The feasibility of implementing structured on-the-job clinical training within existing clinic settings in various types of organizations (e.g., MOH/CW, City Health, ZNFPC) was examined. The monitoring and evaluation strategy for the pilot test focused on a mixture of data collection methods. Baseline data established the conditions at the service delivery site prior to the OJT pilot test. These data included documentation of existing caseloads and clinic stocks as well as the usual work routine at the site and information gathered from logbooks, stock records and service statistic summaries. Data collection activities used to produce this baseline are described below, and the type of data collection form is given for each activity.

• Creating a register of all providers at each clinic (i.e., those previously trained in IUD—with/without GTI), trainer/participant background (education, designation, previous FP/IUD experience and training), caseload for IUD insertions (Register form to record the information)
• Tracking caseload information (i.e., IUD insertions, recording/reporting GTI diagnoses/ treatment) (Register form to record the information)
• Documenting commodities/medications levels and average usage (Recording form to track this information during both the baseline and evaluation phases of the feasibility pilot test)

Key questions examined in the monitoring visits are presented in Table 4.

Table 4. Questions Examined During On-the-Job Training Pilot-Test Monitoring Visits

Category	Question
Participant progress	How long does each participant take to complete the OJT course?
Appropriateness of training topics/sequence	How does the training sequence work? Are participants having problems (e.g., with a particular section, practice exercise, trainer-participant practice session)?
Implementation problems	Do supply, equipment or other site problems hinder effective OJT?
Service delivery	What effect does OJT have on service delivery? What strategies have clinics used to minimize the disruptions?

Evaluation of the pilot-test experience focused on the feasibility of implementation. Data collection activities included reviewing information from the following documents or assessments:

• Training Review Sheet from the Trainee Workbook that included sections such as length of training period, numbers of cases (by type) seen during a given period and problems encountered

• Knowledge and skills assessments for knowledge levels and skills competency

• In-depth interviews with the OJT site staff and the OJT supervisor/trainer/participant

• Review of clinic site status (e.g., caseload, commodities/medications levels)

The monitoring activities documented how the pilot-test implementation was proceeding. During monitoring visits, the OJT supervisor, trainer and participant (and other personnel, as available) were interviewed and site visit notes from observations during the visit day were reviewed. These activities documented attitudes toward the training process, perceived and actual changes in the work routine during the training period, and changes in client experience at the work site. The OJT Trainee Workbook was also examined. The participant’s progress to date was analyzed through the dating of the completed activities (i.e., comparing expected versus actual completion of a section) and reviewing the cases and experiences that support the structured OJT plan.

At the end of the field-test phase, results were analyzed and then presented in both countries at a national forum (including policymakers, program implementers, trainers, service delivery managers, donors and implementing agencies). Discussions focused on the effect of IUD structured OJT on service delivery and recommendations were made regarding expansion of the structured OJT approach into other FP/RH technical areas.

Findings

"Local needs are benefited by local training." (Nursing Officer/Kenya) "Mrs. X was a changed person when she came back from the Mombasa course after being trained as the OJT Trainer." (Nursing Officer/Kenya) "I think it’s a good programme. If the hospital can train more people locally it will be able to provide more services to more people, although the community will still have to be motivated to increase the number of acceptors." (Matron/Zimbabwe)

Application of the Structured On-the-Job Training Model

The findings presented here are synthesized from a variety of sources. Reports from the monitoring visits made in each country were supplemented by more formalized assessments conducted by (Phiri 1998a; Phiri 1998b) and (Brechin et al 1998) for Zimbabwe and Kenya, respectively. In the following sections, relevant quotations from in-depth interviews and questionnaires are cited along with key results.

The following three OJT models were applied at the pilot sites in both countries (14 sites in Zimbabwe and 6 sites in Kenya):

• In true OJT the trainer and participant are both stationed at the same clinic and work together in training. True OJT occurred at the 6 sites in Kenya and at the majority of sites (9 of 14 sites) in Zimbabwe.

• In temporary OJT staff are trained for other clinics. Staff are moved from a location and assigned to the FP clinic for the training period. Depending on staffing needs, staff may or may not be moved from the FP clinic once training is finished. Temporary OJT occurred at 2 sites in Zimbabwe.

• In site training participants and trainers work together on OJT in the FP clinic even though the participant is assigned elsewhere. The participant frees up time during her work day to leave her ward/clinic and then goes to the FP clinic area to work with the trainer or do her own reading/practicing. Site training occurred at 3 sites in Zimbabwe to satisfy hospital rotation needs.

Comparing Training Experiences in Kenya and Zimbabwe

In Zimbabwe, over the OJT pilot-test period, 1 site trained 4 providers, 9 of the sites trained 2 providers, 3 trained 1 and 1 site trained none. All 6 sites in Kenya started out by training 1 person, but by the second OJT pilot course most sites were training 2 at the same time. Ultimately, 2 sites in Kenya each trained 3 people during the pilot test, 3 sites trained 4 people and at 1 site 7 service providers were trained. (See Table 5.) Most of the OJT participants in Zimbabwe were state registered nurses (SRN) and state certified midwives (SCM); only a few state certified nurses were trained. In Kenya, slightly more Kenya Registered Community Health Nurses (KRCHN) were trained than Enrolled Community Health Nurses (ECHN).⁸ Participants were all active and experienced service providers before starting the structured OJT program.

Table 5. Number of Providers Trained in Each Country During the Pilot Tests

Number of Providers Trained in OJT Pilot Test	Number of Sites
	Zimbabwe	Kenya
None	1 site	n/a
1 provider	3 sites	n/a
2 providers	9 sites	n/a
3 providers	n/a	2 sites
4 providers	1 site	3 sites
7 providers	n/a	1 site

In both countries, the structured OJT approach was very successful. Although structured OJT is self-paced by nature, in both countries the IUD structured OJT program tended to be conducted more formally. The training was directed by the trainer in many instances, but both trainer and participant felt comfortable with this role and interaction.⁹ The trainer would meet with the participant(s) on a set schedule to review the work progress and conduct activities.

The expected IUD structured OJT schedule was 6 weeks, but the range of times for finishing was generally from 4 to 6 weeks in both countries. Graduates in Kenya tended to complete the program a little more quickly if they were KRCHNs, but in both countries 6 weeks was generally felt to be a good estimate of the time required for most participants to complete the program.¹⁰

Conducting Structured On-the-Job Training: The Trainer

OJT trainers in Zimbabwe felt that the program was clear (Phiri 1998b). Several OJT trainers in Zimbabwe felt that training time decreased with subsequent participants but the reason is not explained¹¹ (Phiri 1998a).

Zimbabwe	Kenya
The guided training plan has provided a focus for supervisors to do the training they consider part of their regular duties: "I have something specific to do, with a result." "The course is a practical example of a guide for patient flow, any patient."	Trainers at two sites specifically mentioned liking the work of being a trainer—one notes that it keeps her alert and learning. One unexpected benefit: OJT trainers were found to have better coaching skills than other preceptors.

 

Participant Perspectives "This wasn’t tiring. I could stay at work and stay at home with my family and still get training." (Kenya) "You’re alone in the training so you have to pass with the skills. There is no coverage by someone else." (Kenya) "I think it’s a good program and it’s quite clear." (Zimbabwe)

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