Go to Page 1 of "Assessing the Pilot Test"

Undergoing Structured On-the-Job Training: The Participant

Participants in both countries liked the OJT approach and felt that doing practical exercises reinforced their reading assignments. Despite senior program implementers’ concerns that OJT participants would bypass theoretical knowledge to go straight to the practical skills work, participants did not skip over the theory. And, during monitoring visits it was discovered that participants perceived that interaction with the trainer gave them "permission" to ask questions (i.e., to not know something). This perception was an important factor for learning acquisition.

Seventeen of 18 Zimbabwean participants "indicated that the OJT approach was easy to follow" (Phiri 1998a) and that "the [OJT] training package was straightforward and had adequate information" (Phiri 1998b). All participants liked the idea of having 2 participants going through OJT at the same time and said they would enjoy having someone to study and practice with.

Zimbabwe

Kenya

Participants were not at all reluctant to do homework (reading, practical) exercises, and they did read and use the reference manual. OJT formalized interaction between two colleagues to foster a learning situation: "Discussion with my trainer helps clarify." "You’re dealing with your own people you’re used to so it’s easy to ask (less embarrassment to be wrong)."

At almost all of the sites, participants reported that they liked the detailed program and felt the practical exercises were useful and helped reinforce learning. All participants liked the structure. They also liked the fact that the trainer was always available to them; the participant had the full attention of the trainer during the training period ("more focused attention from trainer"). "I know my trainer, and I feel very comfortable asking questions, and even making mistakes." Participants saw clients in their own work settings so they learned how to manage their work better.

Skills Acquisition

All of the participants who completed the course had above-passing scores on the final knowledge assessment (i.e., scored at least 85% on the knowledge assessment) and all were competent in IUD insertion, first with anatomic models and then with clients. In Zimbabwe, participants generally did 4 to 7 IUD insertions on clients—except at the 2 large hospital clinics where participants did more than 20 insertions. Many participants in Kenya inserted more than 20 IUDs during the training period.

The Kenya team felt that OJT was truly competency-based because training had no time limit. Participants had more time to practice with anatomic models; they were not rushed to go to a client until they felt ready and confident. A higher client caseload was possible because insertions could be done as clients became available over the training period. The use of models also enabled participants to become more confident, "We communicate with Madame ZOE^® as if she were a client." (Kenya)

 

Zimbabwe	Kenya
"I never thought it could be possible that I would insert an IUD."	Provider IUD counseling and insertion skills were equivalent to those of 6-week basic FP course participants (4 of 6 sites said skills were "better"). Participants were able to attend to a wider range of clients and give FP in a variety of settings (3 of 6 sites). Issue: In some cases, participants’ general FP skills were weak because they had not had basic FP education in nursing school.

During the post-implementation study in Zimbabwe, only 3 insertions were actually performed on clients and 14 on a ZOE model. Two of the 3 insertions on clients were done competently (Phiri 1998a). Insertions done on a ZOE model varied, generally on the tasks related to infection prevention (IP) (decontamination of used equipment) and postinsertion counseling as well as inadequate performance of the speculum and bimanual exam. All 18 participants had done at least one IUD removal (mean=4) and 17 had done at least 1 insertion (mean=11) since completing training (Phiri 1998a).

In Kenya, the DTC trainers in the pilot test felt that providers trained through the OJT approach had better IUD skills and that their counseling skills were better because they had practiced more. According to one OJT trainer, "OJT-trained staff are better FP counselors because they have much more practice counseling all types of clients. During the 6-week course, the participants need to meet their ‘quota’ so they spend much of their time ‘motivating’ clients to accept an IUD so they can insert it."

Service Delivery Improvement—Kenya "We follow the clients’ choice and give them the method they want." (Participant) Nurses believe the improved counseling learned during this program "pulls clients to the hospital and they’re getting more information on FP methods."

Service Delivery Improvement

In both countries, the OJT teams noted a positive effect on service delivery that went beyond the numbers of IUD insertions performed. Several sites in Zimbabwe reported that "word of mouth" about the IUD OJT at the clinic was bringing them more IUD acceptors. In addition, providers were doing more counseling about IUDs when women came for a FP method and they found that this increased counseling also helped recruit more acceptors.

Zimbabwe	Kenya
OJT trainers felt the work in their own FP clinics was strengthened (more counseling was done for the IUD which resulted in more acceptors, and more attention was given to IP). Women would be more likely to accept an IUD if counseled well.12 Providers at one OJT site were being asked to provide IUD insertions at other clinics.	Clients received better service because they were not pressured to accept an IUD. Clients were less likely to be exposed to incompetent providers because of extensive practice on anatomic models. Participants at 4 sites mentioned that the updated insertion technique made IUD insertion more comfortable for the clients.

Nine facilities in Zimbabwe reported an increase in the demand for IUD services since IUD/GTI OJT started because (Phiri 1998b):

• Participants provided increased and appropriate client motivation and counseling.

• Services were available.

• Clients realized that the IUD is a long-term method and that it is cheaper.

Preliminary findings from the OJT post-implementation assessment (Phiri 1998a) reported barriers to IUD use at 4 sites in Zimbabwe. These barriers included high cost of the service and myths and misconceptions. These barriers, however, were not cited in a final report (Phiri 1998b).

Institutional and Personal/Professional Commitment to the Training Process

In both Zimbabwe and Kenya, training took place during work hours. Everyone involved recognized that it was important for the participant to have enough time to do the training work (reading, practicing, exercises) during work hours. Sites generally had lulls in the afternoons when few or no clients came for services. Individual study and practice were done during these lulls. Participants usually worked about two hours each day on their own or with a trainer.

At most sites a room was set aside for the training work. Supplies and equipment needs were covered under provincial or district budgets.

 

Zimbabwe

Kenya

All sites arranged for training time during work hours. Some participants also did work in the evenings (e.g., reading, taking the ZOE model for practice). Participants who were not working at the site freed up their schedules to come to the training site every day. (They made the effort to get to the training site with available transport.)

Hospital nursing officers’ support was key to the OJT success. They: Allowed release time for both trainers and participants Deployed participants to the maternal and child health clinic for an extended period of time until participants were proficient in FP Left OJT trainers in place because nursing officers could see the benefit to the hospital, even though other FP staff are redeployed annually

Training Access

Training access was the same in both countries: the structured OJT program gave many service providers the opportunity to be involved in training. Because ownership of the training was decentralized to the site, not only was the institutional commitment present but more providers felt they had a chance, finally, to receive IUD training. Participants felt the training was desirable and that it was attainable for them. They believed that opportunities to attend a group-based training program would have been rare.

One initial concern about structured OJT was the lack of financial "motivation" found in group-based courses (i.e., going off-site for training with the resultant per diem). Without travel and per diem as incentives it was feared that participants would not be as enthusiastic about the OJT program. In Kenya, however, this concern proved to be unfounded. OJT appeared to have made training more accessible to young, recently trained nurses, many of whom have young children at home and could not attend a long group-based course. Participants at 5 of the 6 sites in Kenya stated that they liked the OJT approach because it did not require them to leave their work settings or their families for an extended period of training. And, anecdotal evidence shows that OJT has shifted FP participant demographics from older nurses who are close to retirement age to younger nurses who have many years of service ahead of them.

Even though selection criteria had been established for the pilot test,¹³ in Zimbabwe, many sites instituted a formal application process after a circular or other information about the program was posted. The participant applied and was interviewed before being selected instead of being chosen simply because she was working in the appropriate clinical area (i.e., FP or maternal and child health [MCH]/FP clinic).

 

Zimbabwe

Kenya

Sites demonstrated ownership of the training. Training proceeded on schedule without external assistance. Although participant selection was more formalized, all service providers in a site felt they would have an opportunity to be trained with OJT. The OJT participant was visible; others on site could see the training as it occurred.

Service providers who had been on the waiting list for the 6-week basic FP course for many years finally received IUD training. Other staff were not envious because they felt they would also have access to training through the OJT approach. Participants with travel constraints (small children) had access to training. Two sites trained staff from other service delivery points. So, decentralization seems possible.

Promoting Sustainability

A number of factors in Zimbabwe and Kenya indicate that the OJT program could continue—and even expand. Besides demonstrating ownership for OJT training, sites now have increased ability to meet "demands" for training. For example, OJT can reduce the long waiting lists for training that currently exist at many sites in Kenya. In addition, participants are so interested in OJT, they are willing to pay for some of the costs of training. To increase program efficiency, in both countries participants and trainers recommend that two participants be trained at the same time. In this way, participants can work together on role plays, practices and discussions.

In Kenya, because OJT trainers have not been redeployed outside the FP clinic (as described above), the potential for sustainability has improved. In addition, keeping the OJT trainer in the clinic improves service delivery by ensuring a highly skilled provider is available to insert IUDs, an experienced preceptor is accessible for nursing student training (because OJT trainers also serve as preservice preceptors) and that inservice FP training can continue without interruption.

Zimbabwe	Kenya
All staff at the site give the training formal recognition: The competency of the OJT trainer in IUD skills is acknowledged. ("I can call my trainer when I have a difficult IUD insertion.") The trainer has the title of "trainer" and is recognized for her skills even after the OJT program is finished. Trainers wanted to continue as trainers even after the IUD pilot test.	Because of "unmet demand," additional staff (beyond the numbers expected to be trained for the pilot test) received training. Because participants learned in their work setting, no major staffing disruptions occurred. Participants were willing to pay for their own workbook or other costs.14 Nursing officers/medical superintendents seemed willing to pay for some or all of the training supplies.

One area that needs to be explored further is the effect of required certification on the success of OJT. In this OJT pilot test, participants needed a certificate to be able to insert IUDs. (This certificate was provided at the completion of OJT training by the ZNFPC in Zimbabwe and the DPHC in Kenya.) Although participants who were interviewed expressed happiness with the opportunity to receive training and said they would do self-paced learning for a variety of subjects, in both countries a certification is required for nurses to perform IUD insertion.

Unexpected Benefits

In both countries, the pilot test validated the credibility of structured OJT as a training intervention to improve provider performance. Everyone involved recognized the potential for meeting training needs outside of group-based training programs.

In addition, structured OJT is an approach that can be adapted to a variety of topics. OJT trainers were interested in continuing in their roles as trainers after the IUD pilot test. Thus, OJT trainers could add new OJT packages within current service delivery systems fairly easily. (They would, however, need technical assistance for a clinical skills update and the structured OJT learning package relevant for the technical topic, such as acute respiratory infection.)

Zimbabwe	Kenya
Site supervisors were very interested in expanding the range of services in their institutions. They saw OJT as a mechanism to achieve this expansion more quickly.	Nursing officers were not scheduling the OJT trainer/preceptor to do night duty. In some cases, the OJT trainers were not redeployed from the MCH/FP clinic. OJT trainers/participants felt better prepared to teach nursing students.

Constraints

No program is without constraints, and this pilot test also had them. In both countries, some sites had no supplies, even though the need for basic supplies was given special emphasis during the pilot-test period. In addition, Zimbabwe’s continued low caseload, low demand for IUDs and high incidence for GTIs had the potential for prolonging the learning period.

Zimbabwe

Kenya

The low demand for IUDs combined with inappropriate participant selection may result in a lack of skills retention. (For example, if the participant selected works in a location where she cannot apply her new skills, she may not retain them.) Consideration needs to be given to how a participant can be ensured of ongoing practice once she is competent. Shortage of supplies such as bleach and cotton swabs (and one site had no IUDs in stock)

Lack of supplies/instruments at three sites Shortage of staff at one site

 

---

⁶This model was less than ideal because there was no guarantee that the provider would be in a position to provide IUD services after completing the OJT course.

⁷In 2 sites, an OJT participant was transferred or resigned before completing the course.

⁸ECHNs who had graduated since 1992, KRCHNs or nurses who had attended the 8-day FP course were eligible.

⁹"Trainer sets the assignments." (Zimbabwe) The "formalized" approach to this interaction in both countries was almost universal: meeting every afternoon for 1 to 2 hours during the didactic part of the training and reversing the schedule (i.e., meeting every morning for 1 to 2 hours) for working with clients in the practical part of the training.

¹⁰In a March 1998 summary of preliminary findings, 9 of 18 participants interviewed felt that the OJT duration was inadequate (Phiri 1998a). This response was not unexpected because those involved in the pilot test tended to view the OJT program as a formal course more than as a truly self-paced learning approach.

¹¹We postulate that decreased training time may occur, in part, because trainers feel more comfortable with the OJT program after conducting it at least once.

¹²Two hospitals had not done insertions for more than a year until the IUD OJT program started. At the acceptors’ 6-week visits, no problems were found.

¹³See ZNFPC. 1996. IUD/GTI Programme: On-the-Job Training (OJT). Supervisor’s Guide, Trainee’s Workbook, Trainer’s Guide.

¹⁴Participants at 5 of 6 sites in Kenya paid for the Trainee Workbook photocopying costs. At one site, the participant paid for the costs associated with the final assessment as well.

Go to Page 1 of "Assessing the Pilot Test"

Go to Performance Improvement