Presentation on theme: "TRAINING OF NPCS IN MATERNAL HEALTH AND LEADERSHIP IN TANZANIA BY GODFREY MBARUKU AND SENGA PEMBA MAY 2012."— Presentation transcript:
TRAINING OF NPCS IN MATERNAL HEALTH AND LEADERSHIP IN TANZANIA BY GODFREY MBARUKU AND SENGA PEMBA MAY 2012
BACKGROUND With a physician to population ratio of close to 1:25,000 and further challenged by % of medical doctors practicing in urban areas the majority of the Tanzania population has no access to care by a physician However, there is potential of using the existing mid-level cadres in the system to provide essential services if their skills can be upgraded through targeted short courses or long courses
BACKGROUND CTD… AMOs and Nurse midwives for instance can effectively be upgraded to provide CEMOC in rural areas where Medical doctors are not willing or ready to work
WHY TRAIN NPCS FOR CEMOC SERVICES? WHO estimates that 1 in 10 pregnant women in Tanzanian requires emergency maternal health care so the need to have a trained health worker in EMOC We need to accelerate the attainment of health related MDG especially MDG 4 and 5
THE ETATMBA PROJECT: TRAINING OF ADVANCED LEADERS IN MATERNAL HEALTH To implement the ETATMBA Project, IHI in collaboration with TTCIH set out to train Non Physician Clinicians (NPCs) from disadvantaged HC and District Hospitals in CEMOC, anaesthesia and leadership and thereafter assess its impact on Maternal and Perinatal Mortality in their respective areas We were guided by the training life cycle to ensure success
Phase 1 Training conceptualization Phase 2 Planning the training Phase3 Execution of training Phase 4 Termination TIME EMOC TRAINING PROGRAMME: LIFE CYCLE
SELECTION AND RECRUITMENT OF TRAINEES We opted for a small intake of about trainees per batch To be able to show an impact, a pair (AMO, NW) were recruited from one health centre The NPCs were selected from facilities that were remote and hardly accessible during rainy season. The Facilities given priority were Heath Centers (HCs) that were already upgraded with theatres or were in the process of being upgraded. However, in certain disadvantaged districts there were no such HCs and therefore the District hospital was selected.
MAP OF TANZANIA
DURATION OF TRAINING Duration of Training was 16 weeks undertaken at the Tanzanian Training Centre and St. Francis Referral Hospital in Ifakara. AMOs: 10 weeks on CEMOC, 2 weeks on Leadership and 4 weeks of internship. Nurses: 10 weeks on Anesthesia, 2 weeks on leadership and 4weeks on internship The internship was done in their Regional Hospitals
DAILY TIME TABLE FOR NPC TRAINING am am: Review of Emergency cases managed by AMO within 24 hrs am-1.00 pm Major ward round pm: Lecture on EMOC topics including Neonatal Resuscitation pm-7:30 am: Night Duty for one AMO daily including weekends and public holidays
WHAT TRAINING STRATEGY ARE WE USING? We are training the AMOs and Nurse midwives using a competence based education approach Competence-based education is an approach that is related to on-the-job performance and has a close relationship between the knowledge or skill required and on-the-job application
TRAINING CURRICULUM FOR NPCS Two competence based training curricula are used (one for AMOs in EMOC and another for Nurses in Anaesthesia) The actual training duration is three months (12 weeks) full time with an addition of one month (4weeks) for internship The implementation of the curriculum requires the use of training facilities at a training centre as well as opportunities to practice at the hospital Training materials addressing the various areas of CEMOC are prepared in advance and availed to trainees A schedule detailing the day to day topics is usually prepared to standardise the teaching/learning process A logbook to guide the training of skills is given to each trainee
TRAINING CURRICULUM CTD… All NPC (AMO and Nurses) underwent 10 day- Leadership course during which management and leadership skills were taught by an expert in this area. See next slides for the leadership course!
Provide leadership in key areas of maternal health services Conduct organizational capacity assessment Manage change in a health facility Improve quality of services LEADERSHIP: OBJECTIVE- LEARNING OUTCOMES
Demonstrating Personal Qualities Working with Others Managing Services Improving Services Setting Directions TOPICS IN LEADERSHIP AND MANAGEMENT
TRAINING METHOD Develop research proposals Bring to this course own experiences Benefit own experience and knowledge Forum for sharing information Learning by Doing
LENGTH OF THE COURSE Day 1 Introduction and Orientation Personal Qualities Day 2 Values Day 3 Work improvement Day 4 Team work and Change management Day 5 Evaluation and way forward
WHO ARE THE TRAINERS OF THE NPCS? The trainers comprise of the following: – Obstetricians local and international – Anaesthetists/Anaesthetic Officers – General Medical Officers working in OBGY Department – Nurse midwives working in the in maternity ward – Leadership and Management experts
WHAT TEACHING METHODS DO WE USE? A variety of teaching/learning methods are used including: – Lectures discussions – Involving the trainees in the actual doing through practicing in the theatre as well as in the maternity and surgical wards at the teaching hospital – Encouraging trainees to conduct their own group discussions and presentations and availing trainees the opportunity for self study – Use of Clinical Skills Lab for demonstrations and simulations – A team approach to learning is emphasised where AMOs and Nurse Midwives learn together
TRAINING CURRICULUM: ASSESSMENT The assessment process is designed to promote the highest possible standards of demonstrable achievement within and beyond the scope and content of the curriculum. To achieve this, assessment of the trainees involves the following: – Course work and individual assignments – Class participation and group assignments – Self assessment – Monthly tests – End of module assessment using written exams and OSCE
INTERNSHIP The last 4 weeks of the course were on Internship in their Regional Hospitals. No Lectures were given at the hospitals. AMOs managed the Maternity wards as well as labour wards under our supervision and did surgical procedures (C/S, vacuum etc) on patients with indications. The nurses administered anesthesia and did neonatal resuscitation in the theatre
ACTUAL MODE OF INTERNSHIP Clinical meeting- attended daily by NPCs, all senior hospital staff and supervisor Lively discussion of all cases admitted during the 24 hrs Administrative problems discussed and sorted out Acts as a forum for continuing education and leadership role in action
ACTUAL MODE OF INTERNSHIP CTD... Daily ward rounds in the maternity ward Discussion on management of cases Focus on correct use and interpretation of the partogram Demonstration of practical procedures Applying skills and mentorship both in labour ward and theatre
MATERNITY DATA DURING INTERNSHIP:AN EXAMPLE OF S’WANGA HOSPITAL CESARAN SECTIONS 58 DELIVERIES 373 RUPTURED UTERUS 3 MATERNAL DEATHS 4 ( DUE TO ECLAMPSIA, RUPTURED UTERUS, ANAESTHETIC ACCIDENT). AUDIT OF MATERNAL DEATHS WERE ATTENDED BY ALL NPCs
Demand for accrediting the training programme is increasing How to effectively supervise the trainees in the clinical areas as trainers are few How to handle the issue of absenteeism from work places for the selected staff (12 weeks absence) How to make the course really hands-on as some of the trainers lack teaching methodology skills CHALLENGES RELATED TO THE TRAINING OF NPCS IN CEMOC
OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs At the end of the course, all NPC could fill the Partograms and interpret them correctly whereas before they could not Before training, all AMOs could do C/S but were not conversant with the indications as well as the importance of C/S on the lower segment and the prevention of bladder injury. Following the training, the importance of Preoperative antibiotics, catheterization (Catheters frequently not available in HCs) and early ambulation were well understood.
OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs CTD... In most health facilities, power supply was erratic and ~70% of C/S in Geita district hospital for instance were done without power. Transparent iron sheets were used for the roofing of theatres. No complications occurred despite this and NPCs appreciated the importance of internship within their home environment. Due to lack of power, manual aspiration machines were used for suction during the operation and sterilization of the tubes was emphasized
There was a scarcity of gauze nationally and therefore NPCs learned to use abdominal packs during C/S. NPC were unaware of the use of Misoprostol in prevention of PPH and induction of labour especially IUD Although use of V/E was emphasized it was rarely used even in cases of IUD due to obstructed labour with descent 1/5 and full dilatation; C/S was preferred instead OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs CTD...
Only Spinal anaesthesia and bolus ketamine were used in their HC/District hospitals but after the course all the Nurse-NPC could give GA by intubation. The Leadership course which the NPCs underwent helped them to face the often arrogant District Authorities. The NPCs met the District Authorities several times to present the problems their facilities faced and they were neither shy nor scared during the encounters. OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs CTD...
WAY FORWARD All the District hospitals that were visited had no Obstetrician and therefore the Maternity services were run by AMO who did not have up to date knowledge of CEMOC. At Geita District Hospital, the authority requested the CEMOC- trained- NPC to remain working there instead of going to the HCs but this was declined.
WAY FORWARD CTD… AMOs running District Maternity services should also be given priority for CEMOC courses as they receive all the referrals from HCs. Due to scarcity of medicines, gauze etc, the funds collected for the CHF should be retained by NPCs for purchasing these items instead of sending it to the District where it is used for other non medical purposes. Discussions with District authorities are under way
WAY FORWARD CTD… The NPC we have trained are now complaining that their burden of work has increased tremendously and cannot go on leave/holidays and despite all this, they have not received any on - call - allowances for the extra work nor accreditation from the Ministry. This has to be discussed with the authorities concerned. To improve communications with the supervisors, the trained NPCs requested Lap Tops for internet services. Supervisors need reliable transport to enable them to follow up the trainees in their working places
WAY FORWARD CTD… Supervisors should go with supply kits to avoid compromising the internship experiences Further training of the NPCs from the regions is required to encourage and promote continuing education culture for NPCs