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The CMNH blog is a space for our academics and PhD students to showcase their research projects and areas of interest for the wider community to read and enjoy!

Each post will include the contact details of our featured writer. We encourage you to get in touch with them for further discussion of the topics raised. If you would like to write a blog post for the website please contact Tim Garner.


February 2017

Completing the feedback loop from in-service training to pre-service education in healthcare

The author had earlier on explained the potential mutual benefit that can be harnessed when feedback from in-service training programmes informs pre-service (formal) training. However, such accordance cannot be automatic. The responsible parties need to actively engage. Who are these responsible parties? How can they engage? 

The partnership for maternal, newborn and child health highlights importance and position of professional organisations/associations in healthcare training. Obstetrics/Gynaecology and Paediatrics associations in each country need to take a pivotal and leading role in overseeing quality of maternal and newborn training programmes specific for a country. The association’s influence needs to permeate the entire spectrum of training programs from curriculum review to the actual training. The ministries of health (MOH), regulatory bodies (eg doctor’s or nurse’s) pre-service institutions and other stakeholders involved in teaching need to be on board and all work collaboratively.

Do professional associations and regulatory bodies exist in all low resource countries? Do all MOH have a section to oversee training?

There is lack of global information on existence and duties performed by professional associations however the WHO reported in 2006 that poor health care worker performance could be linked to weak professional associations. Most MOHs would have a specific section to deal with training. However, the extent to which stakeholders involved in training collaborate with such a unit is clearly beyond the scope of this short piece. Professional associations, regulatory bodies and the government (MOH) would be key in making sure lessons learnt from in-service training programs shape pre-service training and vice-versa. 

How can such feedback be collected and used?

It would be helpful to see MOHs taking an active coordinating role to all pre-and in-service training. This would also be strategic since MOH is a portal to all programs (including vertical) and the assumption is that MOH will have a direct link to pre-service institutions. MOH also has to ensure that regulatory bodies spearhead and enforce Continuous Professional Development (CPD) programs.

Existing CPD programmes may need strengthening. “Development” in this sense suggests a broader, holistic focus not just to lack of skills and knowledge. The aim should be to improve efficiency and professionalism at the workplace. Work environment and healthcare worker attitude need to be revised and addressed.

When new guidelines are issued by organisations such as the WHO, responsible authorities (often MOH) would decide when to endorse them. The gap between when new evidence is published to when it filters to regular practice will vary in each country. Existence and effectiveness of profession associations and regulatory bodies might be the main determining factor. In the UK, organisations such as The National Institute for Health and Care Excellence (NICE) cover up such a gap. 

New guidelines are commonly disseminated through in-service training in form of workshops and seminars, should pre-service be targeted at the same time? can in-service course schedules (often quite tight) accommodate additional training?

It will be helpful if stakeholders implementing health programs with a ‘training’ component (including CMNH) find answers to the following questions from the outset:

  • How is the training aligned to the pre-service curriculum?
  • How will professional associations, MOH and regulatory bodies be involved?
  • How will feedback be managed to make sure the loop is complete?

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Mselenge Mdegela is a Clinical Research Associate at the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine. He is involved in designing, implementing and evaluating sexual and reproductive health teaching programs at LSTM and overseas. He is part of the EMOC team which provide technical assistance for implementing EMOC programs in low resource settings and a PhD student in the area of Human Resource for Health.

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January 2017

Can in-service training influence pre-service education in healthcare?

The success of any training programme depends on a good curriculum. Curriculum, a plan of the learning experience, needs to be focused and tailored to trainee needs, the training environment and the end user key demands. Following completion of a pre-service (formal) training, usually healthcare workers need in-service training, commonly referred to as Continuous Professional Development (CPD), to keep their knowledge and skills fit for purpose. In-service training in healthcare often aims to complement gains from pre-service training and its success will be dependent on how it is aligned with the pre-service training among other things. However, can in-service training also be useful in providing feedback that will improve pre-service training?

Key considerations for curriculum development in healthcare programmes include clearly define competencies based on current evidence-based practice, resources and support structures available for teaching. Upon graduation, a candidate is expected to have attained competency, at least at the acceptable minimum level, in all aspects of a particular cadre.

It is mundane that rapid scientific discovery and innovation can easily overtakes a carefully made package of competencies that was considered up-to-date at the start of a 3 to 5-year course. The dynamic nature of the evidence for healthcare may result into frequent change in guidelines and other patient management processes hence the need for in-service training.

In high income countries with well-developed systems for professional registration, licencing and CPDs, the additional competencies may be defined in terms of credit points and a healthcare provider is required to accrue certain level of credit points before their licence is renewed in a set time interval. Same may not always be possible in low resource settings where organising a effective CPD programs may prove challenging. Often times in-service training happen as an opportunity arising from a vertical time bound program.

Through the “Making it Happen” programme, the Centre for Maternal and Newborn Health at Liverpool School of Tropical Medicine has supported short time competency based in-service training programmes for emergency obstetric & newborn care (EmOC) in 8 countries in sub-Saharan Africa and 2 countries in south-east Asia. Some participants exclaimed that the training was their first opportunity to attend a ‘skills and drills’ type of training since their graduation.

On several occasions, trainees who received the short term EmOC training demonstrated competency in skills that were not part of their in-service training, but which were badly needed at their workplace. This points towards a potential mismatch between pre-service training and skills need to provide care to the end user. What could explain the mismatch? At least two thoughts come to mind. Either pre-service curriculum is inappropriate, not based on current research or the actual teaching fall short of the required standard. 

A sound basic pre-service training is invaluable in inculcating basic professional concepts, knowledge and skills, that without which it would be difficult to implement CPDs. Thus efforts to continually improve pre-service training should be considered by stakeholders involved in both pre- and in-service training programs.

Pre-service training is usually quite even in coverage and the training environment is controlled, on the other hand, in-service training is usually patchy and liable to apt modifications based on prevailing conditions at work place. Compelling job responsibilities, restrictive policies and human resource shortage and the available training equipment etc can lead to inevitable modifications of in-service training. Also, whereas a national registration board or body sets minimal competencies to be achieved for pre-service training, in-service training is not always as regulated especially when training is part of a vertical programme.

It may therefore be important then to ask a question: How can experiences in implementing in-service training programmes help inform pre-service education programmes? If it happening already, how can the process be made more efficient and timely? Should in-service programs embrace strategies to improve pre-service training from the start?

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Mselenge Mdegela is a Clinical Research Associate at the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine. He is involved in designing, implementing and evaluating sexual and reproductive health teaching programs at LSTM and overseas. He is part of the EMOC team which provide technical assistance for implementing EMOC programs in low resource settings and a PhD student in the area of Human Resource for Health.

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