Training of Trainers – Community Midwives Workshop Report Fatima Memorial Hospital, Shadman, Lahore, Pakistan
INTRODUCTION Pakistan at present is facing the challenge of achieving the millennium development goals 4 & 5 to reduce the child and maternal, mortality & morbidity rate up to 2015. An estimated 350 to 550 Pakistani women die for every 100,000 live births. Pakistan's high maternal and infant mortality rates reflect the country's shortage of trained health workers and its inadequate health infrastructure. Currently, more than 65 percent of women in Pakistan deliver their babies at home, and onl y eight percent of these home births are supervised by a trained attendant. Only 36 percent of Pakistani mothers currently deliver their babies with the assistance of a skilled birth attendant. Deaths among newborns, infants and children have not decreased in the past 10 years.1 There is global consensus on the need for skilled attendants at childbirth hence midwife specifically is the most appropriate health care professional for women during pregnancy, childbirth and the postnatal period. Fatima Memorial System has always taken a lead in initiating health sector reforms in the past and this time again took this initiative of training the present and potential health work force at Saida Waheed FMH College of Nursing. It is a unique model of public and private partnership to address the acute shortage of health work force. It is not only providing quality education and training to students enrolled in Diploma in General Nursing, Community Midwifery, Post Basic Diploma Courses, B.Sc Nursing (04yrs)Program and Post RN B.Sc (02yrs)Program but is also focusing on the professional development of the current public and private sector nursing staff and faculty, who are the nursing leaders of the future. Although the midwifery training is already being imparted to develop this cadre of health work force but the concerned stakeholders felt the need to have a comprehensive program in line with the practices laid down by the International Council of Midwifery .Thus a task force was constituted comprising of local and foreign nursing and midwifery experts.
1
Source; USAID Report April -June 2008
1. OBJECTIVE OF T RAINING To improve the teaching of Midwifery, including Community Practice, resulting in improving the maternal health and reducing the child mortality
2. SPECIFIC OBJECTIVES This three-weeks training is initiated with the intentions to strengthen teaching abilities of the faculty for through pupil midwifery and community midwifery courses and in the long run to improve the performance of services provided by the health care organizations. By the end of this training, participants will be expected to: 1. Strengthen midwifery faculty skills by improving theoretical knowledge and clinical competencies. 2. Standardize the curriculum for advanced midwifery in line with the International Midwifery Council 3. Develop an understanding of Code of Conduct; Regulatory mechanism for midwifery practices. 4. Focus on Professional Relationship, Collaboration of midwives with other team members and Allied professions. 5. To update the theoretical knowledge of midwifery tutors 6. To help upgrade professional practical skills of midwifery tutors
P ARTICIPANT PROFILE The participants for the training were nurses from different cities of Punjab. The diversified representation provided an excellent platform for them to meet and interact with each other about their currently methodology and issues they are facing within their communities. It also provided an excellent opportunity to voice their problems and concerns to the policy makers. NAME
CITY
Attia Khatoon
Multan
Fauzia Zafar
Gujrat
Imrana Yasmin
Multan
Iqra Habib
Chinniot
Ireen Zaib un Nisa
Multan
Isbella James
Hafizabad
Musarat Parveen
Khanewal
Nusrat D/O Gh. Muhammad
Muzafargarh
Razia Sultana
Shahiwal
Rehana Kokab
Jhang
Rubina Benjamin
Lahore
Shaheen Kousar
Lahore
Surriaya Bano
Narowal
Tanveer Akhter
Chakwal
Zakira Firdous
Lahore
TRAINER PROFILE Keeping in view the need of the content, different trainers and one facilitator were decided upon. The list of trainers included:
Dr. Ayesha Nauman
Dr. Fatima Imran Prof. Dr. Jovaria Mannan Dr. Attiqa Muzzammil Prof. Dr. Taslim Malik Dr. Naveed
Director Human Resources Senior Registrar Professor of Pediatrics Associate Professor Visiting Consultant PG Trainee
Irshad Begum
Director Nursing Education & Development
Saleema Dewan
Coordinator
Dr. Anis Fatima
Faculty
Shafqat Hussain Zaidi
Faculty
Masters in Human Resource Management , Diploma in Project Management, Certified in Human Resource Management, Master in Business Administration, Bachelor in Medicine and Bachelor in Surgery MBBS, FCPS MBBS, FCPS, DCH MBBS, MCPS, FCPS MBBS, FRCS MBBS, FCPS Part-I Diploma in General Nursing & Midwifery (PNC), Diploma in Nursing Management & Nursing Education, B.L.L.B From Bahauddin Zakariya University, Certificate Course Infertility Management & Reproductive Health (John Hopkins University Baltimore Mary Diploma in General Nursing & Midwifery (PNC), Diploma in Nursing Management & Nursing Education, Post Basic Diploma in Advaced Midwifery F.C.P.S-1, Diploma in Gynae & Obs (DGO),M.B.B.S MS leading to PhD in applied linguistics (continue) MA English literature, MA TEFL, PGD,ELT, Certified teacher trainer (PEF).
TRAINING M ETHODOLOGY Designed and delivery of the training is via theoretical as well as practical approach embedded in participatory techniques of adult education. The methodology is based on principles of adult learning, using a mixture of presentations, interactive discussions, and group work. The training methodology included:
Illustrated lectures, audio visual aids in addition to verbal explanation Discussion/ Brainstorming, to share views and problems using reasoning power, to get all possible ideas from the group members Group work, to interact with each other and learn together Case studies, to develop and practice clinical decision-making skills Role plays, to develop and practice interpersonal communication sills Learning guides and checklists, to learn to provide (emergency) obstetric care Demonstration/practice on Dummy, to show how to perform a procedure Hands on training/Bedside teaching, to practice under supervision Self study, to gain deeper insight and more profound knowledge
Tools needed;
Training Manuals, Multimedia Audio Visual Aids Mannequin Community and DHQ Health Center Visits OSCE visits Handouts
AGENDA OF THE WORKSHOP
SESSION NAME
TIME
Registration (First Day only)
9:00 –9:15 am
Orientation to Workshop (First Day only)
9:15 –9:30 am
Session #1:
09:00 –10:00 am
Tea/Coffee Break
10:00 –10:30 am
Session #2:
10:30 –11:30 am
Session #3:
11:30 –12:30 pm
Lunch & Prayer Break
12:30 – 13:30 pm
Session #3:
13:30 –14:30 pm
Closing Ceremony (Last Day only)
10:00 – 12:00 pm
OBJECTIVES
Introduction of participants Pre-workshop assessment
Post-workshop assessment Workshop & Trainer Evaluation Certificate presentation
WORKSHOP PROCEEDING Sessions Outline – Week I
Time Slot
Day I
Day II
Introduction 8:30 am to 10:00am
Goals and Objectives Pre-Training Assessment
Trainer
Dr. Ayesha Nauman
History Taking in Obstratical & Gaynacological Patients Calculation of EDD Dr. Anis Fatima
Day III Implication of cognitive, psychomotor and effective domain in midwifery education and clinical practice Mrs. Irshad Javed
Day IV
Day V
Day VI
Learning theories
Competency -1 Social epidemiologic and cultural context of maternal and newborn care
Mrs. Irshad Javed
Mrs. Irshad Javed
Physiology of Mestuctal cycle Physiology of Pregnancy Dr. Ayesha Nauman
Tea 10:00 to 10:30 a.m
10:30am to 11:30am
Trainer 11:30am
Sign & symptoms of pregnancy
Midwife, Midwifery, Philosophy of Midwifery Community Health Nurse/Worker
Ethics in midwifery practice
Dr. Anis Fatima Introduction to Safe motherhood
Mrs. Irshad Javed Learning objectives in the context of
Development of Lesson Plan
Mrs. Irshad Javed Group Presentation on Lesson Plan
Teaching & learning methodologies
Mr. Shafqat Zaidi Reflective Teaching
Learning theories
Mrs. Irshad Javed Initiatives at public & private
Diagnosis of pregnancy Role of ultrasound during pregnancy Mrs. Irshad Javed Developing of check list from ICM
to 12:30pm
Pre Pregnancy Care & role of Pre Pregnancy Care Clinics
bloom’s taxonomy i.e., Cognitive, Psychomotor & effective domain
Trainer
Mrs. Irshad Javed
Mrs. Irshad Javed
1:30 pm. to 2:30 pm
Introduction to Community Midwifery Training Manual
Trainer 2:30 pm to 3:00pm
Mrs. Irshad Javed Feed back on today session + Assignment
Trainer
Mrs. Irshad Javed
Mrs. Irshad Javed Lunch + Prayer Break 12:30 to 1:30 pm Learning objectives in Introduction to the context of monitoring and bloom’s taxonomy i.e, evaluation Group presentation Cognitive, M & E Tools on lesson plan Psychomotor & Its importance in effective domain midwifery practice Mrs. Irshad Javed Mrs. Irshad Javed Mr. Shafqat Zaidi Feed back on today Feed back on Feed back on today session + today session + session + Assignment Assignment Assignment Mrs. Irshad Mrs. Irshad Javed Mrs. Irshad Javed Javed Mrs. Irshad Javed
sector to reduce MMR & IMR
cognitive, psychomotor and effective domain for Competency 1.
Mrs. Irshad Javed
Dr. Anis Fatima
Brief on essential competencies for basic midwifery practice by ICM
Developing of check list from ICM keeping in mind cognitive, psychomotor and effective domain for Competency 2.
Mrs. Irshad Javed Feed back on today session + Assignment
Mrs. Irshad Javed
Mrs. Irshad Javed
Mrs. Irshad Javed
Feed back on today session + Assignment
Sessions Outline – Week II
Time Slot
8:30 am to 10:00am
Trainer
10:30am to 11:30am
Day I
Day II
Group presentation and feedback on check list from ICM keeping in mind cognitive, psychomotor and effective domain for Competency 1 & 2.
Clinical experience in OPD l in various setting in the context of Competency 1,2 &3 Taking health history and physical examination
Mrs. Irshad Javed
Ms. Saleema Deewan Dr. Anis Fatima
Competency 3 - in provision of care during pregnancy in the context of cognitive, psychomotor & effective domain. Management of Normal Pregnancy
Minor age mention pregnancy, hyper amanasis gradvidarum of pregnancy
Day III
Brief on Competency 4 - in provision of care during labor and birth) in the context of cognitive, psychomotor & effective domain
Dr. Saadia Usman
Day IV
Major disorders during pregnancy Pregnancy induced hypertension Pre eclampesia Eclampesia
Day V
Major disorders in pregnancy Diabetes, mellitus during pregnancy Risk factors
Dr. Anis Fatima
Tea 10:00 to 10:30 am Diagnosis of onset Competency 5 - in of labor, labor provision of care management. 1st, for women during 2nd & 3rd stage of the postpartum labor period Lactation management and Obstetric Importance of indication for breast feeding emergency,
Day VI
Competency 6 in postnatal care of the newborn Brief session on Neonate Assessment
Dr. Anis Fatima
Prof. Jovaria Mannan
History & Examination taking of dibetes patients Ultrasonographic reviews of the fetus for congenital abnormalities and management
Developing checklist of group presentation on Competency 6 in postnatal care of the newborn Infant development in
referral or transfer for obstetrician. Trainer
11:30am to 12:30pm
Dr. Anis Fatima
Developing check list for Competency 3 (Competency in provision of care during pregnancy.
Dr. Anis Fatima
Diagnosis and management of miscarriages
Ms. Saleema Deewan Lunch + Prayer Break 12:30 to 1:30 pm Rights of the patient 1:30 pm. Maintaining Heptoses to confidentiality pregnancy 2:30 pm Documentation Record keeping Trainer
Dr. Anis Fatima
the first year
Dr. Saadia Usman
Dr.Anees Fatima
Dr. Anis Fatima
Developing check list of Competency 4 - in provision of care during labour and birth
Developing check list for competency 5 - in provision of care for women during the postpartum period
Group discussion Role play
Dr. Saadia Usman
Mrs. Irshad Javed
Dr. Anis Fatima
Group presentation and feedback on checklist from ICM for competency 4
Anemia’s in pregnancy
Gestational debates and dietary management
Trainer
Mrs. Irshad Javed
Dr. Anis Fatima
Dr. Saadia Usman
Dr. Anis Fatima
Dr. Anis Fatima
2:30 pm to 3:00pm
Feed back on today session + Assignment
Feed back on today session + Assignment
Feed back on today session + Assignment
Feed back on today session + Assignment
Trainer
Mrs. Irshad Javed
Feed back on today session + Assignment Mrs. Irshad Javed
Mrs. Irshad Javed
Mrs. Irshad Javed
Mrs. Irshad Javed
Prof. Jovaria Mannan Developing check list for competency 6 in context of cognitive, psychomotor and effective domain Prof. Jovaria Mannan
Group presentation of competency 6 Prof. Jovaria Mannan Feed back on today session + Assignment Mrs. Irshad Javed
Sessions Outline – Week III Time Slot
8:30 am to 10:00am
Trainer
10:30am to 11:30am
Trainer
Day I
Day II
Day III
Feedback of previous session brief on Competency 7 (competency in facilitation of abortion related care) in the context of cognitive, psychomotor and effective domain
Feedback of previous session Clinical Experience competency 6 Brief session on Neonate Assessment (reflexes, APGAR scoring, Resuscitation)
-Brief on community mapping. Community sensitization and mobilization Community partnership Formation of community support group for enhancing community acceptance
Dr. Saadia Usman
Saleema Dewan
Prof. Amanullah Khan Tea 10:00 to 10:30 a.m Briefing on essential factor for community visit and community experience Community visit to a public sector RHC at Sheikhupura
Developing checklist for Competency 7 Policies, protocols, and law related to abortion Medical eligibility criteria for abortion Sign and symptoms of incomplete abortion and abortion complications Dr. Saadia Usman
Clinical Experience competency 6 (continue)
Prof. Amanullah Khan
Day IV
Community visit to a public sector RHC at Sheikhupura
Day V
Day VI
Community visit to Malikpur
•Feedback of previous session •Drug related to community midwifery •Recognize the importance of rational use of drugs •Classify the group of essential drugs use in midwifery in the care of mother and new born. Mrs. Irshad Javed
Community visit to Malikpur
Administering drugs adverse effects and contradiction in relation to trimesters of pregnancy Responsibilities of a midwifery while prescribing and administering drug Mrs. Irshad Javed
11:30am to 12:30pm
Session on introduction to EMOC Obstetric indications for per-natal complications
Communication skills Interpersonal Community Clinical relationship with visit to a experience medical and other allied public sector Competency 7 in professions RHC at the context of Communication of bad Sheikhupura post abortion news to mother and related care) family for baby loss, mother death Prof. Amanullah Khan Lunch + Prayer Break 12:30 to 1:30 pm
Trainer
Mrs. Irshad Javed
1:30 pm. to 2:30 pm
Hospital policies and protocols for transfer and referral system for high risk patients to a tertiary care facility Role of midwife in EMOC
Trainer
Dr. Tasleem Malik
2:30 pm to 3:00pm
Feed back on today session + Assignment
Feed back on today session + Assignment
Feed back on today session + Assignment
Trainer
Mrs. Irshad Javed
Mrs. Irshad Javed
Mrs. Irshad Javed
Clinical experience Competency 7 (continue)
Group presentation on a case study
Community visit to a public sector RHC at Sheikhupura
Community visit to Malikpur
Essential elements of quality of care including compliance with standards, competency, continuum of care
Dr. Anis Fatima
Community visit to Malikpur
Dr. Anees Fatima Ms. Saleema Deewan
Related the quality in health care to competency, continuum of care, compliance Related monitoring and supervision to quality of care. Mrs. Irshad Javed
Community visit to a public sector RHC at Sheikhupura
Community visit to Malikpur
Feed back on today session + Assignment Mrs. Irshad Javed
Sessions Outline – Week IV Time Slot
8:30 am to 10:00am
Trainer
Day I Feedback of previous session How to monitor and supervise deployed CMWs for providing them technical support
Feedback of previous session Brief session on OSCE By: Mrs. Irshad Javed
Mrs. Irshad Javed Saleema Dewan
Graded presentation on antenatal care (Group-1) Dr. Saadia Trainer Usman Graded presentation on Graded 11:30am presentation on to Postnatal Care 12:30pm (Group-2) Post Abortion (Group-3) Trainer Mrs. Irshad Javed 10:30am to 11:30am
Day II
Orientation to the participants in OSCE center. Mrs. Irshad Javed
Practice on OSCE 4 - stations
Day III
Day IV
Feedback of previous session Practical session for Practical session for OSCE on individual OSCE on individual skill competency skill competency By: By: Dr. Anees Fatima Dr. Anees Fatima Ms. Saleeema Ms. Saleeema dewan dewan Mrs. Irshad Javed Mrs. Irshad Javed Tea 10:00 to 10:30 a.m Practical session for OSCE on individual skill competency By: Practical session for Dr. Anees Fatima OSCE on individual Ms. Saleeema skill competency Dewan By: Dr. Anees Fatima Ms. Saleema Dewan
By: Mrs. Irshad Javed Mrs. Irshad Javed
Mrs. Irshad Javed
Day V
Day VI
Feedback of previous session on OSCE
Review and quarries in last three week session By: Dr. Anees Fatima Review and quarries in last three week session
Mrs. Irshad Javed
Closing Ceremony
Lunch + Prayer Break 12:30 to 1:30 pm
1:30 pm. to 2:30 pm
Trainer 2:30 pm to 3:00pm Trainer
Hospital policies and protocols for transfer and referral system for high risk Clinical experience patients to a Competency 7 tertiary care facility Role of midwife in EMOC Dr. Tasleem Malik Reflective practice
Reflective practice
Mrs. Irshad Javed Mrs. Irshad Javed
Practical session for OSCE on individual skill competency By: Ms. Saleeema Dewan
Dr. Anees Fatima
Practical session for OSCE on individual skill competency By: Dr. Anees Fatima Ms. Saleeema dewan
Post Test By: Mrs. Irshad Javed Dr. Anees Fatima
Mrs. Irshad Javed
Reflective practice
Reflective practice
Feed back
Mrs. Irshad Javed
Mrs. Irshad Javed
Mrs. Irshad Javed
FEEDBACK & COMMENTS The participants were selected from different parts of the province all having experience and adequate educational level. Their theoretical knowledge about midwifery was limited and not updated in accordance with the latest guidelines with the international bodies. They are able to list, state and memorize theory. But they often lacked comprehensive, applying and synthesizing skills to work with theoretical knowledge. We notice a language problem but the lectures were kept in the way that most of the participants were able to understand and comprehend the basic concepts which were being explained to them. The training was not only confined to theoretical lectures only but also different interactive teaching methods were used as well including audio, visual, tours to wards, health care centers and community. The NCRP team believes that we need to improve these methods while incorporating new ones as well to improve the performance. Majority of them were in favor of more hands on experience in community and treating/witnessing actual patients/cases. The participants were very eager to learn to perform different examinations techniques and even delivering a baby. They also demanded that knowledge should be transferred more through visual aid like documentaries and lectures. The participants were very eager to acquire midwifery skills and they did participate actively during lectures. The trainers focused on the fact that the professional attitude expected from an independent midwife who is working as a community midwife differs essentially from the professional attitude of a nurse. An independent midwife is a medical practitioner, trained to work autonomous, being a specialist in normal pregnancy childbirth and puerperium. This attitude was lacking in some of the participants and it takes much more time to develop this attitude under supervision of competent midwifery teachers functioning as a role - model. Regarding teaching skills we saw only a few participants who are competent teachers. Other than the operational problems faced b the participants (mainly stay and food arrangements by MNCH), the participants were satisfied with the program. They appraised the teaching quality and abilities of the trainers. Most of the participants were motivated and willing to learn these techniques and implemented once they are back. This is a positive thing since it is very important that the training shouldn’t end right here, in fact there would be no results unless they go back and actually make a difference by adopting these practices. Few participants expressed themselves that there is lack of training at district level and this training would help them implementing these techniques to their areas plus they would also teach the other community midwives in those areas. Another important session which was need of the hour was communication and community mobilization. Participants expressed that they find it difficult to communicate with the women in their areas i.e. rural far flung areas where the elderly women mostly takes the charge in case of pregnancy. The sessions on communication skills and community mapping/mobilization were included in the program and highly appreciated by the participants.
THE W AY F ORWARD
The NCRP Team with MNCH should review the content and session outli nes and need to update and revise the content where necessary in accordance with the short and long term objectives explained in the project proposal
The theoretical part should be supported by more visual/audio aids
The handouts, notes, slide printouts, books should be provided on timely basis so participants can revise on daily basis
Feedback sessions and evaluation should be done more actively at the end of every week to monitor the progress on timely basis
At the end of program, the participants should be test on theory as well as in practical examinations with announcement of top three participants during the closing ceremony
The participants should be encouraged to do self analysis of the improvements they have achieved and how it would improve individual and collective effort when they go back to their areas
The most important thing is the actual implementations of these techniques when they go back thus follow up visits to the areas of participants to judge the performance or improvement
ANNEXURE ANNEXURE 1: LIST OF PARTICIPANTS PARTICIPANT PROFILE Name
Address
Fauzia Zafar
School of Nursing & Midwife, Gujrat
Shaheen Kausar
Public Health Nursing School, Lahore
Iqra Habib
DHQ Hospital, Chinniot
Imrana Yasmin
Public Health Nursing School Nishtar Hospital, Multan
Attia Khatoon
Public Health Nursing School Nishtar Hospital, Multan
Razia Sultana
School of Nursing DHQ Teaching Hospital, Shahiwal
Musarat Parveen
School of Nursing DHQ Hospital, Khanewal
Rehana Kokab
School of Nursing, Jhang
Ireen Zaib un Nisa
School of Nursing, Multan
Nusrat Ghulam Muhammad
School of Nursing DHQ Hospital, Muzafargarh
Zakira Firdous
Lady Aitcheson Hospital, Lahore
Isbella James
G.N. School DHQ, Hafizabad
Fauzia Zafar
School of Nursing & Midwife, Gujrat
ANNEXURE 2: EVALUATIONS F ORMS
ANNEXURE 3: EVALUATIONS
EVALUATIONS RESULT 4.0
3.0
2.0
1.0
0.0
PARTICIPANT RESPONSE ON WORKSHOP CONTENT 10.0 8.0 6.0 4.0 2.0
Strongly Disagree Disagree
0.0
Neutral Agree Strongly Agree
MOST VALUABLE ATTRIBUTES OF WORKSHOP 35
30
25
20
15
10
5
0 Valuable & Qualified and Good Good Updated and Informative Experienced behavior of learning Review Topics trainers trainers environment Content
Teaching methods
Helpful lectures
Objective
Improve Knowledge
ANNEXURE 4: P ICTURES
“It is most important to conduct such programs for community midwives since there is no trainings for them at distract level. I would definitely go back and teach others about the things we have learnt here.”
“The workshop and arrangement exceeded my expectations. I had heard a lot about the Fatima Memorial Hospital and after experiencing it firsthand I must it is one of the top institutions in the country with excellent teachers”