Evaluating the Effectiveness of a Training Intervention in Neonatal Resuscitation: Establishing Grounds for Further Rollout Faith Kayembe (MA, BSc, PGCert.Ed, RM, Krankenschwester Germany) Senior Midwifery Lecturer/Project Lead Canterbury Christ Church university, Kent, UK
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Evaluating the Effectiveness of a Training Intervention in
Mr & Mrs Chowen – Project Benefactors Prof. Newport – Chair BLHL Prof. Hatzidimitriadou - CCCU
Mr Wisdom Chelu – Zambia
MoH Ms Jean Musonda -
UTH
Scoping Key suggestions: • Staff knowledge/skills in
neonatal care including assessment, initial management at birth and resuscitation
• Standardisation of approach
to neonatal resuscitation • Leadership
• Clarify communication systems • Equipment including fetal &
neonatal monitoring • Transportation between wards • Thermoregulation • Discharge examination of the
newborn • Health care support role
Intervention…
Multidisciplinary Team
Teaching material Neonatologist
Senior Neonatal
Nurse
Senior
Resuscitation
Officer
Midwife/
Lecturer
Intervention: Preparation and set up
Teaching: theory, skills, simulation, TTT
Immediate evaluation
0
5
10
15
20
25
30
35
Pre-testscore
Post-testscore
Candidates
Scores
Defining effectiveness…
Author Measure of effectiveness
Dempsey et al (2015) Opiyo et al (2008) Disu et al (2015)
Neonatal mortality rate
Trevisanuto et al (2015) Dempsey et al (2015) Opiyo et al (2008)
Clinical practice/ Change in team work and resuscitation behaviour
Hoban et al (2013) Dempsey et al (2015) Fuchs et al (2015) Bookman et al (2010) Carlo et al (2009) Enweronu-Loryea et al (2009)
Knowledge (immediate and long-term)
Defining effectiveness for the Zambia project:
Further training
More staff
Quality and integrity of training
Positive impact on trainee knowledge
Goals
Clinical practice
Methods
Methodology Single Case study approach (Yin
2009; Taylor & Thomas-Gregory 2015)
Selection/recruitment of participants
o Process/arrangements
o different levels
o informed consent
Methods - Triangulation
1-1/focus groups/telephone;
Range of settings:
Health/shopping centres
Interviews Documents Observation
Training records;
Pre/post-test results;
Training
programme
Lectures;
Team interaction/ Meetings;
Feedback;
Skills and
Simulation Stations
Review of goals
Questionnaire
Findings
Thematic map
Clinical Impact
Moving
forward
Further Training
Activity
Positive
accounts from
practice
Challenges
Successes
Challenges
Efforts & work
in progress
Suggestions/Support
required
Implications for
future practice
Quality
of
training
Review
of goals
Clinical impact
Individual accounts from practice (I)
‘’… from August up to February this year, we have not recorded any mortality … the referrals can even be counted … it has greatly improved our skills…’’ (Midwife)
‘’Since I received that neonatal resuscitation…we refer them at the point the babies are stable now … we know how to manage…’’(Nurse)
Individual accounts from practice (II)
‘…we managed to resuscitate the baby until the baby was out of danger. And then we referred …for further management…’ (Midwife from lower level hospital)
‘… the training we have got has really impacted on our services in a positive way, in that our babies and mothers are being saved. We no longer lose lives…’ (Midwife)
Clinical guidelines
Interviewee by a resucitaire in a local neonatal unit – notice algorithm on the wall
Clearer view of algorithm on the wall
Internalising Clinical knowledge (I)
‘…you don’t even go through those complicated stages, where you need to intubate and the rest…’’’ (Paediatrician)
‘’… I’ve seen it as a good thing, this course. It has really changed the way we used to look at some of the things, as in where we resuscitate now, where the priority is not centred in oxygen...’’ (Midwife)
‘…I really did apply, you know, stage by stage – the … inflation, yes. … inflation breaths was not something that was emphasised, yes, we would go into the ventilation breath immediately …’ (Paediatrician)
Internalising Clinical knowledge(II)
‘
‘…apart from the resuscitation itself there are other things … We are now delivering the babies onto the mother’s abdomen because we have learnt about the skin to skin contact. We are delaying cord clamping. All those majors are helpful in making the baby alive. Yes, so there is change like that…’ (Midwife)
Important insights from Clinical log of experience
…delivered as an emergency caesarean section due to cord presentation and fetal distress
…resuscitaire warmed…baby…wiped, stimulated and wrapped in dry clean clothing…assessed…not breathing…floppy…blue…low heart rate
…five(5) inflation breath given chest expansion observed…
…baby reassessed breathing normal, heart rate fast, tone good and colour pink …cried…wrapped in warm clothing and given to mother…
…I did not start the clock…
Challenges to clinical application
Equipment
Poor Staffing levels
Clinical and professional guidelines – limitations
Competing guidelines
Lack of Leadership/mentorship
Further training
Successes Support
Candidate receiving certificate of attendance from Medical superintendent LGH
Formal activity
Summary of training
Date Venue Numbers Staff groups trained
6-8.4.17 Livingstone 50 Doctors, nurses, midwives, anaesthetists (From one hospital)
Informal activity ‘’…Our unit, we always get new doctors,
new nurses, … as part of, probably you could call it an orientation, when they come to the unit we do take them through resuscitation of the babies …’’
(Senior Neonatal Nurse)
Quality of training: evolving content Initial launch content
Immediate care at birth
Newborn physiology
Resuscitation at birth
Prematurity /Meconium
Teamwork/communication/documentation
Post resuscitation care
Post launch content
Immediate care at birth
Newborn physiology
Resuscitation at birth
Prematurity /Meconium
Teamwork/communication/documentation
Post resuscitation care
Neonatal Intubation
Umbilical Vein Cannulation
Day 2 – KMC/Nutrition & growth
monitoring/infection
prevention/hand hygiene
One day Two days
Teamwork and constitution
Team member consulting with team leader during a session – note manual in use for reference
Team members discussing approach prior to a session
Trainers working in pairs to support each other facilitating a skills station
Observation of training… Set
(includes environment) Please tick √ below or mark as N/A if not applicable Needs further
development
Effective and
competent
Comments
Checks and adjusts
layout and equipment
√√√√√ √
Introductions √√√√√ √
Establishes usefulness
and clearly states
learning outcomes
√ √√√ √ Could be
emphasised
further
Uses visual aids
appropriately
√√ √√√ √
Uses voice appropriately √ √√√√ √
Uses eye contact
appropriately
√√√√√ √
Demonstrated
enthusiasm
√ √√√√ √
resus.org.uk
Lectures
Candidate being taught how to administer ventilation breaths using a BVM
Learning to perform cardiac compressions
Teaching UVC insertion
Team leader offering support to refine the rate of ventilation breaths a little more accurately
More Observations …
Test Type Lowest Score Highest
Score
Mean Score
Pre test 33% 80%. 61.9%
For Post test 57% 97%. 84.7%
Test Type Lowest Score Highest
Score
Mean Score
Pre test 53% 90% 84.7%
For Post test 67% 100% 88.12%
PRE TEST AND POST TEST - FIRST GROUP
PRE TEST AND POST TEST - FIRST GROUP
Challenges to further training
Funding for rollout
Recognition
Equipment
Previous learning/approaches
Review of goals
Goal Achieved Not achieved No response
Target Lusaka Province health centres/staff
8 1
Create list of potential participants
6 3
Quarterly training 5 3 1
Identify and approach funders
3 5 1
Formulate action plan
7 2
Trainers split into two groups
9
Support from MoH 9
Create minimum requirements for Health Centres – equipment…
8 1
Database for trained personnel
5 4
First training Sept./Oct. 2016
9
Train in-service nursing students
Suggestions moving forward
Recognition
Train more trainers
Evaluation in the clinical area
Mentorship
----------------
o CPD strategies
oNeonatal mortality outcomes
Moving forward…
Further forward…
Government and professional body recognition, funding and support are vital to ensure successful rollout of neonatal resuscitation training
Moving Forward…
Standardisation of neonatal resuscitation guidelines to facilitate application of knowledge and skills to practice
Implications for future practice ‘…we have come up with a profile ... all the members
having input … I think actually it will give us a good direction because we will be guided with what we have documented ourselves…’
Focused
Pilot site/
Clinical area
Inform further training
activity - quantity &
quality
Measure impact
Neonatal morbidity & mortality /clinical
practice
outcome measures
Adjust post evaluation/
audit of relevant issues
Sufficient grounds for further rollout?
the evidence…
Further training activity undertaken
More staff strained
Knowledge improvement
Goals achieved/progress
Clinical impact
Lives are Being Saved
Questions?
Reference list
Bookman L.; Engmann, C.; Srofenyoh, E.; Enweronu-Laryea, C.; Owen, M. ; Randolph, G.; Price, W.; Barker, P. (2010) Educational impact of a hospital-based neonatal resuscitation program in Ghana Resuscitation, Vol.81(9), pp.1180-1182
Carlo WA, Wright LL, Chomba E, Mcclure EM Carlo ME, Bann CM, Collins Harris, H. (2009)Educational Impact of the Neonatal Resuscitation Program in Low-Risk Delivery Centres in a Developing Country. The Journal of Paediatrics, Vol.154 (4), pp.504-508
Central Statistical Office (CSO) (2015) Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: Central Statistical Office, Ministry of Health, and ICF International. 2015
Dempsey E., Pammi M., Ryan A.C., Barrington K.J. (2015) Standardised formal resuscitation training programmes for reducing mortality and morbidity in newborn infants (Review) Cochrane Database of Systematic Reviews
Disu E.A., Fergusson I.C., Njokanma O.F., Anga L.A., Solarin A.U., Olutekunbi A.O., Ekure E.N., Ezeaka V.C., Esangbedo D.O., Ogunlesi T.A. (2015) National neonatal resuscitation training program in Nigeria (2008-2012): A preliminary report Nigerian Journal of Clinical Practice Jan-Feb Vol. 18 Issue 1 p.102-109
Enweronu-Laryea, C.; Engmann, C.; Osafo, A.; Bose, C. (2009) Evaluating the effectiveness of a strategy for teaching neonatal resuscitation in West Africa Resuscitation, Vol.80 (11), pp.1308-1311
Fuchs, T. ; Nibbe, Y. ; Mahmoud, E. (2015) Impact of on-site training of neonatal resuscitation techniques in Shirati district hospitals: Does on-site training improve knowledge, attitude, and practices? Annals of Global Health, January-February Vol.81(1), pp.26-27
Hoban R, Bucher S, Neuman I, Chen M, Tesfaye N, Spector JM (2013) ‘Helping babies breathe’ training in sub-Saharan Africa: Educational Impact and learner impressions Journal of tropical Paediatrics Jun;59(3):180-6
Opiyo N, Were F, Govedi F, Fegan G , Wasunna A, English M, Belizan JM. (2008) Effect of Newborn Resuscitation Training on Health Worker Practices in Pumwani Hospital, Kenya (Newborn Resuscitation Training) PLoS ONE, Vol.3(2), pp.1599
Taylor R & Thomas-Gregory A (2015) Case study research Nursing standard Vol.29(41), pp.36-40
Trevisanuto, D ; Bertuola, F ; Lanzoni, P ; Cavallin, F ; Matediana, E ; Manzungu, Ow ; Gomez, E ; Da Dalt, L ; Putoto, G (2015) Effect of a Neonatal Resuscitation Course on Healthcare Providers' Performances Assessed by Video Recording in a Low-Resource Setting Plos One, Dec 11, Vol.10(12)
Yin RK (2009) Case Study Research: Design and Methods. 4th ed. Sage Publications, London.