The challenges of mentorship system at Tabriz University of Medical Sciences and providing solutions from the perspective of mentors, students and collaborators

Introduction Universities that are responsible for guiding students and the elite of society are faced with constant challenges and changes due to the complex and changing nature of the existing environment, which has a direct impact on students. At many points in their lives, especially in the early years of college, students experience a lot of stress and discomfort.1 Young people who are interested in university education face many barriers in pursuing higher education at universities; if serious measures are not taken to prevent or overcome some of these barriers, there can be serious consequences, particularly for students who are new to higher education and are entering into a vast and special cultural environment from different cities and


Introduction
Universities that are responsible for guiding students and the elite of society are faced with constant challenges and changes due to the complex and changing nature of the existing environment, which has a direct impact on students. At many points in their lives, especially in the early years of college, students experience a lot of stress and discomfort. 1 Young people who are interested in university education face many barriers in pursuing higher education at universities; if serious measures are not taken to prevent or overcome some of these barriers, there can be serious consequences, particularly for students who are new to higher education and are entering into a vast and special cultural environment from different cities and villages across the country, where they are faced with novel problems such as varying social status between student and professor, physical and social maturity, the presence of other students in different academic fields, independence and distance from family, dormitory living or finding rental homes, university constraints, naivete and possibly overly-ambitious thoughts, and, finally, new hopes, all of which can lead to a decline in their education. [2][3][4] Therefore, counseling and guidance of students in order to provide them with mental, psychological and social support is essential. Student counseling and guidance, which is one of the most important prevention strategies in the university setting, is a dynamic and purposeful relationship that is based on the participation of the professor and the student and is done in accordance with the student's needs. Such an approach can help expand insight, resolve internal conflicts and develop constructive relationships with others, and make the educational system more efficient and reduce academic failure. 1 Academic counseling is a collaborative process that addresses the needs, problems, and interests of higher education students. Academic counseling program is an integral part of a university's total educational program; it is developmental by design, focusing on needs, interests, and issues related to various stages of student growth. 5 Mentorship consists of one of the faculty members of the university, proposed by the education deputy of each faculty in the university and order of dean of the faculty, who is responsible for guiding and advising students at various levels of education in terms of education, research and individual problems in accordance with the regulations approved by the Supreme Council of Planning at the Ministry of Medical Sciences, including 36 articles and 14 notes. Implementation of the mentorship system at the university, which began in 2004, outlines the following objectives: improving the insight and psychological knowledge of students about personal and social problems and needs, mentoring the student to properly understand their strengths and weaknesses and making informed decisions and good choices as well as preventing or solving behavioral, emotional, cognitive, educational, family and marriage problems, increasing effective adaptation of students to the education and living environment, and development of social relations and academic achievement. With these factors in mind, the mentor must have the knowledge, attitudes, and skills needed to provide effective guidance in consulting with students and a key performance indicator is measurable behavior that indicates the acceptance or non-acceptance of the expected professional competence of a particular role. [5][6][7] Obviously, lack of guidance or inappropriate counseling can disrupt the achievement of educational goals and professional skills, while proper counseling by competent authorities can lead to solving student problems and provide opportunities for growth as well as change in students' behavioral patterns. 8 In addition, a precise and continuing valuation, identification of weaknesses and strengths, stakeholder satisfaction, and process efficiency in achieving goals are essential for any ongoing process. The mentorship process is no exception, particularly regarding the important role of this process in improving the education, motivation and health of medical students, which calls for a more precise evaluation and scrutiny. 9,10 A literature review carried out at the Tabriz University of Medical Sciences showed a lack of integrated and comprehensive studies in any faculty of the university regarding the mentorship system. Studies conducted in the faculties of Medicine, Pharmacy, and Paramedical Sciences were primarily descriptive studies presented at the Shahid Motahari Festival as a process implementation discussion. In these studies, the status of the implementation and the attitudes of faculty members and students were examined, and the strengths and weaknesses of the program implementation were reported. However, challenges and strategies to improve implementation were not covered in these studies.

Materials and Methods
The present study is a mixed methods study conducted in 2016 that was conducted in three phases as described below after receiving approval of the code of ethics from the Regional Ethics Committee of the university. Prior to the start of the study, consent was obtained from all participants in the study and they were assured that all information would be reported confidentially and anonymously. In the first phase, in order to determine the current status of the mentorship system in different faculties, the performance reports of the Tabriz MEDICAL UNIVERSITY faculties (eleven faculties in all, including Medicine, Dentistry, Pharmacy, Nursing, Nutrition, Paramedical, Health, Health Services Management, Modern Sciences, Traditional Medicine, and Rehabilitation Sciences) regarding the mentorship system were obtained.
For a more detailed review, an open-ended questionnaire containing 20 questions about the structure and implementation process of the mentorship system was compiled. To compiled this questionnaire, were used the regulations of the mentorship system, which were communicated to all medical universities in the country by the Ministry of Health and Medical Education. In order to determine the validity of the questionnaire, formal validity was used, in which 8 faculty mentors were asked to determine the degree of simplicity, relevance and questioning of the items; finally, the questions were approved in terms of formal validity with a Content Validity Index (CVI) value over 0.75. Then, in order to complete the questionnaire, the researcher met with all mentors of the faculties, the educational deputies of the faculties and the experts of the mentorship offices and asked the questions from the questionnaire and recorded the answers with the permission of the respondents. The results were then summarized and reported.
To determine the mentorship system status at the Tabriz University of Medical Sciences and challenges in this field from the students' perspective, a researchercreated questionnaire was used, the first part of which included questions about the structure and process of implementation, etc. based on a 5-point Likert scale (where 5=Very good, 4=good, 3=moderate, 2=bad, 1=very bad). In the data analysis, the obtained averages were scaled to 0-100 and scores were rated as 0-25 poor, 25.1.-50 moderate, 50.1-75 good and 75.1-100 excellent. In the second part, students' opinions were asked regarding the challenges and weaknesses of the mentorship system. To design the questionnaire, a list of problems and challenges was collected and included in the questionnaire using a review of the literature and existing documentation. The students were asked to express their own concerns, which may not have been included in the questionnaire, to examine the system more precisely. Cronbach's alpha was used to determine the reliability of the questionnaire. In order to determine the validity of the questionnaire, the developed questionnaires were given to some supervisors and practitioners of medical education and their views on the transparency, necessity, simplicity and relevance of each question were applied to the questionnaire. An average content validity ratio (CVR) = 0.73 and CVI = 0.98 indicate appropriate validity and reliability of the questionnaire.
Sampling was done via cluster and then randomly among students (since mentorship program is done in basic sciences in the medical faculty, sampling was done among basic science students; in other faculties, it was done among all students). However, guest students from other universities excluded from the study. SPSS 17 and descriptive statistics (mean and standard deviation) were used to analyze the quantitative data. Concerns that the students raised were also examined and added to the results obtained from the questionnaire.
In the second phase, in order to determine the challenges and problems associated with the mentorship system from the perspective of mentors and practitioners, a focused group discussion was held with faculty mentors with at least two years of experience as mentors and faculty deputies who also had experience in the mentorship system. These participants were chosen purposefully. Their selection was based on their experience with student consultation and they were familiar with the problems and challenges of this system. All participants completed an informed consent form. The meeting was held in a group of 12 people (seven mentors and five education deputies) in the medical education conference hall. The meeting also included five members of the research team, one note taker for recording key points and nonverbal behaviors, and one facilitator with experience in conducting focused group discussions. At the beginning of the group discussion, the facilitator provided explanations for the purposes of the discussion, the method of group discussion and the generalities of the questions, and asked the participants to let them record the discussion and take notes. The general framework of questions was developed based on the research objectives and findings from the first phase of the study. The data were analyzed using qualitative content analysis: the information recorded in the focused group discussion was transcribed by a researcher and was coded after reviewing and matching with notes and the results were reviewed to improve the accuracy of coding by another researcher in the research team and, if necessary, corrected. Based on the results of coding, the main themes were extracted and categorized. The main questions that were prepared based on the research objectives and findings from the first phase of the study were: 1. How do you assess the current situation of the mentorship system? 2. What problems does the university face in implementing this system? 3. What problems do the mentors have in this field? 4. What challenges do the students face in this regard?
In the third phase, in order to provide corrective strategies and solutions to improve the mentorship system, a meeting was held with the participants who attended the second phase of the focused group discussion. At this meeting, the results of the focused group discussion were discussed by the facilitator and participants in the meeting; then, possible strategies for solving problems were suggested and discussed by the participants, and solutions were presented using the consensus of the participants.

Results
A review of the mentorship system at the Tabriz University of Medical Sciences showed that: • All faculties have at least one mentor, except for one faculty (modern sciences faculty), because there is only postgraduate level in that faculty. • School officials consider the existence of the mentorship system necessary because of the problems students face throughout their academic career. • All faculties with a mentorship system have a designated person to administer it.

•
None of the faculties have peer student mentors.
• In 50% of cases, the mentor advises the student face to face in the field of student education; in other cases, only educational documents are approved. • In most cases, mentors play a leading role in social and welfare areas, but this role depends on the initiative of the student. • Matching the gender and student field of study with the mentor is considered as much as possible; however, it is not possible in every case due to the lack of balance between the number of students and mentors and their gender. • A large percentage of experienced faculty members have participated in related training courses, but a number of newly employed faculty members have not participated in similar workshops because they are not currently being offered. • All mentors have been engaged in their duties dating from the establishment of the role; thus there has been no need to determine successors. Skilled nonacademic experts have not been used as mentor assistants in any of the faculties. In one case, one counseling expert was consulted due to a need for psychological counseling; in another case, an expert opinion was sought by the education office. • The mentors examine and verify all forms of education (unit selection, medical certificates, party, etc.) in one semester in only two faculties. • Mentors are aware of the students' past, present, and future status, and students are evaluated continuously to a large extent (mostly through the Sama system). • Mentors are aware of students' economic, emotional, psychological, social and cultural problems and, if needed, they refer students to related centers and their families and consultation is done (most often for at-risk students who are in danger of dropping out). • Heads of departments or educational deputies are often informed of students' problems from attending educational meetings and mentors provide reports to them in some cases. Sometimes mentors do not attend university meetings, such as the Special Cases Commission and the Disciplinary Committee, etc., in which problems of students are often discussed. They are informed of students' problems by receiving minutes, letters and surveys. • All mentors participate in conferences, orientation and training workshops. and meetings of mentors. • Mentors report their performance to the executive at the end of each semester, but follow-up is needed. • In all faculties, the mentor is present on the day of registration as well as on drop-add days and emergency drops, except in one case. • Most mentors have been helpful during each semester with a regular schedule. • The performance of the mentors has been evaluated by students several times. The results of this study showed that the current status of the mentorship system in all faculties at the Tabriz University of Medical Sciences was considered moderate, with an average of 47.9.
The highest scores received was for the items "making a file for each student with respect to the confidentiality of personal, educational, social and economic information, " and "introducing educational, research, student, and disciplinary regulations at the relevant level" to the students (59.3 and 54.4, respectively). The lowest scores received were for "holding regular counseling sessions, " "referring students' problems to the appropriate area, " and "identifying students' potential abilities and talents and helping them grow" (36.5, 43.1, and 43.0, respectively; Table 1).
The analysis conducted on the focused group discussion led to the identification of three themes: organizational challenges (four sub-classes), challenges faced by the faculty members in the mentorship system (4 sub-classes), and challenges faced by students (5 sub-classes), shown in Table 2.
In order to overcome the challenges of mentorship system, after summarizing the results from the first and second phases, some strategies were presented by mentors and practitioners of the mentorship system, shown in Table 3.

Discussion
The results obtained from the first phase of the study based on the review of documents available in the faculties and the collection of information through the questionnaires showed that the system of the consultant-professor has been implemented in all faculties, but there are shortcomings. For example, at the time of the study, there were no peer students to cooperate with the mentors. In addition, matching the gender and student field of study with the mentor was not fully implemented.
The current situation of the mentorship system in all faculties of the Tabriz University of Medical Sciences was evaluated by students in terms of identified indicators with an average of 47.9 (in the average range). Data obtained from the focused group discussion led to the identification of three themes; organizational challenges, challenges faced by the faculty members in the mentorship system and the challenges faced by students.
Generally, it seems that the position of the mentorship system at Tabriz University of Medical Sciences is at a moderate level. It is necessary to use a proper mechanism to promote the mentorship system so that both the planning and the implementation of the program can be improved. Tabrizi concluded that the performance of the mentorship system did not enjoy the necessary quality from the viewpoint of students and mentors, and he suggested strategies such as the use of interested mentors, optional membership of mentors, use of various communication methods, orientation workshops for students, and a research-centered system of mentors. 11, 12 Khansa's study also indicated dissatisfaction with the mentorship system in Lebanon's educational system. 13 In the present study, the allocation of highest score to activities by students, such as making a file for each student, observing the confidentiality of personal, educational, social and economic information, and introducing educational, research, student and disciplinary regulations to the students, indicate that the system is in a desirable situation in terms of the implementation structure and the mentors are aware of educational regulations related to the students and the need to keep good records that are confidential. The high motivation and interest of the mentors for guiding and counseling in terms of students also indicate that the selection of mentors has been done appropriately. Therefore, it can be concluded that the Tabriz University of Medical Sciences has been structured to facilitate proper implementation of the mentorship system. Despite such successes, some results indicate areas for improvement in implementation.
In studying the current situation, lower satisfaction of students in holding counseling sessions is a barrier identified due to the lack of qualified mentors suitable for the number of students, lack of a suitable place for consultation, and the high workload of the mentors. Lee et al described the existence of a limited and inappropriate support network as a challenge faced by mentors. 12 Khansa discussed a limited number of specialists as one of the challenges of the mentorship system. 13 Some strategies have been developed by the mentors and collaborators that may help address this issue. For example, holding public meetings on general topics can help solve some problems of individual consultation by presenting information Table 2. Themes identified by focused group discussion on the challenges faced by the mentorship system

Organizational challenges
The high number of students compared to the counselors The lack of motivational mechanisms for mentors Lack of the right place to provide consultation for students Unsuitable name for the e system (as mentorship system)

Unfamiliarity of university authorities with mentorship system
Challenges faced by the active faculty members in the mentorship system High workload of mentors and the impossibility of holding consultation sessions for students The inability of mentors to solve some student problems, such as job problems, etc.
Inadequate familiarity of faculty members with the content of regulations and the duties of the mentorship system and the educational regulations and rules Unfamiliarity of mentors with appropriate counseling centers to refer students Not attending of the students voluntarily to counseling sessions Challenges faced by students Students don't intend to disclose their identity to mentors (students prefer to raise most of their problems without being known by mentor) Students are not familiar with the mentorship system The students' use of private mentors and other experts in different fields due to the fact that they don't trust on their counselors Students trust the older and more experienced mentors without identifying students with emergency needs for consultation, including students at risk of academic decline or students living in dormitories and away from the family, although individual follow-up is needed. This strategy can partially solve the problems faced due to a low ratio of mentors to students. The use of private consultants who have more experience and information than academic mentors can also be appropriate for use in this regard, which, given the sensitivity of the problem, should be done carefully with knowledge about their abilities and competencies. The lack of motivational mechanisms for mentors is another challenge for the university, which is a subset of organizational problems. In terms of this challenge, a review of student feedback has shown that they are satisfied with the high motivation and interest of the mentors in supervising and advising but mentors complain about the lack of incentive mechanisms. Such mechanisms as an increase in executive score, base promotion for the activities of the mentors, compensation or reduction of mentors' course teaching load, acknowledging mentors at the Shahid Motahari educational festival, etc., could help the mentors devote more time and effort to consult with their students. Sum et al showed the high impact of compensation and scores on mentors' motivation and interest in consultation. 14 The lack of a suitable place to provide counseling is another challenge: limited space of faculties is the main reason for this challenge. Venolia emphasizes the impact of the environment in various physical, mental and emotional aspects on the outcome of counseling, and believes that the availability of the right place for consultation in terms of specificity, space, light, arrangement, etc., are necessary for consultation. 15 However, there is no special room in most cases for counseling at the university, and students are required to attend counseling sessions in rooms where there are several other students, which has caused dissatisfaction on the parts of both students and mentors. Sum et al found that mentors greatly appreciated the effectiveness of having dedicated space for counseling. 14 In the present study, in order to solve this problem, allocating appropriate rooms for consultation was a priority, but due to limited space among the faculties, other solutions such as holding general meetings on general topics, or designing and launching an IVR phone consultation were also recommended. The unwillingness of students to disclose their identity to the mentor and the tendency to address most of their problems without being known by the mentor is also a challenge. The solution that the present study suggests is setting up an IVR to answer student questions which could help solve this problem. The heavy workload of the mentors in the field of clinical, educational and research activities was mentioned as another challenge. In this study, a solution suggested by faculty members and practitioners was matching the activity of the mentorship system with the teaching course as well as scores in this regard with research activities. Mentors could devote time to student counseling and addressing their problems instead of spending that amount of time on education and research, if these strategies are implemented, and not suffer a detriment to their professional record within the faculty and university. Tabrizi et al also stressed that the absence of mentors and lack of allocation of time for consultation indicate a heavy workload. He suggested a research-based mentorship system as an appropriate solution for this problem. 11 Allocating insufficient time to provide counseling is due in part to a heavy workload among the students in addition to disinterest of selected mentors to work as mentors. In this study, as well as the study by Tabrizi et al, the use of interested mentors for counseling and guiding students is proposed as a solution to this problem, but this solution faces difficulties due to a limited number of mentors compared to the number of students. Using motivational strategies among mentors may be more appropriate, such as allocating the same weight to counseling activities as to educational and research activities.
Not voluntarily attending students in counseling sessions, students' dissatisfaction with retelling and sharing their personal information with counselors, and students' trust in only a limited number of senior mentors as well as students' use of private consultants and other experts for consultation indicate that students may lack trust in the mentors. The formal and institutional relationship between students and mentors as well as the inability of mentors to communicate and a lack of skill on the mentors' parts to win students' trust are the main causes. The empowerment of mentors with the skills required to communicate and to win the trust of students and using senior mentors already trusted by students as a model for educating mentors may help in solving this problem. Furthermore, preparing student recreational programs in order to ameliorate the more formal and institutional relationships between the students and the mentors and to establish a more sincere communication between them may be helpful, since in the recreational and social events, the dry and formal structure between the students and the mentors is lessened and can be more easily replaced by empathy and intimacy. Mentors need help in identifying potential talents and abilities of students and helping them grow, another challenge for the mentorship system suggested by students. This indicates that mentors are not familiar with talent identification skills. Therefore, in addition to communication and winning trust, mentors should also be trained in talent identification skills.
Solving some students' problems (for example, financial, occupational, family, etc) was another challenge which may require more specialized consultation. In this regard, a strategy for making mentors familiar with credible counseling centers outside the university such as job and career counseling centers or psychiatric and family relations counseling centers was proposed: these external resources can help mentors since they already have the knowledge and skills in these fields. Last, terminology used in the system (such as "supervisor" and "advisor") is also a challenge. These names are closely related to academic relationship of supervisors and advisors of student theses and thus can lead to a misconception of the role of the mentor in the minds of students, and it seems that renaming mentors as "supporters" could be helpful for engaging students' attention in this regard.

Conclusion
Despite the success and relative satisfaction with the mentorship system, there are challenges in several dimensions. Fortunately, the challenges in this area were such that it was possible to resolve them within the organization, and appropriate solutions were suggested to solve these challenges, which are discussed in the text of the article.
We hope that with the support of the university officials through the proposed solutions and the creation of appropriate mechanisms for implementation, the proposed solutions can be an effective step in improving the quality of this system.

Ethical approval
This study is extracted from a research project, with the ethical code of IR.TBZMED.REC.1394.1145. In this study, ethical considerations were considered, including confidentiality, informed consent from participants, considerations of possible conflicts of interests of the participants, etc.