TRAINING OF NPCS IN MATERNAL HEALTH AND LEADERSHIP IN TANZANIA

TRAINING OF NPCS IN MATERNAL HEALTH AND LEADERSHIP IN TANZANIA

BY GODFREY MBARUKU AND SENGA PEMBA

MAY 2012

BACKGROUND

With a physician to population ratio of close to 1:25,000 and further challenged by 80-90% of medical doctors practicing in urban areas the majority of the Tanzania population has no access to care by a physician

However, there is potential of using the existing mid-level cadres in the system to provide essential services if their skills can be upgraded through targeted short courses or long courses

BACKGROUND CTD…

AMOs and Nurse midwives for instance can effectively be upgraded to provide CEMOC in rural areas where Medical doctors are not willing or ready to work

WHY TRAIN NPCS FOR CEMOC SERVICES?

WHO estimates that 1 in 10 pregnant women in Tanzanian requires emergency maternal health care so the need to have a trained health worker in EMOC

We need to accelerate the attainment of health related MDG especially MDG 4 and 5

THE ETATMBA PROJECT: TRAINING OF ADVANCED LEADERS IN MATERNAL HEALTH

To implement the ETATMBA Project, IHI in collaboration with TTCIH set out to train Non Physician Clinicians (NPCs) from disadvantaged HC and District Hospitals in CEMOC, anaesthesia and leadership and thereafter assess its impact on Maternal and Perinatal Mortality in their respective areas

We were guided by the training life cycle to ensure success

Phase 1 Training conceptualization

Phase 2 Planning the training

Phase3 Execution of training

Phase 4 Termination

TIME

EMOC TRAINING PROGRAMME: LIFE CYCLE

SELECTION AND RECRUITMENT OF TRAINEES

We opted for a small intake of about 12 -16 trainees per batch

To be able to show an impact, a pair (AMO, NW) were recruited from one health centre

The NPCs were selected from facilities that were remote and hardly accessible during rainy season.

The Facilities given priority were Heath Centers (HCs) that were already upgraded with theatres or were in the process of being upgraded.

However, in certain disadvantaged districts there were no such HCs and therefore the District hospital was selected.

MAP OF TANZANIA

DURATION OF TRAINING

Duration of Training was 16 weeks undertaken at the Tanzanian Training Centre and St. Francis Referral Hospital in Ifakara.AMOs: 10 weeks on CEMOC, 2 weeks on Leadership and 4 weeks of internship.Nurses: 10 weeks on Anesthesia, 2 weeks on leadership and 4weeks on internshipThe internship was done in their Regional Hospitals

DAILY TIME TABLE FOR NPC TRAINING

1. 7.45 am - 9.00 am: Review of Emergency cases managed by AMO within 24 hrs

2. 9.00 am-1.00 pm Major ward round

3. 3.00-5.00 pm: Lecture on EMOC topics including Neonatal Resuscitation.

4. 5.00 pm-7:30 am: Night Duty for one AMO daily including weekends and public holidays

WHAT TRAINING STRATEGY ARE WE USING?

We are training the AMOs and Nurse midwives using a competence based education approach

Competence-based education is an approach that is related to on-the-job performance and has a close relationship between the knowledge or skill required and on-the-job application

TRAINING CURRICULUM FOR NPCS

Two competence based training curricula are used (one for AMOs in EMOC and another for Nurses in Anaesthesia)

The actual training duration is three months (12 weeks) full time with an addition of one month (4weeks) for internship

The implementation of the curriculum requires the use of training facilities at a training centre as well as opportunities to practice at the hospital

Training materials addressing the various areas of CEMOC are prepared in advance and availed to trainees

A schedule detailing the day to day topics is usually prepared to standardise the teaching/learning process

A logbook to guide the training of skills is given to each trainee

TRAINING CURRICULUM CTD…

All NPC (AMO and Nurses) underwent 10 day- Leadership course during which management and leadership skills were taught by an expert in this area.

See next slides for the leadership course!

Provide leadership in key areas of maternal health services

Conduct organizational capacity assessment Manage change in a health facility Improve quality of services

LEADERSHIP: OBJECTIVE- LEARNING OUTCOMES

TOPICS IN LEADERSHIP AND MANAGEMENT

TRAINING METHOD

LENGTH OF THE COURSE

WHO ARE THE TRAINERS OF THE NPCS?

The trainers comprise of the following:– Obstetricians local and international– Anaesthetists/Anaesthetic Officers– General Medical Officers working in OBGY

Department– Nurse midwives working in the in maternity ward– Leadership and Management experts

WHAT TEACHING METHODS DO WE USE?

A variety of teaching/learning methods are used including: – Lectures discussions– Involving the trainees in the actual doing through

practicing in the theatre as well as in the maternity and surgical wards at the teaching hospital

– Encouraging trainees to conduct their own group discussions and presentations and availing trainees the opportunity for self study

– Use of Clinical Skills Lab for demonstrations and simulations

– A team approach to learning is emphasised where AMOs and Nurse Midwives learn together

TRAINING CURRICULUM: ASSESSMENT

The assessment process is designed to promote the highest possible standards of demonstrable achievement within and beyond the scope and content of the curriculum.

To achieve this, assessment of the trainees involves the following:– Course work and individual assignments– Class participation and group assignments– Self assessment– Monthly tests– End of module assessment using written exams and

OSCE

INTERNSHIP

The last 4 weeks of the course were on Internship in their Regional Hospitals.

No Lectures were given at the hospitals. AMOs managed the Maternity wards as well as

labour wards under our supervision and did surgical procedures (C/S, vacuum etc) on patients with indications.

The nurses administered anesthesia and did neonatal resuscitation in the theatre

ACTUAL MODE OF INTERNSHIP

Clinical meeting- attended daily by NPCs, all senior hospital staff and supervisor

Lively discussion of all cases admitted during the 24 hrs

Administrative problems discussed and sorted out

Acts as a forum for continuing education and leadership role in action

ACTUAL MODE OF INTERNSHIP CTD...

Daily ward rounds in the maternity ward Discussion on management of cases Focus on correct use and interpretation of

the partogram Demonstration of practical procedures Applying skills and mentorship both in labour

ward and theatre

MATERNITY DATA DURING INTERNSHIP:AN EXAMPLE OF S’WANGA HOSPITAL

CESARAN SECTIONS 58 DELIVERIES 373 RUPTURED UTERUS 3 MATERNAL DEATHS 4 (DUE TO ECLAMPSIA,

RUPTURED UTERUS, ANAESTHETIC ACCIDENT).

AUDIT OF MATERNAL DEATHS WERE ATTENDED BY ALL NPCs

Demand for accrediting the training programme is increasing

How to effectively supervise the trainees in the clinical areas as trainers are few

How to handle the issue of absenteeism from work places for the selected staff (12 weeks absence)

How to make the course really hands-on as some of the trainers lack teaching methodology skills

CHALLENGES RELATED TO THE TRAINING OF NPCS IN CEMOC

OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs

At the end of the course, all NPC could fill the Partograms and interpret them correctly whereas before they could not

Before training, all AMOs could do C/S but were not conversant with the indications as well as the importance of C/S on the lower segment and the prevention of bladder injury.

Following the training, the importance of Preoperative antibiotics, catheterization (Catheters frequently not available in HCs) and early ambulation were well understood.

OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs CTD...

In most health facilities, power supply was erratic and ~70% of C/S in Geita district hospital for instance were done without power.

Transparent iron sheets were used for the roofing of theatres. No complications occurred despite this and NPCs appreciated the importance of internship within their home environment.

Due to lack of power, manual aspiration machines were used for suction during the operation and sterilization of the tubes was emphasized

There was a scarcity of gauze nationally and therefore NPCs learned to use abdominal packs during C/S.

NPC were unaware of the use of Misoprostol in prevention of PPH and induction of labour especially IUD

Although use of V/E was emphasized it was rarely used even in cases of IUD due to obstructed labour with descent 1/5 and full dilatation; C/S was preferred instead

OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs CTD...

Only Spinal anaesthesia and bolus ketamine were used in their HC/District hospitals but after the course all the Nurse-NPC could give GA by intubation.

The Leadership course which the NPCs underwent helped them to face the often arrogant District Authorities. The NPCs met the District Authorities several times to present the problems their facilities faced and they were neither shy nor scared during the encounters.

OUR OBSERVATIONS REGARDING THE TRAINING OF NPCs CTD...

WAY FORWARD

All the District hospitals that were visited had no Obstetrician and therefore the Maternity services were run by AMO who did not have up to date knowledge of CEMOC.

At Geita District Hospital, the authority requested the CEMOC- trained- NPC to remain working there instead of going to the HCs but this was declined.

WAY FORWARD CTD…

AMOs running District Maternity services should also be given priority for CEMOC courses as they receive all the referrals from HCs.

Due to scarcity of medicines, gauze etc, the funds collected for the CHF should be retained by NPCs for purchasing these items instead of sending it to the District where it is used for other non medical purposes. Discussions with District authorities are under way

WAY FORWARD CTD…

The NPC we have trained are now complaining that their burden of work has increased tremendously and cannot go on leave/holidays and despite all this, they have not received any on - call - allowances for the extra work nor accreditation from the Ministry. This has to be discussed with the authorities concerned.

To improve communications with the supervisors, the trained NPCs requested Lap Tops for internet services.

Supervisors need reliable transport to enable them to follow up the trainees in their working places

WAY FORWARD CTD…

Supervisors should go with supply kits to avoid compromising the internship experiences

Further training of the NPCs from the regions is required to encourage and promote continuing education culture for NPCs

END

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