Improving
Performance of Healthcare Providers |
Discussion
Structured OJT met an identified training need in both countries.
In Zimbabwe, most of the sites trained the expected number of participants. All Kenyan OJT sites were able to train more participants than had been planned for the pilot test.15 At the site in Kenya where 7 participants were trained, the participants stated that having a colleague to work with during the course, to practice role plays and to study together was a real advantage.16
OJT participants were able to practice much more on the anatomic model and to insert many more IUDs on clients prior to qualification than participants in Kenya’s 6-week, group-based FP course. Preceptors and DTC trainers reported that OJT-trained providers had better skills than those who were group-based trained. This finding was verified during clinical skills assessment visits made by DPHC trainers (Cege 1997).
At all 6 sites in Kenya, hospital nursing officers had lists of more than 20 people who were waiting to be trained in the "next" IUD OJT program. Zimbabwe OJT supervisors also had waiting lists and efforts were made to continue the IUD structured OJT program.17 These continuation efforts clearly demonstrate that a structured OJT program is able to respond to the needs of the work site. And, responding directly to work site needs is increasingly critical as countries become more and more decentralized.
The structured OJT program builds commitment and motivation to the learning process.
In this pilot test, all the participants who were selected were very interested in being trained. Structured OJT programs allow for a more targeted selection of participants. Targeted selection ensures that those being trained are motivated because they will be trained in the skills they need to use in their work setting.
Structured OJT provides a mentoring environment for trainers.
An unexpected benefit of the OJT program in Kenya was that OJT trainers were found to have better coaching and demonstration skills than clinical preceptors who teach only during group-based courses. OJT trainers may have better skills in these areas because they are more familiar with the course content and have long periods of practice (supervised by the OJT supervisor) in these skills.18
The structured OJT approach would be useful for training in a variety of health topics.
The participants were interested in the structured OJT process and the access to learning. They felt the approach could be useful for learning other skills/information. In Zimbabwe, one site began using the same kind of training approach to train service providers in the provision of diaphragms. RH professionals from Kenya, Zambia and several other countries are already developing a structured OJT program for preparing providers to deliver postabortion care (PAC) services. In both Zimbabwe and Kenya, the following question has yet to be resolved: Would participants be motivated/stimulated for training without the certification incentive that was included in the IUD training?
Retention of competency after training needs to be planned for before the training program is implemented.
Structured OJT programs allow providers to acquire new skills and improve their performance in locations where caseload for the new service may be low. Therefore, in low-caseload areas, it is important that the structured OJT program includes a country-specific plan which provides for regular practice on anatomic models after qualification so that skills can be retained.
An expanded group of trainers is needed but transferring OJT skills to additional OJT trainers requires a mixed training approach.
It is possible to transfer OJT trainer skills to new trainers using an on-the-job approach although it may be more efficient to train trainers periodically in a group-based training course. In Kenya, the OJT team felt that having at least 2 OJT trainers and 2 OJT supervisors for every site was very important to ensure that training continued uninterrupted when trainers and supervisors were sick or on leave. (Trainers in both countries felt that they needed a 1-month break between training periods.) Following the pilot phase, a group-based training was conducted to train an additional trainer and supervisor from the pilot sites.
In addition to the OJT trainer who was trained in the job setting at one site in Kenya, OJT trainers have found that many graduates of the OJT program have begun assisting them to conduct training almost as soon as their own training is completed. At one site, the first OJT participant to complete the course was transferred to a nearby health center. After the OJT supervisor visited the health center to deliver equipment and resource materials and to assess the OJT graduate’s skills, the graduate initiated her own OJT program. Because OJT participants are much more familiar with the course materials than group-based course graduates, and because the skills component is truly competency-based, pilot testing an on-the-job training-of-trainers course for graduates of the OJT program may be feasible.
Implementing an OJT program does not obviate the need for group-based training—either for training trainers or training other participants. It does, however, allow more efficient use of training resources by ensuring that funds are allocated for group-based training only where and when this type of training is needed.
Mechanisms need to be explored for the support of visits by the OJT supervisor to district sites to initiate training and certify participants.
In both countries, OJT supervisors are being asked to travel to additional sites to provide training support and to certify providers at the end of training. The OJT expansion sites in Kenya include hospitals and health centers that are at a considerable distance from the OJT supervisors’ location. Because the Kenya program is intended to be self-financing, the new sites have been asked either to send transport to pick up the OJT supervisors or to pay for public transport out of their cost-sharing funds. (This part of the structured OJT program is still in its infancy so whether this approach is a feasible way to expand OJT to many more sites is not yet known.) In Zimbabwe, discussions about how to ensure efficient use of trainers have been held.
Once a critical mass of providers is trained, selection criteria may need to be reviewed.
In Kenya, for example, if OJT expands to include pre-1992 graduates of the basic FP 6-week course, general FP skills may be a problem. Selection criteria as well as the OJT program itself should be reviewed to ensure that revisions are made, when necessary, to meet the needs of changing provider characteristics.
Funding constraints precluded a longer-term evaluation that would have compared IUD service providers trained in different training approaches.
Originally, the pilot test in Zimbabwe was expected to include a level 3 training evaluation (change in job performance) of IUD service providers that would compare and contrast the various training approaches (group-based, structured OJT, computer-assisted learning approaches). This evaluation was not feasible for a variety of reasons that were related to logistics and funding. Discussions about conducting this type of evaluation in Kenya are ongoing.
Recommendations
Continue to support the flexibility of the structured OJT approach which allows it to meet the training needs of a variety of service delivery settings. The various models of structured OJT that were implemented during this pilot test demonstrated OJT’s flexibility (i.e., its ability to meet different training needs and situations).
Train two providers at a time for increased efficiency of training and for ensuring motivation and continued commitment to the self-paced nature of structured OJT. It is recognized that ensuring adequate numbers of clients for two participants "competing" for the same type of client could take longer in low-caseload areas.
Both countries should develop and implement a plan for continuing to develop a critical mass of OJT trainers who could expand the structured OJT program.
Develop and implement an annual workplan or other formalized assignment system to ensure that resources invested in the OJT participants and trainers are maximized.
In low-caseload areas, mandate practice time—at the minimum on an anatomic model—to ensure retention of competency. Providers need at least one morning of clinical practice each week to retain clinical skills competency and at least an hour of practice on the ZOE model per month to retain models-competency skills. This practice time should be scheduled in the monthly work assignments.
JHPIEGO should continue exploring ways to assist both countries in applying the structured OJT approach to a related MCH topic. MCH application can expand the program while maximizing the use of OJT trainer skills.
Conclusion
The pilot test of the IUD structured OJT program in both Zimbabwe and Kenya was very successful. It was especially successful in Kenya where it stimulated and transferred to the provinces a decentralized responsibility for FP skills training. The various models of the structured OJT approach that were applied in Zimbabwe and Kenya demonstrated its flexibility as a learning approach that could be adapted to various work settings. Additional efforts in sexually transmitted infection (STI) and PAC training are also showing that the flexibility and responsiveness of structured OJT can improve provider performance and ensure the delivery of quality services.
At the country level, continuation and expansion of structured OJT will ensure that resources invested thus far are maximized. JHPIEGO is continuing to promote the structured OJT approach along with other learning approaches. Structured OJT is also being used as a guide for other training interventions such as the Zimbabwe and Kenya preservice nursing programs where the Student Clinical Placement Guide has been modeled on the OJT program.
15At one site where the OJT trainer-designate was unable to attend the OJT training-of-trainers course, the OJT supervisor trained the trainer using an on-the-job approach. The trainer’s skills were assessed by a DPHC trainer who authorized her to begin training, and she trained 4 service providers during the pilot test. At another site, the OJT trainer died less than a year after the initial training-of-trainers course, but the OJT supervisor continued training the third participant.
16These participants also acted as clients with each other in role plays so they could practice counseling; then they did an IUD insertion on the ZOE model. At this site, the OJT supervisor’s very active involvement in the training process may explain this site’s ability to train so many participants.
17After the JHPIEGO program closeout in late 1997 in Zimbabwe, JHPIEGO staff were unable to track the continuation of the program.
18During the recent implementation of a self-directed FP learning program for nursing students, OJT sites had a smoother transition to the new system because they were already familiar with a self-directed learning process (Smith and Brechin 1998).
