Developing Effective Trainers for Sustainable Training Systems: Lessons Learned
(January 2003)

We are continuing to summarize some of the key presentations made during the "Training: Best Practices, Lessons Learned and Future Directions" conference held in May 2002. To date we have summarized:

• Top 10 best practices and lessons in training learned at the conference (Rick Sullivan, PhD)
• Developing effective group and individualized learning materials (Rick Sullivan, PhD)
• Case Studies and Role Plays: "Getting them Right" (Wilma Gormley and James McCaffery, senior consultants at TRG/PRIME II)

This month, we will summarize: Developing Effective Trainers for Sustainable Training Systems: Lessons Learned by Lunah Ncube, JHPIEGO Regional Program Officer and Patricia Gomez, Director, Midwifery Services, Maternal and Neonatal Health Program, JHPIEGO.

Faculty and Trainer Development Pathway

Until recently, trainers had few ways to learn training skills. To some it came "naturally," but usually only after many years of trial and error. Some individuals have had the opportunity of being taught by good clinical trainers whose style they could copy. For most people, however, little training in these skills was available. For that reason, JHPIEGO developed the Faculty and Trainer Development (FTD) Pathway, which outlines a series of steps that will assist clinicians in making the transition from healthcare provider to clinical trainer to advanced and, finally, master trainer. The Pathway also addresses the unique needs of preservice education. This systematic approach to the preparation of trainers recognizes that:

• there is a logical progression to the development of training skills,
• time and practice are required to master one level of skills before moving to the next, and
• skills needed at each trainer level are unique.

At each level of the trainer development process there is a series of steps comprising:

• Coursework to begin development of new training skills 
• Practice to become competent in those skills

JHPIEGO's FTD Pathway includes a progression from service provider through clinical, advanced and master trainer levels.

Becoming a Clinical Trainer

Progression through the levels begins with a healthcare provider who is proficient in the clinical skill that will be taught. The healthcare provider completes a:

• Knowledge update
• Skills standardization
• Clinical training skills (CTS) course, during which the provider learns the skills necessary to transfer clinical knowledge and expertise effectively

After completing these steps, the healthcare provider is a "candidate clinical trainer." Once the candidate clinical trainer completes a practicum--that is, conducts one or more clinical skills (CS) courses with an advanced or master trainer--the candidate becomes a "qualified clinical trainer" and can train healthcare providers without supervision.

Preservice Education

In the preservice setting, there are two groups of individuals working with students. The first group is classroom faculty. Classroom faculty includes those individuals who work almost exclusively in the classroom, transferring knowledge, and sometimes skills on models. The second group is clinical preceptors. Clinical preceptors include those individuals who work exclusively in the clinical setting, transferring predominantly clinical skills while working with both models and clients. Preservice faculty members follow a somewhat different learning process.

Classroom faculty members complete a reproductive health knowledge update and a clinical skills standardization on models only. Then, they complete a CTS course that is focused on effective presentation skills and use of models for clinical skills demonstration.

Clinical preceptors also complete a reproductive health knowledge update and a clinical skills standardization. But, then they complete a CTS course that emphasizes skills in clinical demonstration, coaching, and assessment of clinical skills with models and clients.

Upon completion of the CTS course, the individual is a "candidate classroom faculty" or "candidate clinical preceptor." Now, the candidate completes a practicum. An advanced or master trainer will observe the candidate presenting in the classroom (faculty) or working with learners in the clinical setting (preceptors). After successful observation, the candidate becomes a qualified classroom faculty or qualified clinical preceptor.

More than one practicum may be needed to demonstrate competency at any level. The timing of the practicum is very important to its successful completion. Ideally, it should be completed immediately after the course. If that isn't possible, it should be completed as soon as possible because the greater the time between course and practicum, the greater the deterioration of skills.

Malawi Experience

The development of trainers has been a goal of JHPIEGO's project with the Ministry of Health and Population in Malawi. The specific objectives are:

• To increase and expand the quality of reproductive health (RH) services in Malawi by expanding the national service delivery guidelines
• To develop an integrated clinical training network for both preservice and inservice family planning (FP)/RH clinical training
• To integrate selected FP/RH topics into the preservice medical and nursing curricula
• To strengthen FP/RH content in inservice curricula for FP service providers

Training in Malawi

The development of a core group of trainers was undertaken in Malawi. This process included knowledge and skills standardization for a core group. Then, the following individual clinical skills courses were offered over a two-year time frame:

• Counseling workshop 
• IP workshop 
• STI workshop 
• Minilap under local anesthesia course 
• Quality assurance workshop 
• Norplant(r) clinical skills course (joint with EngenderHealth)

Lessons Learned

A number of lessons were learned through this process.

1) There should be trainer selection criteria. Potential trainers should have expressed interest in training. They should exhibit competence as an RH service provider, or they should already be conducting FP/RH classroom and/or clinical training and plan to continue to do so for the near future. Finally, they must be able and willing to make an extensive time commitment.

2) Those conducting the training must be subject matter experts and must be trained in training skills including skills that relate to:

• Skill standardization and knowledge update
• Classroom and clinical training skills
• Practice using the course materials in presentations, demonstrations, coaching, etc.

3) Trainers should be provided with a learning package and must be oriented as to how to use the course materials. This is important because most trainers are not instructional designers. It also encourages the trainer to use a variety of training methods, improves the trainer's time management, and helps ensure standard delivery of training. Trainers can adapt the materials as necessary.

4) It takes time to develop trainers adequately. A program manager should not underestimate the amount of time needed to move people through the trainer development process. It is important to start with a larger number than you think you will need. Take attrition of core group members into account when beginning to plan.

5) Develop a critical mass representing both classroom faculty and clinical trainers at each institution in order to be able to ensure consistency in both classroom teaching and clinical practice

Maternal and Neonatal Health (MNH) Project Experience

The MNH Project has experience in developing regional trainers. These trainers have been developed to be able to:

• Advocate for changes in maternal and neonatal care practices 
• Articulate the evidence for these changes 
• Perform the necessary skills 
• Teach at preservice education and inservice training levels 
• Provide leadership in their institutions, countries and regions

MNH Training Process

The training process for these trainers required 8 to 10 weeks over the course of a year and included the following activities:

• Technical Update (1 week; classroom)
• Clinical Skills Standardization (2 weeks, clinical site, commitment statements developed)
• Followup (within 2 to 3 months)
• Clinical training skills course (2 weeks)
• Conduct training course with coaching from experienced trainer
• Advanced Training Skills (ATS) and Change Leadership Workshop (1 week, problem solving and clinical decision-making, change leadership)

Trainers were also encouraged to act as agents of change in their own institutions throughout the process.

MNH Training Materials

For the technical update, two reference manuals were used:

• Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors (MCPC)
• Basic Maternal and Newborn Care (BMNC), Draft.

The MCPC reference manual was accompanied by a learning resource package that features case studies, role plays, checklists, skills practice, and more.

For the clinical skills course, the manual and courseware for Clinical Training Skills (CTS) for Reproductive Health Professionals were used.

For the Advanced Training Skills course, the manual and courseware for Advanced Training Skills for Reproductive Health Professionals were used along with a change leadership curriculum.

Results

To date, the following results have been achieved:

• Africa - 17 participants from 7 countries have completed the entire process.
• Asia - 13 participants from 3 countries have completed the CTS. The ATS will occur in early 2003.
• Latin America/Caribbean - 15 participants from 8 countries have completed the entire process.

Followup

Follow-up activities will be undertaken in each region with the following objectives in mind:

• Assess and strengthen clinical skills 
• Assist with problem solving 
• Assess progress towards commitments; provide recognition and encouragement 
• Act as supportive link with supervisor

The followup methodology involves interviews with participants and supervisors to assess progress towards commitments, identify obstacles encountered, help with problem solving and develop communication strategies. Knowledge retention will be evaluated using questionnaires and case studies. Skill retention will be evaluated using checklists. Finally, trainers will complete a questionnaire designed to assess their confidence.

Lessons Learned: Clinical Component

1. Clear criteria for selection of participants should be articulated.
2. Participants should work in teams (physician/midwife or physician/nurse) whenever possible.
3. Adequate preparation of clinical sites is critical.
4. Complex skills require creative methods to ensure mastery.

Lessons Learned: Follow-up Component

1. Participants should practice "rare event" skills often after training, using models and checklists.
2. Program staff should meet with supervisors and participants soon after training to clarify commitments.
3. A network should be set up so participants can communicate with each other and with faculty.
4. Promotion of experts is needed to make them known as regional resources.

Lessons Learned: CTS Component

To prepare clinical trainers adequately, the CTS course must address:

• Adequate time to prepare clinical sites
• Use of clinical simulations and drills to teach clinical decision-making
• Conducting and supervising clinical practice opportunities

Summary

Although the experiences described above occurred in different regions of the world, and with diverse types of healthcare providers, it is evident that by using JHPIEGO's Faculty and Trainer Development Pathway many countries have been successful in increasing their training capacity. It is interesting to note the many "lessons learned" that are common to the activities in Malawi and the MNH Program:

1) Potential trainers should be selected according to well-defined criteria (e.g., their expertise as service providers, their expressed interest in becoming trainers, and their willingness to commit the time necessary to serve as qualified trainers).

2) In selecting candidates to become trainers one should start with a larger number than may actually be needed to account for the attrition that may occur during the process.

3) Effort should be given to the strengthening of clinical training sites so that trainers can focus on modeling appropriate skills in an environment conducive to learning them.

4) Adequate time should be allotted for the development of trainers because they must practice their training skills with the mentorship of advanced trainers until competency is reached.

5) Once qualified, trainers should be given adequate training packages and oriented in their use in order to enhance their time management skills, allow for a variety of teaching methods, and ensure consistency among trainers.

For more information about trainer development, contact Lunah Ncube, Patricia Gomez, or Lois Schaefer at repro@jhpiego.net.

For more information about the Training: Best Practices, Lessons Learned and Future Directions Conference held in the U.S. in May 2002, contact Rick Sullivan at repro@jhpiego.net

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