Challenges of Clinical Training in the 'Real World'
(May 2003)

This is the last installment of 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)
• Strengthening Preservice Education: A Systematic Approach and Lessons Learned (Lois Schaefer, Susi Wyss, and Behire Ozek, JHPIEGO)

This month, we will summarize: "Challenges of Clinical Training in the 'Real World'" by Carmela Cordero, MD and Levent Cagatay, MD of EngenderHealth.

Learning Objectives

After attending this session, participants will be able to:

• Identify particular characteristics of clinical training 
• Identify barriers to clinical training 
• Identify different means to ensure successful clinical training

Why is Clinical Training Needed?

Clinical training is necessary for a variety of reasons. The four key reasons are to:

• Increase access - if more providers are trained, a larger population can be reached with services
• Improve service delivery - informed providers will be able to provide higher quality care
• Introduce new services - when new services become available, providers need to be trained to be able to provide the services
• Ensure choice - clients can choose among a wider variety of services made available.

Characteristics of Clinical Training

Clinical training involves the three learning domains. Those domains are knowledge, skills and attitudes. Clinical training relates directly to provider performance and is largely affected by non-training conditions, those that are anticipated and those that are unpredictable. The clinical training process is complex and involves several players including supervisors, providers, colleagues and clients. It is dependent on the availability of many clients (caseload) for trainees to practice and become technically competent, though models and role plays can be used to become comfortable with skills before working with clients. Clinical training is potentially a stressful situation for everyone involved: the client, the trainee and the trainer.

Barriers to Clinical Training

There are a number of barriers to clinical training:

• Inappropriate design and/or poor implementation 
• Good service providers who are 'weak' as trainers 
• Identification of an appropriate training site: central (international or not), regional, local, on-site. 
• Lack of time 
• Language barriers 
• Low caseload 
• Client consent to be treated by a trainee 
• Difficulties dealing with clients 
• Unexpected incidents 
• Number of participants 
• Improper selection of participants (based on considerations other than capability and interest) 
• Participants difficult to deal with

Conditions for Successful Clinical Training

It is important to have an appropriate training design to meet the learning needs of the participants and to impact their performance. When selecting a training site, it must be assessed. The training facility must meet high quality service provision requirements (for example, have necessary supplies, appropriate counseling provision) and should be an established service site for the particular subject being taught. It is necessary to have experienced service providers AND skilled trainers and the trainees should be interested and motivated. The trainees should also come from an environment that is supportive of their training. The training should also be culturally appropriate. Logistically, the course length should be realistic given the content as well as the needs of the trainees and their available time for the training. The number of participants should be limited based on the number of clients expected and complexity of the skills being learned. There should be balance between practice on models versus practice on clients. Finally, it is important that the appropriate equipment, supplies and drugs are available.

Lessons Learned

There are three key lessons learned from experience conducting clinical training.

1. Clinical training must be tailored to meet local needs and conditions. The following should be adjusted to meet those needs:

• Including multiple content areas at the same time, as appropriate; for example: 
  • Counseling 
  • Clinical techniques 
  • Process for quality improvement

Implementing a training event for each one of the content areas is difficult. To satisfy local training needs, it may be best to combine multiple content areas in one training event.

• Agenda- Planning the agenda needs to take into account that working hours are different in every country.
• Time- The time allocated to the training needs to be adjusted to avoid interruption of services and to avoid having service providers away from their posts for a long time.
• Increasing provider participation - As much as possible, training should be implemented on-site, at the service site, to increase the participation of the service providers of all levels, according to the content being taught.
• Participant site reality - On-site training can be more time consuming to plan, but the transfer of training into services will be better as the trainee will be in his or her own environment.
• Management orientation - Managers should participate in some of the program-related training sessions (for example, how to establish intrauterine device services) as training frequently fails in its intent for the lack of participation or understanding of training goals by management.

2. The training design and tools need to be reviewed and adapted EVERY time according to:

• Purpose 
• The country, the site, the institution (to actually respond to local needs and conditions)

In addition, they should be used as guides, NOT as a rigid framework.

3. Training alone will not translate into service provision or improvement. It should be part of a comprehensive plan that also includes:

• Clients' issues (that is, Information, Education and Communication) 
• Management issues (that is, cost, supplies) 
• Staff issues (that is, motivation) 
• All the performance improvement factors.

Summary

It is important to conduct an assessment of local conditions (site standards and protocols). The training program should be flexible, but comprehensive (identify critical content), and close attention must be paid to non-training conditions. Finally, training is ONE of multiple interventions needed to establish or improve services. Trained supervisors, supplies and equipment, and strong client demand are other key elements necessary to establish or improve services.

For more information about the challenges of clinical training, contact Carmela Cordero at Engenderhealth.

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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