.2015.03.019 Bluestone J, Johnson P, Fullerton J, Carr C, Alderman J, BonTempo J. Effective in-service training design and delivery: evidence from an integrative literature review. Hum Resour Health . 2013;11:51. doi:10.1186/1478-4491-11-51 Anatole M, Magge H, Redditt V, et al. Nurse mentorship to improve the quality of health care delivery in rural Rwanda. Nurs Outlook . 2013;61(3):137-144. doi:10.1016/j.outlook.2012.10.003 Gomez PP, Nelson AR, Asiedu A, et al. Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial. BMC Pregnancy and Childbirth . 2018;18(1):72. doi:10.1186/s12884-018-1705-5 Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana - PubMed. Accessed March 10, 2025. https://pubmed.ncbi.nlm.nih.gov/22533352/ Shikuku DN, Bar-Zeev S, Ladur AN, et al. Experiences, barriers and perspectives of midwifery educators, mentors and students implementing the updated emergency obstetric and newborn care-enhanced pre-service midwifery curriculum in Kenya: a nested qualitative study. BMC Med Educ . 2024;24(1):950. doi:10.1186/s12909-024-05872-7 Asirifi MA, Mensah BA, Marfo EA, et al. Implementing Preceptorship in Baccalaureate Nursing Program in Middle-Low-Income Countries: A Scoping Review. Global Journal of Health Science . 2024;16(8):14-36. Middleton L, Howard A, Dohrn J, et al. The Nursing Education Partnership Initiative (NEPI) Innovations in Nursing and Midwifery Education. 2014. Accessed March 10, 2025. https://journals.lww.com/academicmedicine/fulltext/2014/08001/the_nursing_education_partnership_initiative.9.aspx Panda S, Dash M, John J, et al. Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis. Nurse Educ Today . 2021;101:104875. doi:10.1016/j.nedt.2021.104875 Mann J, Brooks MB, Kella F, et al. The impact of clinical placement site, community clinic versus tertiary hospital, on midwifery students’ clinical learning experience in Sierra Leone: a cohort study. BMC Med Educ . 2023;23(1):416. doi:10.1186/s12909-023-04413-y Shikuku DN, Mohammed H, Mwanzia L, et al. Evaluation of the feasibility of a midwifery educator continuous professional development (CPD) programme in Kenya and Nigeria: a mixed methods study. BMC Med Educ . 2024;24(1):534. doi:10.1186/s12909-024-05524-w Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 Jun, 2025 Reviews received at journal 04 Jun, 2025 Reviewers agreed at journal 20 May, 2025 Reviews received at journal 01 May, 2025 Reviewers agreed at journal 07 Apr, 2025 Reviewers agreed at journal 05 Apr, 2025 Reviewers invited by journal 02 Apr, 2025 Editor assigned by journal 31 Mar, 2025 Submission checks completed at journal 31 Mar, 2025 First submitted to journal 27 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Water","suffix":""}],"badges":[],"createdAt":"2025-03-27 13:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6320975/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6320975/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81191071,"identity":"e3cc576d-4841-40ac-bc59-bfb235bc403f","added_by":"auto","created_at":"2025-04-23 09:14:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":985788,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6320975/v1/670cc5f3-793f-4147-b398-ec7b2a739508.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Helping me, helping others, helping the nation”: Using the Consolidated Framework for Implementation Research to qualitatively assess a midwifery preceptor program in Sierra Leone","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSierra Leone has one of the poorest maternal health indicators globally, with a maternal mortality rate of 443/100,000 live births.\u003csup\u003e1\u003c/sup\u003e Strengthening midwifery care, which can substantially reduce perinatal mortality in low- and medium-income countries, is integral to addressing high rates of preventable maternal mortality in Sierra Leone.\u003csup\u003e1,2\u003c/sup\u003e The government of Sierra Leone projects it needs 3,000 midwives to provide minimally adequate maternal health care services; however, the country has fewer than 500 midwives who collectively serve less than 15% of the population.\u003csup\u003e3\u003c/sup\u003e To address this critical workforce shortage, the national government and midwifery schools in Makeni and Bo have collaborated since 2010 to increase enrollment of midwifery students in Sierra Leone.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to increasing the quantity of midwives, improving maternal health in Sierra Leone depends upon high-quality midwifery care aligned with the skills and competencies recommended by the International Confederation of Midwives.\u003csup\u003e2\u003c/sup\u003e According to educational standards set by the Nurses and Midwives Council of Sierra Leone, a novice student develops into a professional midwife through exposure to an academic program that consists of 40% theory and 60% clinical competence-building.\u003csup\u003e5\u003c/sup\u003e To produce a competent midwifery workforce that meets national and international standards, an effective clinical teaching program is vital.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn response to this need, Seed Global Health (Seed) developed a novel four step midwifery preceptor program (MPP) to facilitate the transfer of competencies for quality midwifery care.\u003csup\u003e6\u003c/sup\u003e In collaboration with the two schools of midwifery, Seed implemented the program in the Makeni and Bo districts of Sierra Leone. To understand barriers and facilitators to program implementation, we conducted qualitative interviews with individuals who participated in, facilitated, or were highly engaged with the first year of the program.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eSeed, a non-profit organization that supports healthcare workforce training in resource-limited countries, has been working to strengthen midwifery education in Sierra Leone since 2021.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Seed piloted the MPP at Makeni Regional Hospital and Bo Government Hospital. Makeni Regional Hospital is the referral hospital for the five Northern Districts of Sierra Leone and the primary training site for midwifery students from the School of Midwifery Makeni. Bo Government Hospital is the regional hospital in the Southern Province, where another school of midwifery is located. Both schools offer direct-entry diploma programs, as well as certificate programs for nurses seeking midwifery training. Students train at these regional hospitals, as well as other public health units and community health clinics. However, a lack of adequate and effective clinical supervision in the hospitals has negatively affected students\u0026rsquo; skill acquisition.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProgram Design and Implementation\u003c/h2\u003e \u003cp\u003ePreceptorship is a globally accepted and common approach to achieving clinical competency. Seed developed the MPP as a one-year, low-dose, high-frequency program to train experienced midwives to instruct, advise, mentor, assess, and orient new and student midwives in peripartum care. Twenty preceptors \u0026ndash; 10 each from Makeni and Bo \u0026ndash; were selected following an application and interview process. The program included an opening retreat, 12 weeks of intensive skills- and team-building, 12 weeks of preceptor training in the clinical setting, and 7 weeks of supervised preceptorship. Pre- and post-program assessments measured changes in competence and confidence in clinical and teaching skills.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eConsolidated Framework for Implementation Research\u003c/h3\u003e\n\u003cp\u003eThe Consolidated Framework for Implementation Research (CFIR) 2.0 guided our interviews, deductive content analysis, and systematic assessment of MPP implementation.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The framework comprises five domains: innovation, outer setting, inner setting, individuals, and process. Additionally, we followed the Standards for Reporting Qualitative Research.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eWe invited all preceptors (n\u0026thinsp;=\u0026thinsp;20), facilitators (n\u0026thinsp;=\u0026thinsp;5), and stakeholders (n\u0026thinsp;=\u0026thinsp;15) for in-depth individual interviews. Twenty-six individuals \u0026ndash; 18 preceptors and eight facilitators and stakeholders \u0026ndash; completed interviews (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Participants were compensated for their time.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or mean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreceptors (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.5 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitators and stakeholders (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.6 (5.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeed educator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeed employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwife-in-charge (labor ward, triage, maternity theatre)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (26.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwifery school principal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinistry of Health (unspecified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears as a midwife (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.5 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwife with previous experience precepting or teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eInterviews took place via Zoom between May and June 2024. We created an interview guide (Appendix A) using CFIR domains. We obtained written informed consent prior to audio recording and transcribing the interviews using Zoom functions. Two authors (NR and OY) conducted interviews in English, the official language in Sierra Leone, and lasted 30 to 60 minutes. Each interviewer reviewed and edited their corresponding transcripts for accuracy before uploading to Dedoose for coding.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eTranscripts were coded in Dedoose according to the predetermined CFIR codebook. Each of the first 20% of transcripts (n\u0026thinsp;=\u0026thinsp;5) was coded by two reviewers to ensure intercoder reliability. Reviewers engaged in discussion to ensure codes were used similarly and to achieve consensus regarding discrepancies. In these discussions and as supported by CFIR, one additional domain \u0026ndash; future directions \u0026ndash; was created to capture an emerging theme in the data.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The remaining interviews were independently coded by three authors (NR, OY, BvdW). The team reviewed coded excerpts to determine barriers and facilitators per CFIR domain.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics \u0026amp; Reflexivity\u003c/h2\u003e \u003cp\u003e The Boston College Institutional Review Board (#23.147.01) and Office of Sierra Leone Ethics and Scientific Review Committee (017/02/2023) provided ethical approval. This study involved a diverse research team, including nurses and midwives from the U.S. (NR, OY, JM, BvdW) and Sierra Leone (AK, CO, AD, JRV). Throughout the project, team members carefully considered personal, professional, academic, and sociocultural differences and power imbalances between one another and between researchers and participants. U.S.-based researchers continuously reflected on their positionality, consciously sought to mitigate power differentials, and worked to center the voices of Sierra Leonean authors and participants. Sierra Leonean researchers played a crucial role contextualizing the research, facilitating cross-cultural understanding, and ensuring fidelity to the perspectives of local midwives.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eInterviews with participants revealed strengths of the MPP across all five CFIR domains, as well as opportunities for future development. Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarize illustrative quotes, as well as barriers and facilitators per CFIR domain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIllustrative quotes with CFIR domain and construct codes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIllustrative quote\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCFIR domain: Construct\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt's a full package that really instills all the competencies that a learner should have to be able to practice midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInnovation: Evidence-base\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeople remember about 5 or 10% of what they're told, but 90% of what they do, so having opportunities for simulation and debrief embedded throughout the entire program, and then mentorship opportunities throughout the workday \u0026ndash; I think the combination of those two things in an ongoing way is the best educational opportunity that I think we could design for anyone, especially for clinical skills.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInnovation: Design\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe program \u0026ndash; it's not easy, you know; one year is not just one month or one week. Every week, sometimes we go twice. They really take the program in detail. We touched every area of midwifery that we think is necessary and worth knowing. We have gaps there; we try to fill those gaps with some new things.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInnovation: Complexity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThat was just my challenge, that balancing. How am I to balance work, balance precepting, or supervising, and going for class?... You have this document that you need to do, you have test tomorrow, you know, it was so stressful.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInnovation: Complexity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe previous programs were focusing on how to teach students but not enhancing the skills of the preceptors. While ours is both: the skills and how to teach.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInnovation: Relative advantage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis preceptor program has re-molded us. We should know how to talk to our subordinates, how to talk to our students, how to train them if somebody is doing something wrong \u0026ndash; the manner in which you should correct them... It has really added leadership qualities to us as preceptors and as nurses.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInnovation: Relative Advantage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStakeholder #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWe work through the partners. It\u0026rsquo;s a partnership program. So the partners that are in the facility, the school, they will come together. Then we decide, what do they want to achieve for the year? What is the problem that you want us to help them solve?... So that's how the program is developed: it\u0026rsquo;s purely based from the partners\u0026rsquo; perspective.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOuter setting: Partnerships \u0026amp; connections\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI'm just hoping that there will be resources.... After you people [Seed], maybe if there is no finance you left, then I'm not sure this country will be able to take up this venture to train preceptors.... I'm not foreseeing that when Seed will leave our country, there will be continuity. I\u0026rsquo;m not sure, but I am hoping for the better.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOuter setting: Financing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt should be a diploma program or maybe a degree program for me. Because considering the package \u0026ndash; that, you know, it\u0026rsquo;s intense and every day you have a new topic to cover \u0026ndash; considering how it\u0026rsquo;s covered \u0026ndash; practicals, theory in the classroom \u0026ndash; it is really, you know, a big \u0026ndash; it should... be a diploma.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOuter setting: Policies \u0026amp; laws\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStakeholder #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWe are really advocating that the Ministry really recognize these people because that's the only way they will be encouraged to continue precepting other midwives, which will definitely have a profound impact on saving the lives of mothers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOuter setting: Policies \u0026amp; laws\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI want to help my people out there. There are people suffering. We need to put hands together to reduce maternal and child mortality and morbidity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOuter setting: Performance-measurement pressure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis maternal and infant mortality has become a public health emergency in our country. I'm very sure preceptorship will be a key component to help us to reach that \u0026ndash; to bridge that gap.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOuter setting: Performance-measurement pressure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStakeholder #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunication [and] teamwork was a very big challenge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInner setting: Communications; Relational connections\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWe have been practicing this archaic midwifery, and we have been seeing the results of our old practice.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInner setting: Tension for change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhen we had classes here at the hospital, there is no space for us to get these classes... We are eager, we wanted to learn, we wanted these topics to be covered, but then there were no spaces.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInner setting: Space\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGloves were often missing. You can't practice a skill if you can't touch a patient because you don't have gloves or you don't have a way to properly sanitize because you just don't have soap... There were days when we didn't have oxytocin available... or we didn't have needles or syringes available... How can you suture, you know, if you don't have suture kits?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInner setting: Materials \u0026amp; equipment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStakeholder #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe hospital, the medical superintendent, the matron, the heads of the unit, they are very supportive... We are the educators doing the training and they are giving back up.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInner setting: Mission alignment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe program was really valued to the hospital because it helps to mold staffs... They [preceptors] serve as a model; they lead and others follow. You don't take blame, you don't cast blame. That's what the preceptorship taught us... You have a way to reframe it, which was well accepted by the hospital. You can say \u0026lsquo;Where do you think you did well? And where do you think you need improvements? Can we discuss on this?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInner setting: Learner-centeredness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI'm a woman, and I'm in my reproductive age, so in Sierra Leone, as long as you are within your reproductive age... you are at risk of dying whilst giving birth. So... to be competent and feel confident to reduce \u0026ndash; to prevent \u0026ndash; more women from dying from maternal death, and also being competent enough to teach others, that one was a very big incentive for all of us.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Motivation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSome of us really had passion for professional and even the teaching skills. If you have this goal, or this new title that you are a preceptor, you have more respect. Before this time, we are just midwives... But because of the title \u0026ndash; preceptors \u0026ndash; and we are the ones teaching, I think we had more respect, people listen to us.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Opinion leaders\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhen the preceptor program starts, I was angry because when they call for classes, at that time, I have my children to attend to, going for school\u0026hellip;So at first, I was really\u0026hellip; confused if I will able to continue with this preceptorship program.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Opportunity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt [the program] has empowered me. It has helped me to build self-confidence\u0026hellip; I have a strong inner feeling that I can do it... Now, as a midwife who has been empowered with tremendous knowledge, I can make plans, I can make decisions for a patient, then the outcome will be positive.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Motivation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudents have been coming. As me being in-charge, I will sign for them, I will just ask them questions. But now [after the program] I have a different sense that I need to teach them. And I need to know what\u0026rsquo;s their objective of being posted to my unit. What are they supposed to cover? I need to assign them to roles. I need to debrief with them. I need to mentor them. I need to have time for them.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Innovation recipients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEach time we call on [the facilitators], they will respond. They will answer us. They will teach us. Anytime; day, night, whenever we call them; both practical and theory; they are ready for us.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Implementation facilitators\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[Facilitators] are like parents to us; they guide us... [and] are with us whenever... [we] call them.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Implementation facilitators\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[The facilitator] was teaching us with respect and love.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Implementation facilitators\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhen I just arrived at the hospital, you could see that the students were not being supported properly\u0026hellip; [Now] the students will be put with the preceptors. As a result, they will meet their learning objectives, they will be able to achieve their competencies, and I feel \u0026ndash; with the transition of the preceptors \u0026ndash; our students will be far much better than the previous groups.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Need\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[The] matron or the medical superintendent, they are very, very supportive. They give us the classroom or hall. And even the in-charges of the other units, when we go to the various units to precept our students, they are really supportive... So the leadership, they are very, very much supportive.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: Mid-level leaders\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe CNMO [Chief Nursing and Midwifery Officer of Sierra Leone] attends the meetings and sees the presentations we make and what we are doing practically.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndividuals: High-level leaders\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo gain that acceptance was the crucial point. So gaining that acceptance from the Ministry of Health side and bringing down the project to the school side \u0026ndash; so the huge acceptance for the program to begin was, I mean, a huge success for its implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProcess: Teaming\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStakeholder #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne of the huge barriers of the implementation of this preceptorship program is the fact that the [school] faculty staff are left behind. Yeah, they are not included in any of the implementation... If we are talking about sustainability, then we need to include the faculty who are training these midwives. We need to involve them fully.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProcess: Engaging\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAs an implementer \u0026ndash; educator implementing this program \u0026ndash; we didn't have the support; like an orientation for us to know what we are supposed to do. So it was more like you understanding it on your own and delivering it. There wasn't that orientation for us. We were just given the documents. And then you go to the document, and you deliver it as you understand it.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProcess: Reflecting \u0026amp; evaluating implementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeing in this preceptorship program taught me that it's not just about knowledge, but it's about behavior... The preceptorship has taught me to be empathized with you... Not only for your patients, even for the people that you're working with, you need to listen to them; you need to see them and talk to them. Don't work in isolation. At first, I just took decisions as an in-charge. I don\u0026rsquo;t communicate. I don\u0026rsquo;t want to know what you feel... Now... anytime I want to take any decision or I want to implement anything, we'll sit together and talk... So it has really helped me to bond with my subordinates and empathize with them.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProcess: Reflecting \u0026amp; evaluating innovation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStakeholder #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, it's successful, because we are seeing the outcomes before even the completion of the program... The Seed educators assign [our] students to the preceptors and they're seeing what they have been doing. What they are teaching them is what they are applying, so it\u0026rsquo;s a success.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProcess: Reflecting \u0026amp; evaluating innovation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSome people are already asking, 'When is the next cohort going to start? When is the next cohort going to start?\u0026rsquo; So most of the midwives at the maternity units want to be preceptors as well. They want to be trained. They want to learn new things. They also want to start teaching these students that come for clinical placement. So, to me, I think it's a positive impact.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProcess: Engaging innovation recipients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere are other hospitals that I think are still struggling with the skills and knowledge... so by the time they send patient to our hospital, it\u0026rsquo;s late. It\u0026rsquo;s [too] late for us to intervene.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFuture directions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI want this program to be a continuous program because this program can help; it can help reduce maternal mortality rates in Sierra Leone, and not only the reduction of maternal mortality rate; the program can help mold the attitude of staffs, change their negative attitude to positive attitude. It can also help the health sector to understand quality care for patients, clients, and relatives, including other walks of life.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFuture directions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakeni Preceptor #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[The Nursing Council and the Chief Nursing and Midwifery Officer of Sierra Leone] said, \u0026lsquo;No, this is good! So we need to adopt this, we need to cascade it to other institutions. It should not only stop at Makeni Regional Hospital and Bo Government Hospital. We need to expand. We need to own it, as a country, we need to borrow the curriculum, and we need to cascade.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFuture directions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBo Preceptor #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIf this program continues, it will benefit both the students, the patient, and even the colleagues or staff and to make the positive impact. Yes. So, we think this program is very necessary and we hope it will continue to be sustaining so other people can come on board.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFuture directions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIf those that are involved in decision-making know the impact and they're worked through how the program is and what is expected at the end of it, 99.99% [it] will be replicated. Any place.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFuture directions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers and facilitators to MPP implementation per CFIR domain\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFIR Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitators\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInnovation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Complexity, stress, and time commitment of MPP\u003c/p\u003e \u003cp\u003e\u0026bull; Balancing MPP activities with other responsibilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Comprehensive, structured, intuitive design\u003c/p\u003e \u003cp\u003e\u0026bull; Low-dose, high-frequency learning and application\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOuter setting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Concerns regarding viability of MPP beyond Seed\u003c/p\u003e \u003cp\u003e\u0026bull; Need for support, resources, and funding to sustain MPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Strong partnerships between Seed, national government, schools, and hospitals\u003c/p\u003e \u003cp\u003e\u0026bull; Shared goal of improving national perinatal health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInner setting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Limited space, materials, and infrastructure to properly conduct MPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Alignment with hospital mission and values\u003c/p\u003e \u003cp\u003e\u0026bull; Support from hospital leaders and peers\u003c/p\u003e \u003cp\u003e\u0026bull; Tension for change in practice and unit culture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndividuals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; MPP demands time and dedication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Highly motivated preceptors\u003c/p\u003e \u003cp\u003e\u0026bull; Supportive facilitators\u003c/p\u003e \u003cp\u003e\u0026bull; Preceptors felt empowered with improved knowledge, skills, and attitudes\u003c/p\u003e \u003cp\u003e\u0026bull; Preceptors felt highly esteemed by peers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcess\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Insufficient collaborations with school faculty\u003c/p\u003e \u003cp\u003e\u0026bull; Inadequate support for facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Strong teaming among most stakeholders\u003c/p\u003e \u003cp\u003e\u0026bull; Adaptability of MPP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eInnovation Domain: “A whole package; simple but comprehensive”\u003c/h3\u003e\n\u003cp\u003eAccording to participants, the MPP was a novel and necessary innovation for midwifery clinical education. The blend of in-depth learning, skill building, and continuous mentorship seemed an intuitive approach to participants. Although some described the program as stressful, serious, or complex, participants felt well supported by program facilitators, who delivered the program in a way that was thoughtful and easy to follow.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It's a full package that really instills all the competencies that a learner should have to be able to practice midwifery.\u0026rdquo; (Bo Preceptor #1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;People remember about 5 or 10% of what they're told, but 90% of what they do, so having opportunities for simulation and debrief embedded throughout the entire program, and then mentorship opportunities throughout the workday \u0026ndash; I think the combination of those two things in an ongoing way is the best educational opportunity that I think we could design for anyone, especially for clinical skills.\u0026rdquo; (Facilitator #4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants noted that the MPP was challenging but worthwhile. To minimize participant burden, the program was designed to be delivered in the hospitals where the midwives worked; however, several participants reported difficulties balancing class attendance or activities with patient care responsibilities. Additionally, some participants said the yearlong commitment was a significant demand on their time and emphasized the motivation necessary to see the program through to completion.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The program \u0026ndash; it's not easy, you know; one year is not just one month or one week. Every week, sometimes we go twice. They really take the program in detail. We touched every area of midwifery that we think is necessary and worth knowing. We have gaps there; we try to fill those gaps with some new things.\u0026rdquo; (Bo Preceptor #5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;That was just my challenge, that balancing. How am I to balance work, balance precepting, or supervising, and going for class?... You have this document that you need to do, you have test tomorrow, you know, it was so stressful.\u0026rdquo; (Makeni Preceptor #9)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite its challenges, the MPP was much more comprehensive than prior training models, which were often shorter in duration and narrower in scope. As a prerequisite to effective student teaching, facilitators helped midwives to recognize weaknesses in their own practice and offered a comprehensive, standards-based program to improve clinical mastery. Owing to the program\u0026rsquo;s rigor and timespan, participants felt empowered with the knowledge, skills, and attitudes necessary to precept effectively.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The previous programs were focusing on how to teach students but not enhancing the skills of the preceptors. While ours is both: the skills and how to teach.\u0026rdquo; (Facilitator #2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;This preceptor program has re-molded us. We should know how to talk to our subordinates, how to talk to our students, how to train them if somebody is doing something wrong \u0026ndash; the manner in which you should correct them... It has really added leadership qualities to us as preceptors and as nurses.\u0026rdquo; (Makeni Preceptor #2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOuter Setting Domain: \u0026ldquo;Hands together to reduce maternal and child mortality\u0026rdquo;\u003c/h2\u003e \u003cp\u003eParticipants identified several external environmental factors that impacted implementation of the MPP. Key among these were effective collaborations between Seed, the national government, the midwifery schools, and the regional hospitals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We work through the partners. It\u0026rsquo;s a partnership program. So the partners that are in the facility, the school, they will come together. Then we decide, what do they want to achieve for the year? What is the problem that you want us to help them solve?... So that's how the program is developed: it\u0026rsquo;s purely based from the partners\u0026rsquo; perspective.\u0026rdquo; (Stakeholder #1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eGiven Seed\u0026rsquo;s leading role in orchestrating key partnerships and leading the initiative, some participants voiced concern about the program\u0026rsquo;s viability in the absence of a partner like Seed. Specifically, they questioned who would oversee the program, and who would provide funding to sustain and scale the program after Seed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I'm just hoping that there will be resources.... After you people [Seed], maybe if there is no finance you left, then I'm not sure this country will be able to take up this venture to train preceptors.... I'm not foreseeing that when Seed will leave our country, there will be continuity. I\u0026rsquo;m not sure, but I am hoping for the better.\u0026rdquo; (Makeni Preceptor #4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn response to this concern, many participants suggested the national government adopt the MPP. Some believed that formalizing the program via a national diploma or distinct career pathway would attract the interest of more midwives and help to cascade the program to other parts of the country. Others envisioned revising the scope of practice for nurses and midwives to explicate the unique role and responsibilities of the preceptor.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It should be a diploma program or maybe a degree program for me. Because considering the package \u0026ndash; that, you know, it\u0026rsquo;s intense and every day you have a new topic to cover \u0026ndash; considering how it\u0026rsquo;s covered \u0026ndash; practicals, theory in the classroom \u0026ndash; it is really, you know, a big \u0026ndash; it should... be a diploma.\u0026rdquo; (Makeni Preceptor #5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;We are really advocating that the Ministry really recognize these people because that's the only way they will be encouraged to continue precepting other midwives, which will definitely have a profound impact on saving the lives of mothers.\u0026rdquo; (Stakeholder #1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants were motivated to enroll in the MPP by a desire to improve perinatal health in Sierra Leone. Encouraged by anecdotal evidence of the program\u0026rsquo;s effectiveness in improving these outcomes, many were eager to sustain and scale the program to other parts of the country.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I want to help my people out there. There are people suffering. We need to put hands together to reduce maternal and child mortality and morbidity.\u0026rdquo; (Bo Preceptor #3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;This maternal and infant mortality has become a public health emergency in our country. I'm very sure preceptorship will be a key component to help us to reach that \u0026ndash; to bridge that gap.\u0026rdquo; (Bo Preceptor #7)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInner Setting Domain: \u0026ldquo;We fight with everything we have: teamwork, passion, resources\"\u003c/h2\u003e \u003cp\u003eInterviewees recalled characteristics of the inner setting that warranted implementation of the MPP, including negative workplace dynamics and outdated practices. One participant specified that \u0026ldquo;communication [and] teamwork was a very big challenge\u0026rdquo; (Stakeholder #1), while another said that \u0026ldquo;we have been practicing this archaic midwifery, and we have been seeing the results of our old practice\u0026rdquo; (Bo Preceptor #9). However, implementation of the MPP was constrained by a lack of space for preceptorship activities, insufficient material resources, and limited work infrastructure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;When we had classes here at the hospital, there is no space for us to get these classes... We are eager, we wanted to learn, we wanted these topics to be covered, but then there were no spaces.\u0026rdquo; (Bo Preceptor #4)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Gloves were often missing. You can't practice a skill if you can't touch a patient because you don't have gloves or you don't have a way to properly sanitize because you just don't have soap... There were days when we didn't have oxytocin available... or we didn't have needles or syringes available... How can you suture, you know, if you don't have suture kits?\u0026rdquo; (Facilitator #4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNonetheless, other aspects of the inner setting facilitated implementation. According to several participants, the MPP aligned well with the broader mission and values of the hospital. They found that hospital administrators, supervisors, and peers were equally invested in improving unit culture and practice. As one shared, \u0026ldquo;The medical superintendent, the matron, the heads of the unit, they are very supportive... we are the educators doing the training and they are giving back up\u0026rdquo; (Stakeholder #2). Ultimately, participants felt that the program created a positive culture of learning, reflection, communication, and teamwork.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The program was really valued to the hospital because it helps to mold staffs... They [preceptors] serve as a model; they lead and others follow. You don't take blame, you don't cast blame. That's what the preceptorship taught us... You have a way to reframe it, which was well accepted by the hospital. You can say \u0026lsquo;Where do you think you did well? And where do you think you need improvements? Can we discuss on this?\u0026rsquo;\u0026rdquo; (Makeni Preceptor #7)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIndividuals Domain: \u0026ldquo;They are ready for us\u0026rdquo;\u003c/h2\u003e \u003cp\u003eVarious stakeholders contributed to and benefited from implementation of the MPP. Participants were foremost among them. As previously mentioned, many saw the program as a contribution to improving perinatal health nationally. The opportunity for professional growth was also a primary motivation for joining the MPP.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I'm a woman, and I'm in my reproductive age, so in Sierra Leone, as long as you are within your reproductive age... you are at risk of dying whilst giving birth. So... to be competent and feel confident to reduce \u0026ndash; to prevent \u0026ndash; more women from dying from maternal death, and also being competent enough to teach others, that one was a very big incentive for all of us.\u0026rdquo; (Makeni Preceptor #6)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Some of us really had passion for professional and even the teaching skills. If you have this goal, or this new title that you are a preceptor, you have more respect. Before this time, we are just midwives... But because of the title \u0026ndash; preceptors \u0026ndash; and we are the ones teaching, I think we had more respect, people listen to us\u0026rdquo; (Bo Preceptor #1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, participation in the program was not without its challenges. The program was time-consuming, and some participants struggled to balance their professional and personal commitments. One preceptor stated: \u0026ldquo;When the preceptor program starts, I was angry because when they call for classes, at that time, I have my children to attend to, going for school\u0026hellip; so at first, I was really\u0026hellip; confused if I will able to continue with this preceptorship program\u0026rdquo; (Bo Preceptor #6). Nonetheless, participants felt that the program empowered them with knowledge, confidence, and agency, transforming their approach to patient care and student mentorship.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It [the program] has empowered me. It has helped me to build self-confidence\u0026hellip; I have a strong inner feeling that I can do it... Now, as a midwife who has been empowered with tremendous knowledge, I can make plans, I can make decisions for a patient, then the outcome will be positive.\u0026rdquo; (Makeni Preceptor #3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Students have been coming. As me being in-charge, I will sign for them, I will just ask them questions. But now [after the program] I have a different sense that I need to teach them. And I need to know what\u0026rsquo;s their objective of being posted to my unit. What are they supposed to cover? I need to assign them to roles. I need to debrief with them. I need to mentor them. I need to have time for them.\u0026rdquo; (Makeni Preceptor #6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany participants attributed the program\u0026rsquo;s success to its facilitators, who were described as knowledgeable, approachable, and always available for guidance, and who nurtured an enabling learning environment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Each time we call on [the facilitators], they will respond. They will answer us. They will teach us. Anytime; day, night, whenever we call them; both practical and theory; they are ready for us.\u0026rdquo; (Bo Preceptor #6)\u003c/p\u003e\u003cp\u003e\u0026ldquo;[Facilitators] are like parents to us; they guide us... [and] are with us whenever... [we] call them.\u0026rdquo; (Bo Preceptor #9)\u003c/p\u003e\u003cp\u003e\u0026ldquo;[The facilitator] was teaching us with respect and love.\u0026rdquo; (Makeni Preceptor #9).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFacilitators, for their part, believed that successful implementation was the result of mutual commitment from both facilitators and participants. In addition to supporting participants, facilitators played a pivotal role promoting the importance and value of the program for midwifery education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;When I just arrived at the hospital, you could see that the students were not being supported properly\u0026hellip; [Now] the students will be put with the preceptors. As a result, they will meet their learning objectives, they will be able to achieve their competencies, and I feel \u0026ndash; with the transition of the preceptors \u0026ndash; our students will be far much better than the previous groups.\u0026rdquo; (Facilitator #2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThose interviewed also perceived dedicated support from other influential stakeholders.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The matron or the medical superintendent, they are very, very supportive. They give us the classroom or hall. And even the in-charges of the other units, when we go to the various units to precept our students, they are really supportive... So the leadership, they are very, very much supportive\u0026rdquo; (Bo Preceptor #1).\u003c/p\u003e\u003cp\u003e\u0026ldquo;The CNMO [Chief Nursing and Midwifery Officer of Sierra Leone] attends the meetings and sees the presentations we make and what we are doing practically\u0026rdquo; (Makeni Preceptor #6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe collective efforts and commitment of all these individuals were instrumental in shaping the process and outcomes of program implementation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eProcess Domain: \u0026ldquo;People are already asking, 'When is the next cohort going to start?\u0026rsquo;\u0026rdquo;\u003c/h2\u003e \u003cp\u003ePrior to implementation, Seed collaborated with hospital, school, and government stakeholders to ensure the MPP aligned with their needs and goals and, in turn, to secure their buy-in to the program. As a result of this teaming, hospital leaders welcomed the MPP and supported preceptors in balancing class attendance with clinical duties.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;To gain that acceptance was the crucial point. So gaining that acceptance from the Ministry of Health side and bringing down the project to the school side \u0026ndash; so the huge acceptance for the program to begin was, I mean, a huge success for its implementation.\u0026rdquo; (Facilitator #3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some felt that better collaboration \u0026ndash; with school faculty, in particular \u0026ndash; could have benefited implementation and would be necessary to sustain the program.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;One of the huge barriers of the implementation of this preceptorship program is the fact that the [school] faculty staff are left behind. Yeah, they are not included in any of the implementation... If we are talking about sustainability, then we need to include the faculty who are training these midwives. We need to involve them fully.\u0026rdquo; (Stakeholder #2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral facilitators appreciated the adaptability of the program, which allowed them to tailor lesson plans and timelines based on participants' needs and abilities, or available resources. For example, one facilitator dedicated extra time to practicing fundamental peripartum skills. Others, however, expressed a desire for more structure and support to better prepare for and deliver the program.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;As an implementer \u0026ndash; educator implementing this program \u0026ndash; we didn't have the support; like an orientation for us to know what we are supposed to do. So it was more like you understanding it on your own and delivering it. There wasn't that orientation for us. We were just given the documents. And then you go to the document, and you deliver it as you understand it.\u0026rdquo; (Facilitator #3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Reflecting on the success of implementation and innovation, preceptors highlighted positive changes in their clinical skills, patient care, and ability to mentor students and colleagues. Despite role conflicts previously discussed, integrating the MPP with midwifery practice was ultimately beneficial; it allowed preceptors to immediately apply new skills and reflect on challenges they encountered in the clinical setting. Reflecting on the process, many were excited by the opportunity for growth and felt the program was a worthwhile investment of their time and energy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Being in this preceptorship program taught me that it's not just about knowledge, but it's about behavior... The preceptorship has taught me to be empathized with you... Not only for your patients, even for the people that you're working with, you need to listen to them; you need to see them and talk to them. Don't work in isolation. At first, I just took decisions as an in-charge. I don\u0026rsquo;t communicate. I don\u0026rsquo;t want to know what you feel... Now... anytime I want to take any decision or I want to implement anything, we'll sit together and talk... So it has really helped me to bond with my subordinates and empathize with them.\u0026rdquo; (Makeni Preceptor #9)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Yes, it's successful, because we are seeing the outcomes before even the completion of the program... The Seed educators assign [our] students to the preceptors and they're seeing what they have been doing. What they are teaching them is what they are applying, so it\u0026rsquo;s a success\u0026rdquo; (Stakeholder #4)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Some people are already asking, 'When is the next cohort going to start? When is the next cohort going to start?\u0026rsquo; So most of the midwives at the maternity units want to be preceptors as well. They want to be trained. They want to learn new things. They also want to start teaching these students that come for clinical placement. So, to me, I think it's a positive impact.\u0026rdquo; (Makeni Preceptor #2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFuture Directions Domain: \u0026ldquo;Let it cascade\u0026rdquo;\u003c/h2\u003e \u003cp\u003eBuilding on the successful implementation of the MPP in Makeni and Bo, participants advocated for expanding it nationally and internationally. Highlighting an urgent need to scale the program, one participant noted, \u0026ldquo;There are other hospitals that I think are still struggling with the skills and knowledge... so by the time they send patient to our hospital, it\u0026rsquo;s late. It\u0026rsquo;s [too] late for us to intervene.\u0026rdquo; (Makeni Preceptor #4)\u003c/p\u003e \u003cp\u003eSeveral recommendations were made to enhance future iterations of the program. One participant recommended refresher training to maintain connections among cohorts and ensure the most up-to-date practices. Another suggested that reducing the frequency of meetings from weekly to monthly could improve sustainability and ease replication of the program. Overall, participants felt the intervention was highly adaptable and, with appropriate support and contextual adjustments, could be replicated in various settings. They also highlighted the multifaceted impact of the intervention, noting its direct influence on preceptors as well as the broader, indirect benefits for colleagues, students, and patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;If this program continues, it will benefit both the students, the patient, and even the colleagues or staff and to make the positive impact. Yes. So, we think this program is very necessary and we hope it will continue to be sustaining so other people can come on board.\u0026rdquo; (Bo Preceptor #5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;If those that are involved in decision-making know the impact and they're worked through how the program is and what is expected at the end of it, 99.99% [it] will be replicated. Any place.\u0026rdquo; (Facilitator #1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCascading the program would ensure its sustainability, with each cohort of preceptors training the next, thus exponentially increasing the number of preceptors, students, and patients who could benefit from the program\u0026rsquo;s impact.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I want this program to be a continuous program because this program can help; it can help reduce maternal mortality rates in Sierra Leone, and not only the reduction of maternal mortality rate; the program can help mold the attitude of staffs, change their negative attitude to positive attitude. It can also help the health sector to understand quality care for patients, clients, and relatives, including other walks of life.\u0026rdquo; (Makeni Preceptor #7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;[The Nursing Council and the Chief Nursing and Midwifery Officer of Sierra Leone] said, \u0026lsquo;No, this is good! So we need to adopt this, we need to cascade it to other institutions. It should not only stop at Makeni Regional Hospital and Bo Government Hospital. We need to expand. We need to own it, as a country, we need to borrow the curriculum, and we need to cascade.\u0026rsquo;\u0026rdquo; (Makeni Preceptor #6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Preceptors, facilitators, and stakeholders described the MPP as a comprehensive innovation that equipped participants with knowledge, skills, and attitudes to become effective midwifery preceptors. Participants discussed the influence of partnerships and connections, financing, policies and laws, and performance measurement pressures on implementation, sustainment, and scaling of the program. While the need for the program was evident in each setting, the people and resources within these settings were key to the program\u0026rsquo;s success. The support of leadership, the time and dedication of facilitators, and the commitment from preceptors were also critical to intervention fidelity and created a positive culture specific to the MPP. Despite the demands of the program, participants deemed it rigorous and worthwhile for professional development. Moving forward, most participants wanted to maintain the MPP in these facilities and expand the program across and beyond Sierra Leone.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to Implementation\u003c/h2\u003e \u003cp\u003eOne of the primary barriers to MPP implementation cited by interviewees related to the duration and scope of the program. Unlike prior professional development programs, which were brief and had little sustained follow-up, the MPP was higher-frequency and longer lasting, which demanded significant commitment from all parties. However, serial, targeted interventions combined with mentorship or supportive supervision have been shown to improve knowledge, clinical performance, skill retention, and health outcomes more effectively than isolated interventions delivered via traditional training approaches.\u003csup\u003e\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCompeting professional and program demands were another salient barrier. As with the MPP, implementation of a midwifery educational program in Kenya was challenged by staffing shortages, heavy workloads, work infrastructure gaps, and inadequate clinical support.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e A scoping review of nursing preceptorship programs across sub-Saharan Africa identified time constraints and conflicting priorities as primary barriers to implementation of programs in Namibia, Botswana, and Ghana.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Both articles highlighted the need for resources and policy directives to support high-quality education and professional development.\u003c/p\u003e \u003cp\u003eSeveral participants raised concerns about the viability of the MPP without Seed and many believed that long-term sustainability would require local and national partners to take ownership of the program. Suggestions included embedding the MPP in the schools of midwifery and working with the Ministry of Health to develop the MPP into a national diploma program. One model for these efforts is the Nurse Education Partnership Initiative, a capacity-building program that was formally adopted by the Malawi Nurses and Midwives Council after garnering support from 19 nursing and midwifery schools.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Ultimately, adapting the MPP to overcome these barriers will be key to sustaining and scaling the program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFacilitators to Implementation\u003c/h2\u003e \u003cp\u003eFacilitators of MPP implementation included the design of the program, which participants described as comprehensive and well-organized. Preceptors valued the support and mentorship of their educators and appreciated that the program was implemented in their practice settings. Previous studies have described the importance of enabling learning environments to effective clinical training.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Evaluating facilitators of a similar preceptorship program in Kenya, Shikuku et al. (2024) noted that training in the clinical setting was feasible, effective, and particularly valuable for implementation work in resource-limited settings.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRegarding outcomes related to MPP implementation, participants shared that the program resulted in noticeable improvements in preceptors\u0026rsquo; knowledge, competence, and confidence, as found with similar programs implemented in Kenya and Nigeria.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Although outcomes evaluations for this first iteration of the MPP are forthcoming, several preceptors believed that the program was already effecting positive changes in perinatal morbidity and mortality. Encouraged by the personal, professional, and public health benefits of the MPP, most participants were eager to leverage program facilitators to sustain and scale the MPP in settings across and beyond Sierra Leone.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study is not without limitations. Although English is the official language of Sierra Leone and the language used in all hospitals and universities, it is not the first language of many Sierra Leoneans; accordingly, nuances may have been missed in interviews with some participants. Additionally, the interview guide may have limited discussion of facilitators and barriers beyond the CFIR domains. Few participants responded substantively to the final, open-ended interview question, with was intended to mitigate this limitation. Finally, we cannot rule out selection bias among interview participants. We invited all individuals involved in program implementation to an interview; it is difficult to determine whether those who responded are significantly different, or have significantly different perspectives, than those who did not.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e According to the preceptors, facilitators, and stakeholders involved in the first year of program implementation, the MPP is a valuable innovation for enhancing midwifery education and improving perinatal health in Sierra Leone. Participants strongly endorsed the MPP and were eager to expand it across and beyond Sierra Leone. Based on our findings, adaptations can be made to address barriers and leverage facilitators to program implementation, in turn enhancing the efficacy and effectiveness of future iterations of the MPP and facilitating efforts to scale the program up and out.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe Boston College Connell School of Nursing Innovation Grant (BvdW, JM) supported this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNR and OY collected data. NR, OY, JM, and BvdW analyzed data. NR and BvdW drafted the manuscript. All authors made significant contributions and revisions, and all approved of this final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank the participants who generously shared their time and insights for this study.NR is a 2024-2026 Jonas Scholar who gratefully acknowledges Jonas Nursing for their support and encouragement.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the conclusions of this article are included within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Trends in Maternal Mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Published online 2023. https://www.who.int/publications/i/item/9789240068759\u003c/li\u003e\n\u003cli\u003eNove A, Friberg IK, de Bernis L, et al. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2021;9(1):e24-e32. doi:10.1016/S2214-109X(20)30397-1\u003c/li\u003e\n\u003cli\u003eUNFPA Sierra Leone. National Nursing and Midwifery Strategic Plan 2019- 2023. UNFPA Sierra Leone. November 1, 2018. Accessed October 16, 2022. https://sierraleone.unfpa.org/en/publications/national-nursing-and-midwifery-strategic-plan-2019-2023\u003c/li\u003e\n\u003cli\u003eSonnie M, Kella F, Stern A, et al. A Sierra Leone 2021 Midwifery Clinical Training Needs Assessment: A Call to Action to Augment Clinical Precepting. \u003cem\u003eAnn Glob Health\u003c/em\u003e. 2023;89(1):10. doi:10.5334/aogh.3970\u003c/li\u003e\n\u003cli\u003eUNFPA Sierra Leone. Preceptorship policy and implementation guidelines for clinical competency building of midwifery and nursing students and residents. Published online April 2020. https://sierraleone.unfpa.org/sites/default/files/pub-pdf/preceptorship_policy_final.pdf\u003c/li\u003e\n\u003cli\u003evan de Water B, Renning K, Nyondo A, et al. Development and initiation of a preceptor program to improve midwifery and nursing clinical education in sub-saharan Africa: protocol for a mixed methods study. \u003cem\u003eBMC Nursing\u003c/em\u003e. 2024;23(1):365. doi:10.1186/s12912-024-02036-2\u003c/li\u003e\n\u003cli\u003eHome. Seed Global Health. Accessed February 16, 2022. https://seedglobalhealth.org/\u003c/li\u003e\n\u003cli\u003eCFIR. The Consolidated Framework for Implementation Research (CFIR). CFIR. 2022. Accessed January 24, 2022. https://cfirguide.org/constructs/\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. \u003cem\u003eAcademic Medicine\u003c/em\u003e. 2014;89(9):1245. doi:10.1097/ACM.0000000000000388\u003c/li\u003e\n\u003cli\u003eHome | Dedoose. Accessed January 24, 2022. https://www.dedoose.com/\u003c/li\u003e\n\u003cli\u003eAmeh CA, van den Broek N. Making It Happen: Training health-care providers in emergency obstetric and newborn care. \u003cem\u003eBest Pract Res Clin Obstet Gynaecol\u003c/em\u003e. 2015;29(8):1077-1091. doi:10.1016/j.bpobgyn.2015.03.019\u003c/li\u003e\n\u003cli\u003eBluestone J, Johnson P, Fullerton J, Carr C, Alderman J, BonTempo J. Effective in-service training design and delivery: evidence from an integrative literature review. \u003cem\u003eHum Resour Health\u003c/em\u003e. 2013;11:51. doi:10.1186/1478-4491-11-51\u003c/li\u003e\n\u003cli\u003eAnatole M, Magge H, Redditt V, et al. Nurse mentorship to improve the quality of health care delivery in rural Rwanda. \u003cem\u003eNurs Outlook\u003c/em\u003e. 2013;61(3):137-144. doi:10.1016/j.outlook.2012.10.003\u003c/li\u003e\n\u003cli\u003eGomez PP, Nelson AR, Asiedu A, et al. Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial. \u003cem\u003eBMC Pregnancy and Childbirth\u003c/em\u003e. 2018;18(1):72. doi:10.1186/s12884-018-1705-5\u003c/li\u003e\n\u003cli\u003eEvaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana - PubMed. Accessed March 10, 2025. https://pubmed.ncbi.nlm.nih.gov/22533352/\u003c/li\u003e\n\u003cli\u003eShikuku DN, Bar-Zeev S, Ladur AN, et al. Experiences, barriers and perspectives of midwifery educators, mentors and students implementing the updated emergency obstetric and newborn care-enhanced pre-service midwifery curriculum in Kenya: a nested qualitative study. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2024;24(1):950. doi:10.1186/s12909-024-05872-7\u003c/li\u003e\n\u003cli\u003eAsirifi MA, Mensah BA, Marfo EA, et al. Implementing Preceptorship in Baccalaureate Nursing Program in Middle-Low-Income Countries: A Scoping Review. \u003cem\u003eGlobal Journal of Health Science\u003c/em\u003e. 2024;16(8):14-36.\u003c/li\u003e\n\u003cli\u003eMiddleton L, Howard A, Dohrn J, et al. The Nursing Education Partnership Initiative (NEPI) Innovations in Nursing and Midwifery Education. 2014. Accessed March 10, 2025. https://journals.lww.com/academicmedicine/fulltext/2014/08001/the_nursing_education_partnership_initiative.9.aspx\u003c/li\u003e\n\u003cli\u003ePanda S, Dash M, John J, et al. Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis. \u003cem\u003eNurse Educ Today\u003c/em\u003e. 2021;101:104875. doi:10.1016/j.nedt.2021.104875\u003c/li\u003e\n\u003cli\u003eMann J, Brooks MB, Kella F, et al. The impact of clinical placement site, community clinic versus tertiary hospital, on midwifery students\u0026rsquo; clinical learning experience in Sierra Leone: a cohort study. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2023;23(1):416. doi:10.1186/s12909-023-04413-y\u003c/li\u003e\n\u003cli\u003eShikuku DN, Mohammed H, Mwanzia L, et al. Evaluation of the feasibility of a midwifery educator continuous professional development (CPD) programme in Kenya and Nigeria: a mixed methods study. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2024;24(1):534. doi:10.1186/s12909-024-05524-w\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"midwifery, midwifery education, preceptorship, maternal health services, health workforce, capacity building, qualitative research, implementation science, Sierra Leone","lastPublishedDoi":"10.21203/rs.3.rs-6320975/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6320975/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Sierra Leone has the world’s third highest incidence of maternal mortality, with 443 deaths per 100,00 live births. With fewer than 500 midwives serving less than 15% of the nation’s population, strengthening the midwifery workforce is essential to reducing preventable perinatal mortality. In support of this goal, we implemented a novel midwifery preceptor program (MPP) to train experienced midwives to effectively mentor new and student midwives. This study applied the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to implementation of the MPP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003ePreceptors, facilitators, and academic and hospital leaders participated in individual virtual interviews. Using deductive content analysis, 26 interviews were coded according to constructs within the five CFIR domains: innovation, outer setting, inner setting, individuals, and process. Barriers and facilitators to MPP implementation were analyzed per domain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eParticipants identified MPP strengths and opportunities across all five CFIR domains. They described the program as a comprehensive integration of theory and practice that was well-designed and effectively delivered. Facilitator support and stakeholder collaboration were key to successful implementation. Challenges included limited resources and time constraints, which made it difficult for some to balance professional responsibilities with program activities. Nonetheless, participants advocated for formalizing the MPP to sustain the program’s impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e The findings indicate that the MPP is a valuable innovation for enhancing midwifery education and improving perinatal health in Sierra Leone. Participants expressed support for the MPP and were eager to expand it across and beyond Sierra Leone. In addition to enhancing future iterations of the MPP, addressing barriers and leveraging facilitators to program implementation are essential for scaling the MPP up and out.\u003c/p\u003e","manuscriptTitle":"“Helping me, helping others, helping the nation”: Using the Consolidated Framework for Implementation Research to qualitatively assess a midwifery preceptor program in Sierra Leone","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-23 09:05:58","doi":"10.21203/rs.3.rs-6320975/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-05T15:42:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T14:36:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217096827556878966981702336363444628173","date":"2025-05-20T04:59:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-01T16:01:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150295915020113895352164286906285654223","date":"2025-04-07T09:11:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169415579076682805825200803774966592750","date":"2025-04-05T08:59:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-02T09:26:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-31T10:16:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-31T09:56:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Global and Public Health","date":"2025-03-27T13:20:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53b6c2f5-e67a-4c76-94a4-817683c0c688","owner":[],"postedDate":"April 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-27T12:53:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-23 09:05:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6320975","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6320975","identity":"rs-6320975","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}