Pre-Service EducationA New Approach to Learning and Teaching

R E B U I L D I N G B A S I C H E A L T H S E R V I C E S

TECHNICAL BRIEF

Background

Liberia’s 14-year civil war destroyed its health system, with most of the health workforce leaving the country. During the post-conflict period, resource-limited health training institutions did not prioritize the use of lesson plans, teaching methods, objectives, or student assessment practices. Faculty and clinical preceptors were often inadequately trained in pedagogical and clinical supervision skills, and technical course content and on-site reference materials were often severely outdated. As Liberia revives its health system, classroom and clinical teacher training, and institutional management have been identified as essential activities that can help build capacity across the health sector.

The Rebuilding Basic Health Services (RBHS) project developed the Pre-service Education (PSE) Initiative to strengthen two educational institu-tions, the Esther Bacon School of Nursing and Midwifery (EBSNM) and the Tubman National Institute for Medical Arts (TNIMA). These institu-tions train mid-level health professionals, includ-ing certified midwives (CMs), physician assistants (PAs), registered nurses (RNs), and environmental health technicians (EHTs). The PSE Initiative involved the Ministry of Health and Social Welfare (MOHSW), regulatory bodies, professional associations, training institutions, and other stakeholders. Since launching in 2009, the PSE Initiative has expanded nationally. It now includes 16 additional health training institutions that have

Esther Bacon School of Nursing and Midwifery students practice skills in an enhanced clinical simulation center.

Photo: JSI project staff

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received the same training courses as TNIMA and EBSNM, as well as limited equipment and supplies from RBHS.

Objectives

Through the PSE Initiative, RBHS aimed to:

• Enhance the pre-service training of mid-level health care providers

• Improve the technical competencies and teaching skills of faculty and clinical preceptors

Pre-Service Conceptual Model

Pre-Service Conceptual Model. Used with permission, ©Jhpiego Corporation 2012.

• Develop the educational environment and strengthen the management of pre-service training institutions

• Strengthen health facilities serving as clinical sites, with a focus on sites affiliated with EBSNM and TNIMA

• Strengthen the capacity for governance and regulation of the Liberian Board of Nursing and Midwifery (LBNM) and the Liberian Medical and Dental Council (LMDC)

Conceptual Model and Process

RBHS used the “Pre-service Model for Transformation” to focus on professional competence and to illustrate the five factors that influence competence and their relationship with performance outcomes at the individual, community, and health systems levels. This conceptual model was developed by RBHS partner Jhpiego.

Strategies used to address the five factors influencing competence included:

• Developing PSE and clinical quality improvement standards

• Training faculty and preceptors on effective teaching skills (ETS)

• Harmonizing competency-based curricula

• Strengthening clinical sites

• Capacity building of LBNM and LMDC as governance and regulatory bodies

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To support clinical site strengthening, RBHS helped develop clinical standards that align with the Essential Package of Health Services (EPHS), the cornerstone of the National Health and Social Welfare Policy and Plan 2011-2021. The MOHSW adapted these standards in 2010.

Ten critical content areas in maternal newborn and child health (MNCH) were selected:

1) Malaria

2) Family planning and reproductive health (FP/RH)

3) Antenatal care

4) Normal labor and delivery

5) Postpartum care

6) Obstetrical complications

7) Integrated management of childhood illnesses

8) Immunization

9) HIV/AIDS

10) Tuberculosis

Quality Improvement In 2009, RBHS engaged stakeholders to develop a set of PSE standards to improve the quality of teaching and institutional management. These standards were adopted in 2010 by the LBNM as national standards for nursing and midwifery education.

PSE standards were developed across four areas:

• Classroom instruction and assessment

• Clinical instruction, practice, and assessment

• Institutional, infrastructure, and training materials

Institutional Management RBHS adapted the Standards-Based Management and Recognition (SBM-R) strategy that was originally developed by the RBHS consortium partner, Jhpiego. Through SBM-R, health professionals, and instructors developed educational standards and processes to enhance learning environments (upgrading simulation centers, libraries, and computer labs) and strengthen clinical practice sites used by students for practical training.

In 2009, only 39% of education standards were met at two RBHS-supported educational institutions. By 2013, these institutions met 79% of educational standards, and were approved for accreditation.

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Effective Teaching Skills (ETS)RBHS has focused on enhancing faculty and clinical preceptor skills by identifying training needs, conducting competency-based training, and providing feedback to promote learning. ETS courses were provided to all faculty and clinical preceptors. Training workshops on simulation center management, computer literacy, and Multimedia4Learning further en-hanced instructor skills. By updating technical content in emergency obstetric and newborn care, family planning, HIV/AIDS, malaria, IMCI, and mental health, instructors are better prepared to provide students with relevant course content. Monitoring, mentoring, and feedback visits conducted by RBHS and regulatory bodies at training institutions and clinical sites aimed to support the learning environment.

Harmonizing Competency-based CurriculaRBHS, in collaboration with the institutional review boards at Johns Hopkins University and the University of Liberia, developed and conducted two semi-structured surveys analyzing the tasks of health professionals to inform the revision of job descriptions, core competencies, and curricula. The first survey assessed 264 tasks performed by CMs, PAs, and RNs; the second survey assessed 80 tasks performed by EHTs. The tasks covered infection prevention, health facility manage-ment, and the six areas of the Basic Package of Health Services. Recent graduates of health training institutions (46 CMs, 38 PAs, 119 RNs, and 40 EHTs) were asked questions about the frequency of medical tasks performed, training status (whether they were trained to perform specific tasks), and the place of training.

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Over 65 national and international experts from health training institutions, health facilities, regulatory bodies, professional associations, NGOs, and the MOHSW worked together to develop competency-based curricula.

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Proportion of Providers Performing Tasks Frequently, by Area

Training Received by Providers, Per Area

The task analysis revealed that among all cadres, malaria-related tasks were performed most frequently, and mental health-related tasks were performed the least frequently (see Figure 1).

Figure 1.

General findings indicated that all cadres required on-the-job training in order to perform tasks across technical areas, as they often had not received pre-service training for tasks they are expected to perform frequently (see Figure 2).

Figure 2.

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Revising Job Descriptions, Core Competencies, and CurriculaFollowing the task analysis, training institutions worked with stakeholders, including regulatory bodies, to revise job descriptions (JDs), core competencies, and curricula. Over 65 national and international experts from health training institutions, health facilities, regulatory bodies, professional associations, NGOs, and the MOHSW worked together to develop competency-based curricula. This process included validating draft competencies, ensuring that they aligned with international standards, and using them in combination with job descriptions to revise curricula. Finalized curricula included course objectives, teaching methods, and resources needed.

As a next step, the National Education and Training Working Group reviewed the task analysis report, and compared the various tasks with the scopes of work (SOWs) for each cadre. Based upon this review, critical and frequently used tasks were identified and a decision was made based on each cadre’s SOW to decide which tasks belong. JDs were then revised according to the specific needs at community, clinic/health center, and hospital levels.

Internationally recognized core competencies were reviewed and chosen based on how well they aligned with the Liberian context. These competencies reflect the specific knowledge, skills, and attitudes needed by health workers to perform their jobs.

The competency areas include:

• Professional, legal, and ethical practice

• Care-based service delivery

• Critical thinking and analysis

• Professional, personal, and quality development

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In order to maintain quality at training institutions in the future, it is important that pre-service education standards are regularly updated.

Once core competencies were identified and developed, courses were designed to provide students with the knowledge, skills, and attitudes to be successful in their work. The use of these standards led to the need for formalized accreditation, licensure, and continuous professional development (CPD) processes.

Capacity Building of LBNM and LMDCAs part of its objective to develop the governance and regulation capacity of the LBNM and LMDC, RBHS collaborated with these groups to introduce new activities and reinforce ongoing activities. Quality improvement training has enabled them to use standards-based data to inform decision-making. These regulatory bodies conducted monitoring, assessment, and feedback visits at training institutions to collect and analyze data to improve education standards.

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RBHS helped update technical content in pre-service courses such as emergency obstetric and newborn care, which means instructors can better prepare future health providers to effectively perform their roles.

Assessment results were then disseminated to training institutions. Subsequent technical assistance training workshops helped LBNM and LMDC develop accreditation and licensure skills. These capacity building efforts led to the development of a data-driven culture within

the regulatory bodies and training institutions that helps them identify gaps in planning and implementation, and better allocate limited resources to quality improvement. The regulatory bodies have received positive feedback from the MOHSW, donors, and partners.

Photo: Robin Hammond

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KEY ACHIEVEMENTS OF THE PSE INITIATIVE:

• By institutionalizing PSE, the 18 training institutions, LBNM, and LMDC have taken ownership of PSE processes.

• Training institutions now prioritize lesson planning, interactive teaching methods, and evidence-based student assessment practices.

• 120 clinical preceptors from nine training institutions and six clinical sites provide coaching, mentorship, and constructive feedback before, during, and after clinical sessions through direct support by RBHS.

• An additional 100 clinical preceptors from ten training institutions and 20 clinical sites received indirect support from RBHS.

• Clinical preceptors now require that students master clinical skills in simulation centers before practicing on patients.

• Faculty who were computer illiterate now have the skills to use computers to develop lesson plans, search the internet for resources, and communicate via email.

Results

When baseline assessments of education standards were conducted at EBSNM and TNIMA in 2009, 39% of standards were met. After quality improvement plans were developed and imple-mented, a follow-up assessment conducted in 2010 revealed that 51% of standards had been met at the two schools. In 2013, responsibility for conducting these assessments was transferred to LBNM, a successful outcome in itself. This assessment indicated that EBSNM and TNIMA met an average of 79% of the standards, and were therefore approved for accreditation by LBNM. Improvements were documented in the areas of classroom instruction, institutional clinical instruction, and institutional management. So far more than 500 RNs, RMs, PAs, EHTs, and MLTs have graduated using the new curricula.

The two main challenges are the needs to further strengthen the clinical sites and increasingly involve LMDC. To address challenges related to clinical site strengthening and staff turnover, RBHS has trained, monitored, and mentored

faculty, clinical preceptors, and site administrators. Education development committees (EDCs) have been established in each PSE school to train new teachers.

Way Forward

In order to maintain quality at training institutions, it is important that PSE standards are regularly updated. Regulatory bodies will continue to play a critical role in quality assurance and improve-ment. Their responsibilities include conducting monitoring, assessment, and accreditation visits. They are also tasked with revising curricula, in addition to the accreditation, licensure, and continued professional development (CPD) processes using the newly updated standards. More attention should be given to increase the role of LMDC in these tasks.

There is a clear need for stakeholders to continue sharing technical expertise and implementing best practices to further develop the technical and pedagogical capacity of faculty and preceptors and to help students become competent providers.

The Rebuilding Basic Health Services (RBHS) project was a six-year project funded by the United States Agency for International Development (USAID) and implemented by JSI Research & Training Institute, Inc., in partnership with the Johns Hopkins Center for Communications Programs (JHUCCP), JHPIEGO, Management Sciences for Health (MSH), and the Institute for Collaborative Development (ICD).