JHPIEGO TrainerNews™ |
Strengthening Preservice Education: A
Systematic Approach and Lessons Learned
(March 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)
- Developing Effective Trainers for Sustainable Training Systems: Lessons Learned (Lunah Ncube and Patricia Gomez, JHPIEGO)
This month, we will summarize: "Strengthening Preservice Education: A Systematic Approach and Lessons Learned" by Lois Schaefer, Susi Wyss, and Behire Ozek of JHPIEGO Corporation.
Objectives
After attending this session, participants will be able to:
- Identify the advantages and challenges of strengthening preservice education
- Describe a process for strengthening both content and teaching methodologies in preservice education
- Apply lessons learned from JHPIEGO's experience in implementing this process
JHPIEGO Framework for Quality Reproductive Health Training in National Programs
JHPIEGO's Framework for Integrated Reproductive Health Training brings together the educational and health systems of a country to focus on the preparation of a cadre of providers who can deliver standardized, high quality services. Preservice and inservice training are harmonized and coordinated in the model. Service delivery and clinical training are guided by a single set of nationally accepted service delivery guidelines that reflect up-to-date national and international policy. Implementation of this model in various countries has demonstrated its appropriateness and effectiveness in addressing reproductive health training and service delivery needs.
Each element of training is linked to the others. And, while they can be separated for illustrative purposes, in the end they are all part of the entire reproductive health network. The elements are part of a continuum starting with a needs assessment and ending with service delivery points:
- Training needs assessment
- Current international resource materials
- National policy and service delivery guidelines
- Preservice education
- Inservice training for practicing health professionals
- Service delivery and clinical training sites
- Service delivery points
What Is Preservice Education?
In this presentation, we will focus on preservice education. Preservice education has the following features:
- Prepares students to become FP/RH healthcare providers (physician, nurse, midwife)
- Learning takes place in undergraduate and graduate healthcare educational institutions (e.g., medical, nursing, and midwifery schools) over a period of 1 to 6 years
- Ensures a basic set of skill competencies for a general healthcare provider (ideally, based on a post graduation job description)
A typical preservice system extends beyond the teaching institution itself, to include a variety of components and stakeholders, all of which determine what content is included in preservice curricula, how it is taught, and the importance or emphasis that is given to it. Entrance requirements are generally set by the Ministry of Education (MOE) and/or Ministry of Health (MOH), often with input from professional associations. The teaching institutions and how teaching is conducted are often under the supervision of the MOE, while the clinical practice sites where students will develop their skills most fully are under the direction of the MOH. Coordination is required to ensure that adequate opportunities for practice that is consistent with what is being learned in the classroom are provided. What students must achieve in order to graduate successfully from the preservice system is also established by the MOE and/or MOH, often with input from professional associations and licensing bodies. National councils or professional associations determine what is required for licensure after graduation and for maintaining that licensure over time. These groups may work with the MOH in establishing these standards. They may also play a role in accrediting teaching institutions and clinical practice sites. Finally, how new graduates are used within the healthcare system--the location and type of facility to which they are assigned, the role they fill there, and the length of service in that position--is generally determined by the MOH and based upon the most urgent needs of the healthcare system. Change in any one of these areas can have considerable impact on other areas, in both positive and negative ways. Addressing only one factor or including only some of the stakeholders may result in temporary improvements, but often the impact is not sustainable.
Advantages of Preservice Education
Preservice education has many advantages. It reaches more providers at once than inservice training does. And, preservice education ensures that providers share the same knowledge and skills based on updated RH policies and standards. In addition, what students learn during preservice education often determines how they practice throughout their careers. So, preservice education is an opportunity to instill good practices. In addition, preservice education offers an extended learning period for skill and attitude development--rather than just a few days or weeks. Finally, preservice education is more sustainable because it strengthens existing educational institutions and supports the development of model service delivery sites and providers.
Mary's Story
Now, let's look at a hypothetical situation. Mary is 18 years old and wants to become a midwife. The midwifery school has 50 to 70 students per class, with one or two teachers. The classes are lecture style, and Mary must take meticulous notes because very few reference materials are available. The teachers have not maintained their clinical skills, and the classrooms and equipment are old and/or not functioning.
In the clinic, the teacher must "supervise" 10 students. The clinical preceptor often provides different and sometimes even conflicting information. There is too much "down time" because the time spent in the clinic is poorly planned or because there are not enough clients.
In addition to the problems with the learning environments, only written exams are used for assessment. Then, after graduation, students are deployed to a remote site with little support and supervision. Finally, the linkages between MOH, MOE and teaching institutions are poor.
Now that she is posted, does Mary have adequate skills to offer the necessary services? Very often the answer is "No." Regular inservice training is needed as well as motivation to "add on" new skills that are often seen as extra work. Because Mary's salary is, most likely, very low, her motivation to take on any "extra work" may also be low.
So, how do we improve this situation? One way is to improve preservice education by increasing the focus on skill development through use of mastery learning and competency-based training. This includes:
- Learning by doing
- A focus on specific knowledge, attitudes, and skills needed to fulfill job responsibilities
- An emphasis on performance rather than knowledge
- Use of a humanistic training approach (i.e., using anatomic models to ensure competency before working with clients)
There is a continuum of options for integrating mastery learning and competency-based training into curricula to strengthen preservice education. The simplest option would involve focusing just on a module or section in part of a 2- or 3-year curriculum. This would include both the classroom portion and clinical practice. The most complex option would be to strengthen multiple courses, multiple years, or even an entire curriculum. An intermediate option would involve strengthening the internship year or rotation in Ob-Gyn or FP/Maternal and Child Health (MCH), as is frequently done in medical schools.
Strengthening Preservice Education
The best practice for strengthening preservice education involves a process to incorporate mastery learning and competency-based training into health professional schools that addresses all of the elements of the preservice education system.
There are four phases of the process for strengthening preservice education. They are:
- Phase 1 - Plan and Orient
- Phase 2 - Prepare for and Conduct Teaching
- Phase 3 - Review and Revise Teaching
- Phase 4 - Evaluate Teaching
The steps involved in each phase are as follows:
- Phase 1 - Plan and Orient
- Create a national working group
- Conduct a needs assessment
- Develop a national plan of action
- Orient opinion leaders and decision-makers
- Create a curriculum strengthening group
- Phase 2 - Prepare for and Conduct Teaching
- Train the curriculum strengthening group by conducting a technical update and clinical training skills course
- Strengthen the curriculum using principles of instructional design
- Develop and produce teaching, learning, and assessment materials
- Equip the teaching institutions
- Plan for implementation in each institution
- Orient decision-makers, faculty, and clinical staff at each institution
- Train additional faculty and relevant clinical staff
- Prepare clinical practice sites
- Coordinate teaching
- Conduct and monitor teaching
- Conduct followup visits
- Phase 3 - Review and Revise Teaching
- Review the institutional plan of action
- Assess the methods and materials used
- Measure the outcome of teaching
- Revise the institutional plan of action
- Conduct review and revision visits
- Review and revise the national plan of action
Strengthening preservice education produces substantial short-term effects. Even before teaching begins, two significant results are achieved. First, revised curriculum and training materials are harmonized with and reflect national guidelines. Second, clinical practice is updated in quality service delivery sites. Typically, these initial results can be achieved in 12 to 18 months.
Once teaching is under way, long-term outcomes are also achieved-- primarily, students are trained in and are providing essential services. The student clinical practice contributes to ongoing service delivery, and students are immediately productive as service providers when they take their place in the workforce.
How Do We Know It Works? The Philippines
JHPIEGO worked with 27 nursing and midwifery schools for 10 years to strengthen RH/FP. Collaborators on the project were the Association of Deans of Philippine Colleges of Nursing (ADPCN) and the Association of Philippine Schools of Midwifery (APSOM). Three years after program closeout, JHPIEGO conducted an evaluation. A team visited 16 schools and interviewed school and clinic administrators, faculty, and nursing and midwifery students.
The team discovered that preservice FP/RH nursing and midwifery education continued to be strong in all 16 schools. All the schools continued to teach the skill-based FP/RH component. In addition, the competency-based training methods and teaching aids (including instructor's guides and reference materials) were still being used. The trained faculty was still in place and teaching. Faculty assignments took into account faculty training and experience. All schools had at least one fulltime FP/RH faculty member, and 75 percent of faculty respondents had received training through the TRH Project. The clinical faculty obtained government accreditation as FP/RH service providers.
The competency-based teaching methods continued as well. For example, 94 percent of nursing and midwifery students said they were assessed as competent in FP/RH skills at the end of their clinical rotation, they had access to anatomic models, and checklists were used for RH/FP skills assessments. And, 80 percent of students said they had sufficient opportunities to do FP/RH procedures and counseling during the clinical rotation.
Further evidence of the project's success is the fact that graduates from the four strengthened schools performed better on licensure examinations than graduates from other schools. Nationally, the performance in 1998, 1999, and 2000 was 56 percent, 50 percent, and 50 percent, respectively. From the strengthened schools, the performance was 76 percent, 86 percent, and 62 percent.
How Do We Know It Works? Turkey
JHPIEGO first worked with medical schools and national inservice training systems in Turkey from 1992-1998. In 1998-2001, those efforts led to upgrading midwifery training from a vocational level to a university level at 19 of 27 university-based midwifery schools.
The preservice midwifery efforts focused on the following critical components:
- Training midwifery faculty and clinical preceptors (2 per site)
- Linking classroom and clinical sites
- Followup and support
The following key results were achieved:
- By using the same clinical practices sites, one set of trainers was able to meet both inservice and preservice training needs.
- A national-level system, which is in place and functioning, certifies midwifery students to provide RH/FP services as part of their preservice education.
- At the end of academic year, students are assessed for certification with checklists on key RH/FP skills.
A telephone survey conducted in late 2001 showed that 68 percent of midwifery graduates were working specifically in RH jobs (i.e., providing FP on a regular basis). The rest of the graduates were still providing RH services such as pregnancy and delivery care and postpartum FP counseling. Also, a 1998-1999 project evaluation report showed evidence of cost savings. The creation and adherence to infection prevention standards in clinics where strengthening efforts were focused, provides additional evidence of the project's impact on service delivery. Site visits documented that:
- Plastic buckets were used for chlorine solution
- Unused IUD kits were kept sterile
- Medical waste was kept in leak proof containers with lids
- Appropriate containers were available for sharps disposal
Lessons Learned
A number of key lessons have been learned in JHPIEGO's preservice programs in over 21 countries.
- Lesson #1 - Identify a "champion" within the system to lead the way.
- A champion can ensure the buy-in and leadership that are needed from the preservice institutions (the schools and certifying bodies/associations).
- A champion can play a key role, particularly in medical schools, in mobilizing and leveraging funds, especially from local sources.
- Lesson #2 - Strengthen linkages between schools and clinical sites.
- Train teachers and preceptors together.
- Establish a system of regular communication.
- Develop a mechanism for tracking skill development.
- Lesson #3 - Focus on the content area or area of the curriculum where the greatest impact is possible.
- Process, once learned, can then be used locally to strengthen additional content areas.
- Internship year in medical schools is often the best place to intervene.
- Lesson #4 - Foster rational use of limited preservice time.
- Identify skills that will be used by all and/or in a wide number of settings and focus on their development (e.g., examination skills, infection prevention, counseling).
- Kenya, for example, dropped IUD insertion and kept IUD counseling.
- Consider deployment issues. What skills will be needed by new graduates?
- Lesson #5 - Adapt existing curricula and materials whenever possible; don't start over each time! Existing resources may include:
- Generic or standard curricula
- Strengthened curricula from other countries
- On-the-job courses
- Inservice training packages
- Lesson #6 - A learning package helps ensure standardized transfer of training from teacher or preceptor to student. A learning package should:
- Provide all material needed for competency-based training
- Focus on a team approach and self-directed learning by students
- Link classroom and clinical portions of the curriculum
- Lesson #7 - Provide support and followup to the schools as they implement the strengthened curriculum. Support and followup:
- Improve skills through feedback
- Solve problems "on the spot"
- Foster a positive teaching/working environment
- Motivate the teachers and preceptors
- Facilitate full implementation and foster integration into existing curriculum
- Link the schools together in a network for support and assistance
- Lesson #8 - Take advantage of synergies between preservice and inservice systems. Synergies include:
- Clinical practice sites used by both systems
- Clinical trainers also serving as clinical preceptors
- Inservice training packages adapted for use in preservice education
- Coordination between the systems
- Standardized content and teaching methodologies between the systems
Mary's Story Revisited...
If we strengthen preservice education AND establish linkages between preservice and inservice, then when Mary's daughter decides to go into midwifery, she will graduate with the confidence and skills to provide basic services to her clients. And she will be prepared to attend focused inservice training courses to upgrade and refresh her skills.
For more information about strengthening preservice education, contact 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