Guidelines for Basic and Comprehensive InService Final (1)

8/13/2019 Guidelines for Basic and Comprehensive InService Final (1)

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Guidelines for In-Service Training inBasic and Comprehensive Emergency

Obstetric and Newborn CarePrepared by:Blami Dao


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Guidelines for EmONC In-Service Training iii

TABLE OF CONTENTS

ABBREVIATIONS AND ACRONYMS ........................................................................................ iv

1. RATIONALE FOR THE GUIDELINES ..................................................................................... 1

2. TRAINING GOAL AND OBJECTIVES ..................................................................................... 2

3. PRE-TRAINING PREPARATION ............................................................................................. 3

4. COMPONENTS AND CONTENT OF TRAINING IN EMONC .................................................. 5

5. TRAINING DURATION AND SCHEDULES ........................................................................... 11

6. COURSE MATERIALS ........................................................................................................... 20

7. ANATOMIC MODELS ............................................................................................................ 22

8. VIDEOS AND PRESENTATIONS .......................................................................................... 23

9. JOB AIDS ............................................................................................................................... 24

10. DOCUMENTATION OF ACTIVITIES ................................................................................... 24

APPENDIXES

APPENDIX A: ORGANIZATION OF MATERNITY SERVICES ................................................. 25

APPENDIX B: EQUIPMENT AND SUPPLIES LIST .................................................................. 27

APPENDIX C: PRACTICUM LOGBOOKS FOR DOCUMENTING SKILLS PERFORMEDWITH CLIENTS .......................................................................................................................... 30

APPENDIX D: SAMPLE ACTION PLAN FOR LEARNERS ...................................................... 32

APPENDIX E: TRAINING EVALUATION QUESTIONNAIRE ................................................... 33

APPENDIX F: TRAINING INFORMATION SYSTEM: DATA RECORDING FORM .................. 34


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iv Guidelines for EmONC In-Service Training

ABBREVIATIONS AND ACRONYMS

AMTSL Active management of the third stage of labor

BEmONC Basic emergency obstetric and newborn care

CEmONC Comprehensive emergency obstetric and newborn care

CPR Cardiopulmonary resuscitation

CTS Clinical Training Skills

EmONC Emergency obstetric and newborn care

EONC Essential obstetric and newborn care

ETT Endotracheal intubation

HBB Helping Babies Breathe

IP Infection prevention

LRP Learning resource package

MgSO4 Magnesium sulfate

MNH Maternal and newborn health

MVA Manual vacuum aspiration

OR Operating room

PAC Postabortion care

PPH Postpartum hemorrhage

SBM-R Standards-Based Management and Recognition

TIMS Training Information Monitoring System


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Guidelines for EmONC In-Service Training 1

1. RATIONALE FOR THE GUIDELINES

Few developing countries will meet their targets for Millennium Development Goals 4 and 5 by

2015.1One reason they will fall short is that only about 61% of women globally give birth with a

skilled attendant. In some countries in sub-Saharan Africa and South Asia the rate is closer to 50%,

with even lower rates in rural areas.2A compounding problem is that many skilled attendants

(doctors, nurses and midwives) do not have the knowledge and skills needed to prevent, recognize

and manage the major causes of maternal and newborn deaths: hemorrhage, infection, pre-

eclampsia/eclampsia, obstructed labor and newborn asphyxia.

The components of emergency obstetric and newborn care (EmONC) were delineated in the early

1990s by WHO, UNICEF and UNFPA.3These signal functions are interventions that must be

available to all women at the time of birth in order to address the common but unpredictable causes

of maternal and newborn mortality. In outlining the EmONC interventions, WHO, UNICEF and

UNFPA recommended that all providers become capable of managing these common complications

in order to decrease need for referral and improve outcomes. The signal functions for EmONC are

listed below:

SIGNAL FUNCTIONS FOR EMERGENCY OBSTETRIC AND NEWBORN CARE

Basic Emergency Obstetric and Newborn Care(BEmONC):

Parenteral treatment of infection (antibiotics)

Parental treatment of pre-eclampsia/eclampsia(anticonvulsants)

Parental treatment of postpartum hemorrhage(uterotonics)

Manual vacuum aspiration of retained products of

conception Vacuum-assisted delivery

Manual removal of the placenta

Newborn resuscitation

Comprehensive Emergency Obstetric andNewborn Care (CEmONC):

All components of BEmONC

Surgical capability

Blood transfusion

Many countries are working to train more skilled providers in emergency obstetric and newborn care

to increase access to these services. However, few countries have the funds or human resources that

are needed to implement quality in-service training. Training that does not translate into the

improvement of patient care wastes those scarce resources and can cost lives.

Quality training in EmONC (and in any health-related field) goes beyond bringing together

providers for classroom and clinical practice for several days. Evidence suggests that training works

when it is competency-based and quality-focused and when it addresses transfer of learning to

1Hogan MC et al. 2010. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towardsMillennium Development Goal 5. Lancet (375): 16091623.2Crow S, Utley M, Costello A and Pagel C. 2012. How many births in sub-Saharan Africa and South Asia will not beattended by a skilled birth attendant between 2011 and 2015?BMC Pregnancy and Childbirth (12): 4.3Penny S and Murray S. Training initiatives for essential obstetric care in developing countries: A state of the artreview. Health Policy and Planning15(4): 386393.


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2 Guidelines for EmONC In-Service Training

practice through post-training follow-up.4Clinical practice and feedback must be sufficient for the

development of clinical decision-making and psychomotor skills.5Evidence also reinforces the

importance of clinically integrated learning interventions, as they have been found to be superior to

classroom-only instruction for generating positive learning outcomes.6This type of training ensures

that learnerspracticing clinicians and pre-service educatorsare trained by qualified facilitators in

appropriate classroom and clinical settings for an adequate amount of time, using evidence-based

training materials and approaches. And it emphasizes timely follow-up of the learners in theirworkplace, where facilitators can assess how the learners have incorporated their new skills and

knowledge into their management of actual clients.

These guidelines provide the information and guidance needed to implement effective BEmONC

and CEmONC training. Recommendations are made for selecting participants and clinical sites,

training schedules, and where to find the materials and resources needed for effective clinical skills

practice. Use of these guidelines will enable facilitators to train providers who are competent in

evidence-based practices and who will ensure that their facilities offer quality EmONC services.

2. TRAINING GOAL AND OBJECTIVES

The goal of EmONC training is to ensure that health facilities have competent providers who can

offer quality EmONC services. By the end of their training, learners achieve the following specific

objectives and competencies:

1. Identify the evidence basis for EmONC interventions.

2. Demonstrate understanding of clients rights through provision of respectful care to clients and

their families.

3. Utilize positive interpersonal communication techniques with clients and their families.

4. Demonstrate competency (first on anatomic models; then with clients) in EmONC signal

functions.

5. Demonstrate understanding and use of the clinical decision-making process.

6. Formulate action plans describing how they will act as role models and work to institutionalize

evidence-based EmONC knowledge and skills in their own health facilities.

4Kongnyuy E, Hofman J and van den Broek N. 2009. Ensuring effective Essential Obstetric Care in resource poorsettings. BJOG116(Suppl. 1): 4147.5McGaghie WC et al. 2009. Lessons for continuing medical education from simulation research in undergraduate andgraduate medical education: Effectiveness of continuing medical education: American College of Chest PhysiciansEvidence-Based Educational Guidelines. Chest135(3 Suppl): 62S68S.6Coomarasamy A and Khan KS. 2004. What is the evidence that postgraduate teaching in evidence based medicinechanges anything? A systematic review. BMJ (Clinical Research Ed.)329(7473): 10171022.


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3. PRE-TRAINING PREPARATION

Failure to prepare is the worst enemy of quality in any training program. Preparation should start at

least three to six months before the training and should include several activities:

1. Selecting clinical sites

This task is of paramount importance because it will ultimately determine the skills and attitudeslearners will see modeled during the training. The following criteria can be used to select clinical sites:

Buy-in by the clinical sites staff is needed to ensure smooth training.

Clinical site staff must be willing to go through targeted on-the-job technical and skills

updates to be able to model best practices.

Evidence-based clinical standards should be in place at the site (e.g., respectful care, use of

infection prevention practices, use of a partograph and active management of third stage of

labor).

Adequate caseloads that are appropriate to the training (especially surgical cases for

CEmONC) are needed because obstetric emergencies are relatively rare and learners need to

be exposed to as many cases as possible. BEmONC training sites should have at least 1015

deliveries per day, and CEmONC sites should have at least 10 deliveries and two to three

cesarean sections per day. When the caseload is lower than this, night shifts can be organized

or the length of the practicum can be extended so that all learners have the opportunity to

achieve competency. The reality is that in developing countries there are many clinical sites

with a high volume of cases but with poor quality of care, so strengthening of the site will be

needed before training.

Please see Appendix A for a description of key elements in the organization of quality maternity

services.2. Strengthening and preparing clinical sites

Every facilitators nightmare is that they bring learners to a facility where clinical practices are

below standard or where there are frequent stock-outs of supplies. So, at least two weeks before

the training, the facilitators should work with the clinical site staff on the following tasks:

Ensure that written evidence-based guidelines describing best practices in maternal and

newborn health (MNH) (i.e., infection prevention, use of the partograph, active

management of third stage of labor, and so on) are in place.

Determine whether the facility is woman- and baby-friendly (i.e., the rights of women and

families to respectful care, privacy, confidentiality, the presence of a companion andautonomy are recognized; mothers and babies are not separated; early and exclusive

breastfeeding is practiced; and so on).

Ensure that training will not unduly disrupt the facilitys work.

Make sure that sufficient supplies and medications such as infection prevention (IP)

equipment (training necessitates an increased number of gloves), delivery sets, suture kits,

oxytocin, magnesium sulfate (MgSO4) are available at the site. The training facilitators may


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need to bring some of these medications and supplies to the site to ensure that learners will

be able to manage cases in a timely manner instead of waiting for patients to purchase them

before receiving care.

Refer to the Jhpiego publication Site Assessment and Strengthening for Maternal and Newborn

Health Programs,available at www.accesstohealth.org, for a complete description of effective

strengthening of clinical sites prior to training.

3. Selecting learnersSelection of participants for training should be based on the following criteria:

Qualification as an obstetrician (or general practitioner), nurse and/or midwife, or anesthetist

Work experience as a provider in a facility delivering EmONC services and/or as a faculty

member/tutor in a school of medicine or midwifery

Supervisors written commitment to enable the learner to utilize the knowledge and skills

gained in the course in his/her clinical site and a commitment that the participant will be

deployed in the maternity unit for at least 12 months after training

The best way to select learners is to form a three- to four-person team of providers from eachfacility. The suggested composition of the team is as follows:

For BEmONC courses:

An obstetrician, general practitioner, or clinical officer

Two midwives (or nurses/midwives)

The ideal number of learners for the BEmONC course is 1624, depending on the number of

clinical sites available as well as the caseload in each site.

For CEmONC courses:

An obstetrician, general practitioner, or clinical officer with surgical skills

Two midwives (or nurses/midwives)

An anesthetist or a nurse anesthetist

The ideal number of learners is between 16 and 20, depending on the number of clinical sites

available and the caseload at each site.

4. Selecting facilitators

Being a proficient obstetrician, midwife, or anesthetist is not enough to qualify as an

EmONC facilitator. EmONC facilitators must meet the following requirements:

Qualification as a midwife, doctor, or anesthetist trained in EmONC

Qualification as a trainer through a Clinical Training Skills (CTS) course or ModCAL/CTS

Currently working in a facility that delivers EmONC services or has regular

opportunities to maintain clinical skills


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One often-asked question is how many facilitators are needed for EmONC training.

For a BEmONC training with 1624 learners, a minimum of three facilitators (two

obstetricians plus one midwife, or one obstetrician plus two midwives) is needed for the

knowledge update component. Since each team of three to four learners should be

supervised by a facilitator during the clinical skills standardization portion of the course

(including work with anatomic models), an additional two or three facilitators (either two to

three midwives or one obstetrician and one or two midwives) will be needed. These

facilitators will remain with the teams throughout the clinical portion of the course. These

facilitators become critically important if the practicum takes place in a very busy facility

where a few facilitators cannot adequately supervise all the learner teams when they are

working with clients.

For a CEmONC training, an additional obstetrician is recommended for sites with many

surgical cases; the number of midwives is the same as for BEmONC. In addition, two

anesthetists (an anesthesiologist and/or a nurse anesthetist) will be needed.

5. Gathering equipment needed for training (see Appendix B)

6. Developing job aidsSimple job aids that remind the learner of key information can be extremely valuable in helping

the learner apply skills on the job. Posters, pocket guides and simple guidelines assist learners

with quick recall and the application of complex skills. For more information, see section 9.

4. COMPONENTS AND CONTENT OF TRAINING IN

EMONC

Any complete EmONC training (and by extension any good clinical training) should include the

following three components:

Knowledge update

Clinical skills standardization, resulting in the acquisition of competencies in specific skills (a list

of competencies is included below)

Follow-up of learners in their sites within three months of the training, ideally by the facilitators

who conducted the course

Jhpiego has applied evidence from a recent integrative review of the literature regarding the techniques,timing, setting and media used for the delivery of instruction to its EmONC training approach. The

blended approach uses spaced, repetitive questions delivered via mobile phone text messaging (SMS) or

the internet to address key knowledge objectives, followed by clinical practice in simulation and with

clients, and continued follow-up and support after training. The knowledge component of the course

via the internet can be accessed at: http://app.qstream.com/Jhpiego/courses/2042-Basic-Emergency-

Obstetrical-Skills.


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Effective blended learning approaches require each component of training to be dependent on

another component.7Each piece is linked so that a learner cannot successfully complete the course

and master the content without completing each component in succession. Jhpiego applies this

approach by delivering questions that are repeated over time, confirming completion and knowledge

mastery during the clinical practice and live sessions, linking the follow-up to the use of skills in the

workplace, and recording the use of the skills in a logbook. This ensures that funds invested to train

providers result in skills being applied during service delivery and ultimately in improved maternaland newborn health outcomes.

Jhpiegos three training components are discussed in further detail below.

KNOWLEDGE UPDATE

This component is computer- and/or classroom-based and includes the evidence basis for best

practices in the management of normal labor and birth as well as the signal functions of EmONC,

demonstrations of key interventions on anatomic models (via video or real-time if in the classroom),

case studies and role plays. The following topics should be reviewed and knowledge assessed before

advancing to the clinical site:

Basic Emergency Obstetric and Newborn Care (BEmONC)Topics for midwives, doctors and nurses:

Maternal and newborn mortality reduction

Evidence-based practices in maternal and newborn health

Human rights; respectful care of women and their families

Clinical decision-making

Infection prevention practices

Best practices during normal labor and childbirth, including partograph use, active management

of the third stage of labor (AMTSL) and essential newborn care

Care of the mother and baby during the immediate postpartum period

Rapid initial assessment

Management of shock

Vaginal bleeding in early pregnancy and postabortion care (PAC)

Vaginal bleeding in late pregnancy

Headache, blurred vision, loss of consciousness and elevated blood pressure

Management of cord prolapse, breech delivery and shoulder dystocia (optional)

Vacuum-assisted delivery

7Hoffman J and Miner N. 2008. Real blended learning stands up. American Society of Training and Development.Accessed on February 21, 2012, at:http://www.astd.org/LC/2008/1008_hofmann.htm


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Vaginal bleeding after childbirth

Fever during and after childbirth


Newborn sepsis

Improving EmONC through criterion-based audit or other quality improvement approachessuch as Standards-Based Management and Recognition (SBM-R)

Comprehensive Emergency Obstetric and Newborn Care (CEmONC)Topics for doctors (and midwives in some settings):

All BEmONC topics

Pre-, intra- and postoperative care of obstetric patients

Cesarean section (Misgav Ladach method); surgical treatment of ectopic pregnancy

B-Lynch suture

Blood transfusion

Anesthesia and analgesia in obstetrics

Craniotomy (optional)

Tubal ligation (optional)

Topics for anesthetists:

Maternal and newborn mortality

Evidence-based medicine in maternal and newborn health Infection prevention

Setup of operating theater

Rapid initial assessment

Management of shock

Review anatomy of respiratory and cardiovascular systems

Review of anatomy of vertebral column and spinal cord

Headaches, blurred vision, convulsions, loss of consciousness or elevated blood pressure

Cardiopulmonary resuscitation (CPR)

Control of the airway; endotracheal intubation

Intravenous fluid therapy, oxygen therapy, drugs used in resuscitation

Normal newborn care and newborn resuscitation

Pre-operative, intraoperative and postoperative evaluation and care


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Selecting the correct anesthetic technique, including ketamine and spinal anesthesia

Deciding which cases to refer

Blood transfusion

Improving emergency obstetric care through criterion-based audits

CLINICAL SKILLS STANDARDIZATION

Classroom PracticeClinical skills standardization begins in the classroom/skills lab as learners use evidence-based,

standardized checklists to become competent in specific skills using anatomic models. Learners must

be judged competent in all skills before proceeding to the clinical setting to care for clients.

Depending on the number of learners and the level of skills they bring to the training, clinical skills

standardization may require up to two days to complete for all learners. Stations are set up for each

skill that learners will master (e.g., newborn resuscitation, normal birth, AMTSL, immediate

newborn care, suturing, and so on). After each skill is demonstrated by facilitators, learners practicein pairs at the station using checklists. Each learner is then assessed by the facilitators for competency

in the skill using models. Anyone who does not attain mastery of the skill in simulation continues to

practice until competent.

Stations for BEmONC skills assessment and mastery (for midwives, doctors and nurses) in the

classroom:

Normal delivery, including AMTSL and immediate newborn care

Management of severe pre-eclampsia and eclampsia using MgSO4

Repair of episiotomy and vaginal and cervical lacerations Postabortion care and manual vacuum aspiration (MVA)

Vacuum-assisted delivery

Management of postpartum hemorrhage (PPH), including manual removal of the placenta,

bimanual compression of the uterus, compression of the abdominal aorta, and condom tamponade

Normal newborn exam


Breech delivery (Mauriceau-Smellie-Veit and Loveset maneuvers) (optional)

Facilitators must make sure that all learners have mastered these skills in simulation before they

move to the practicum at the clinical site(s).

Stations for CEmONC skills assessment (for providers who perform surgery) in the classroom:

All skills stations listed for BEmONC

Cesarean section


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Laparotomy

Tubal ligation (optional)

Craniotomy (optional)

Facilitators must make sure that all learners have mastered these skills in simulation before they

move to the practicum at the clinical site(s).

Stations for CEmONC skills assessment (for anesthetists) in the classroom:

Adult resuscitation and intubation

Cardiopulmonary resuscitation

Spinal anesthesia


Facilitators must make sure that all learners have mastered these skills before moving to the

practicum at the clinical sites.

Clinical PracticumDuring the practicum facilitators divide learners into groups of three or four, with no more than

four learners per facilitator, and develop rotation schedules in ANC, maternity (triage/admission,

labor, and birth areas, if separate), inpatient antepartum, and immediate postpartum/newborn. It is

important to have a room where anatomic models and supplies can be available for continued

practice and where case studies, partograph rounds, and role plays can be carried out at times when

the service is not busy. Each learner must have a logbook for recording daily activities (Appendix C).

Continual assessment of learners during their clinical work is essential to ensure that each one has an

opportunity to practice various skills with clients. Facilitators should meet daily with each learner to

assess their progress and challenges and to ensure that each has adequate clinical experience and

coaching to become competent in as many skills as possible. The meetings usually take place at the

end of the day. Facilitators should also meet daily as a group to discuss the general progress of

learners and any specific issues that arise during the training.

Last Day of TrainingOn the last day of the training, learners and facilitators meet again in the classroom. Some important

activities take place during the day: Learners complete a written knowledge assessment covering the best practices addressed during the

training. They should score at least 85%; if they do not, they should be coached and then take the

assessment again. They should continue to retake the assessment until they reach the required score.

Depending on the setting, learners may need to participate in clinical simulations with models so

that their competency in key skills can be assessed. They should be coached until they reach a

minimum score of 85% for each skill.


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Each team of learners (if possible) or each individual learner (if the team members come from

different facilities) will develop an action plan to implement in the three months following the

trainings. Action plans ensure that learners continue to use their new skills and teach them to

colleagues, thereby improving the quality of services at their facilities. Usually, learners are asked

to select up to three clinical practices that they want to improve at their facility and delineate the

steps they will take to achieve the improvements. See Appendix D for a sample action plan.

Facilitators and learners discuss next steps, and facilitators share information about:

The use of the logbooks to record all the skills performed by the learners after the training

and before the follow-up visit;

The implementation of the action plans;

The follow-up visit (including, if possible, dates and process); and

Evaluation of the training.

Learners share their feelings and feedback about the training. Each learner fills out an

anonymous questionnaire assessing several components of the training, including the objectives,

methodology, content, logistics, and so on. Appendix E provides an example of a training

evaluation questionnaire.

FOLLOW-UP OF THE TRAINING

Follow-up and supportive supervision are key to helping providers solve problems and apply new

practices on the job. Using performance standards (harmonized and standardized with training

materials) within a post-training follow-up approach or supportive supervision system can also

support performance improvement.8

Before leaving the training site learners will develop action plans in which they will select three orfour skills they have acquired and put them into practice in their workplaces. Follow-up takes place

from six weeks to three months after the training, so learners will have had time to practice their new

knowledge and skills and put their action plans into effect. They will then have the opportunity to

discuss their successes and challenges with a facilitator. If the caseloads in the learners health

facilities are low, it may be better to regroup all learners in a busy health facility for two to three days

to conduct the follow-up visit.

An innovative way to follow up learners, either before or after the first visit, is by using mobile phone

technology in a structured way. Options include sending regular SMS messages to remind learners to

use key best practices; texting questions for them to answer to test their retention of knowledge; andscheduling short phone calls to each team every few weeks to ascertain successes and challenges and

provide coaching even before the actual visit. This form of early and ongoing communication is

being used successfully in many countries; it helps to ensure that the follow-up visit is used to

address the most important issues raised during the mobile phone activities.

8Examples of EmONC performance standards are available in the EONC Toolkit (forthcoming at www.k4h.org).


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When conducting a follow-up visit, you should organize your activities as follows:

1. Assessment of the learners action plan implementation, including successes and challenges

encountered

2. Knowledge assessment for each learner using questions similar to those used in the training

3. Case studies on the partograph and PPH

4. Assessment of skills and attitudes with clients (ideally) or anatomic models (if there are no

clients) using checklists

5. Review of each learners clinical experiences logbook

6. Debriefing with the facility management team

7. Discussion of next steps to ensure that as many elements as possible of BEmONC and/or

CEmONC continue to be practiced in the facility

For more detailed information on how to conduct follow-up of providers, you may wish to consult

Jhpiegos Guidelines for Assessment of Skilled Providers after Training in Maternal and NewbornHealth, available at:www.jhpiego.org/files/GdlnsSkillProvEN.pdf

5. TRAINING DURATION AND SCHEDULES

There is a debate in the EmONC community about the appropriate duration of EmONC trainings.

EmONC training curricula generally range in length from three days to three weeks. It is important

to keep in mind that EmONC training is based on mastery of the EmONC signal functions, and

every training course should result in competent providers. The evidence is clear that sufficient

practice and feedback is essential to the development of the critical thinking and psychomotor skillsrequired to perform these functions.9The knowledge update alone may have little to no impact on

learners clinical practice skills and behaviors.

In countries with scarce human resources, taking any health worker away for training can

compromise the provision of services during the training. To reduce training time and increase

efficiency, Jhpiego now uses an internet-based course built upon repeated questions and feedback

(see section 4). Three options for training schedules are included here: a 12-day BEmONC training

schedule for midwives and obstetricians; an 18-day CEmONC training schedule for midwives and

obstetricians; and an 18-day CEmONC training schedule for anesthetists. The schedules assume

that a blended learning approach will be taken to reduce training time and increase the effectivenessof training.

9McGaghie, WC et al. 2009. Lessons for continuing medical education from simulation research in undergraduateand graduate medical education: Effectiveness of continuing medical education: American College of ChestPhysicians, evidence-based educational guidelines. Chest135 (3 Suppl) (Mar): 62S68S.


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ONCIn-ServiceTraining

BEMONCFORMIDWIVES

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Wastedisposal

Instrumenthandlingand

preparation

Presen

tationand

Discus

sion:Rapidinitial

assess

ment;recognizingand

manag

ingshock;adult

resuscitation;andmonitoring

bloodtransfusion

Agendaandopening

activity

Presentation

and

Discussion:

Reviewof

anatomyofrespiratory

andcardiova

scular

system

Presentation

and

Discussion:

Drugsused

inresuscitation:

adrenaline,e

phedrine,

atropine

Demonstration:

Resuscitation

tray

Presentation

and

Discussion:

Reviewof

physiologyofrespiratory

andcardiova

scular

system;phys

iological

changesinpregnancy

Agendaandopening

activity

Presentationand

Discussion:

CPR

Controlofairway

Principlesofoxyge

n

therapy

Intravenousfluid

therapy

Demonstrationand

SkillsPracticeon

Models:

IVcannulation

Bagandmask

ventilation

CPR

Learnerspracticeinpa

irs

Agendaandopeningactivity

Presentationand

Discussion:

Evaluationandcareof

preoperativepatient

Selectingthecorrect

anesthetictechnique

CaseStudy:Preoperative

casestudies

AnestheticEvaluation:

ExerciseOne:

Preoperativepatient

Demonstrationand

Practice:Evaluationand

careofpreoperativepatient

Agendaandopening

activity

Presentationand

Discussion:Vaginal

bleedingafterchildbirth

Presentationand

Discussion:Intra-

operativeevaluationand

care

CaseStudy:Intra-

operativebreathing

difficultyandbradycardia

AnestheticEvaluation:

ExerciseTwo:

Intra-operativepatient

Presentationand

Discussion:Reviewof

anatomyofvertebral

columnandspinalcord

LUNCH

LUNCH

LUN

CH

LUNCH

LUNCH

LUNCH


22/38


23/38

19

GuidelinesforEm


CEMONCFORANESTHETISTS:18-DAYCOURSESC

HEDULE

ClinicalSimulation

(emergency

drill/clinical

simulation):

Managementofsevere

pre-eclampsiaand

collapse

SkillPracticeon

Models:CPR,newborn

resuscitation,ventilation

Reviewofthedays

activities

Presen

tationand

Discus

sion:Obstetric

surgery:

Ce

sareansection

La

parotomy

Hy

sterectomy

Sa

lpingectomy

VideoFilms:Cesarean

section

Review

ofthedaysactivities

ClinicalPrac

tice

(continued):

Intra-

operativeeva

luation,

monitoringandcare

Demonstration:

Infectionprevention:

Instrume

ntandlinen

preparat

ion

High-level

disinfection

Sterilization

Discussion:Maintaining

operatingroom(OR)

readiness

Reviewofthedays

activities

TouroftheHospital

EmONCFacility

Emergencyreception

area

Laborroom/ward

Antenatalandpost-

deliveryarea

Reviewofthedays

activities

TourofModelDistrict

EmONCFacility

(continued)

Discussion:Settingup

districtORandanesthesia

servicesandfacilities


ClinicalPracticeinOR

Downtime:Casestudies

ordiscussionofactual

cases

DAY13

DAY14

DAY

15

DAY16

DAY17

DAY18


Clinica

lPracticeinOR

ClinicalPrac

ticeinOR



Agendaandopening

activity

Presentationand

Discussion:EmONC

indicators

Presentationand

Discussion:Criteria-

basedaudit

GroupWork:Develop

actionplans

Presentations:Action

plans

NextSteps:Logbook;on-

the-joblearning;planning

mentoringvisits

LUNCH

LUNCH

LUN

CH

LUNCH

LUNCH

LUNCH

ClinicalPracticeinOr



cases

Clinica

lPractice

Downtime:Casestudiesor

discussionofactualcases

ClinicalPrac

tice

Downtime:C

asestudies

ordiscussion

ofactual

cases

ClinicalPractice



cases

ClinicalPractice

Downtime:Casestudiesor

discussionofactualcases

CourseSummary

CourseEvaluation

ClosingCeremony

Note:Shadedareasindicatecom

monmodulesforanesthetists,obstetriciansandmidwives


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6. COURSE MATERIALS

Since the goal of EmONC training is to teach providers evidence-based best practices, training must be

based on the most up-to-date teaching materials and manuals. This section contains links to the

learning resource packages (LRPs) that facilitators will need in order to organize the BEmONC and

CEmONC courses in a logical way. The LRPs contain schedules, session outlines, knowledge

questionnaires, case studies, role plays, skills checklists and PowerPoint presentations. In addition, links

are provided to several reference manuals that contain global evidence-based guidelines for emergency

obstetric and newborn care. The LRPs are formulated to reflect the information in these manuals.

MATERIALS FOR THE BEMONC COURSE

DOCUMENTS TO PREPARE IN ADVANCE

For each learner: For each facilitator:

Course schedule Course schedule and course outline

Precourse questionnaire Precourse questionnaire and answer key

Midcourse questionnaire Midcourse questionnaire and answer key

Action plan Copy of learners action plan

TRAINING MATERIALS TO DOWNLOAD

For each learner For each facilitator

Best Practices in Maternal and NewbornCare: A Learning Resource Package forEssential and Basic Emergency Obstetricand Newborn Care. Learners Notebook.http://www.accesstohealth.org/toolres/pdfs

/ACCESS_BPmnclrpPart.pdf

Best Practices in Maternal and Newborn Care:A Learning Resource Package for Essential andBasic Emergency Obstetric and Newborn Care.Facilitators Guide.http://www.accesstohealth.org/toolres/pdfs/ACCESS_BPmncrlpFacil.pdf

Managing Complications in Pregnancyand Childbirth: A Guide for Midwives andDoctors. World Health Organization, 2003.http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.7.pdf

Pregnancy, Childbirth, Postpartum andNewborn Care: A Guide for EssentialPractice.WHO, 2006.http://www.who.int/reproductivehealth/publications/en/

Managing Complications in Pregnancy andChildbirth: A Guide for Midwives and Doctors.World Health Organization, 2003.http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.7.pdf

Pregnancy, Childbirth, Postpartum and NewbornCare: A Guide for Essential Practice. WHO, 2006.http://www.who.int/reproductivehealth/publications/en/

Emergency Obstetric Care: QuickReference Guide for Frontline Providers.

Jhpiego, 2003.

http://www.jhpiego.org/en/node/477

Emergency Obstetric Care: Quick ReferenceGuide for Frontline Providers. Jhpiego, 2003.http://www.jhpiego.org/en/node/477


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MATERIALS FOR THE CEMONC COURSE

DOCUMENTS TO PREPARE IN ADVANCE


Course schedule for midwives, doctorsand/or other clinicians performing surgery

Course schedule and course outline formidwives, doctors and/or other cliniciansperforming surgery

Precourse questionnaire for midwives,doctors and/or other clinicians performingsurgery

Precourse questionnaire for midwives, doctorsand/or other clinicians performing surgery, andanswer key

Midcourse questionnaire for midwives anddoctors

Midcourse questionnaire for midwives anddoctors, and answer key

Action plan Copy of learners action plans

For each anesthetist: For each facilitator anesthetist:

Course schedule for anesthetists Course schedule for anesthetists

Precourse questionnaire for anesthetists Precourse questionnaire for anesthetists

Midcourse questionnaire for anesthetists Midcourse questionnaire for anesthetists, and

answer key Action plan Copy of learners action plans

TRAINING MATERIALS TO DOWNLOAD


Emergency Obstetric Care for Doctors andMidwives. Learners Guide. Jhpiego/MNHProgram and AMDD, 2003.http://www.jhpiego.org/pt-br/node/445

Emergency Obstetric Care for Doctors andMidwives.Teachers Notebook Guide.Jhpiego/MNH Program and AMDD, 2003.http://www.jhpiego.org/pt-br/node/445

Managing Complications in Pregnancy andChildbirth: A Guide for Midwives andDoctors. World Health Organization, 2003.

http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.7.pdf

Pregnancy, Childbirth, Postpartum andNewborn Care: A Guide for EssentialPractice. WHO, 2006.http://www.who.int/reproductivehealth/publications/en/

Managing Complications in Pregnancy andChildbirth: A Guide for Midwives and Doctors.World Health Organization, 2003.

http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.7.pdf

Pregnancy, Childbirth, Postpartum andNewborn Care: A Guide for Essential Practice.WHO, 2006.http://www.who.int/reproductivehealth/publications/en/

For each learneranesthetist: For each facilitatoranesthetist:

Anesthesia for Emergency Obstetric Care.Learners Guide. Jhpiego/MNH Programand AMDD Program, 2003.http://www.jhpiego.org/en/node/444

Anesthesia for Emergency Obstetric Care.Teachers Notebook. Jhpiego/MNH Programand AMDD Program, 2003.http://www.jhpiego.org/en/node/444

Anaesthesia at the District Hospital(2d ed.),by Michael B. Dobson. WHO, 2000.http://whqlibdoc.who.int/publications/9241545275

Anaesthesia at the District Hospital(2d ed.), byMichael B. Dobson. WHO, 2000.http://whqlibdoc.who.int/publications/9241545275

Managing Complications in Pregnancy andChildbirth: A Guide for Midwives andDoctors.World Health Organization, 2003.http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.7.pdf

Managing Complications in Pregnancy andChildbirth: A Guide for Midwives and Doctors.World Health Organization, 2003.http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.7.pdf


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MATERIALS FOR FOLLOW-UP OF LEARNERS

For each midwife and doctor: For each anesthetist:

Clinical experience logbook Anesthesia for EmONC clinical experiencelogbook

Guidelines for Assessment of SkilledProviders after Training in Maternal and

Newborn Health. Jhpiego, 2004.www.jhpiego.org/files/GdlnsSkillProvEN.pdf

Materials for follow-up of health care providerstrained in anesthesia for EmONC can be found

in the EONC Toolkit (forthcoming in 2012; visitwww.k4health.org)

Action plan Action plan

Related standards Related standards

7. ANATOMIC MODELS

Listed below are descriptions and ordering information for anatomic models and other

equipment needed for EmONC trainings. At a minimum, models for childbirth (for practicing

AMTSL, immediate newborn care, and PPH treatment) and newborn resuscitation should bemade available for BEmONC training. Models for lumbar puncture and airway management can

be added for CEmONC training.

DESCRIPTION SOURCE

Childbirth simulator BUYAMAG INC.www.buyamag.com

GAUMARD SCIENTIFICTel: 001305-971-3790www.gaumard.com

MamaNatalie (normal birth & vacuum) LAERDALwww.laerdal.com/mamaNatalie

Pelvic model for breech delivery SUPERIOR MEDICALsuperiormedical.com/l_models.html

Model and equipment for MVA IPASwww.ipas.org

Fetus model for vacuum extraction PELICAN HEALTHCARE LTD.www.pelicanhealthcare.co.ukTel: 029 2074 7000Fax: 029 2074 7001Email: [email protected]

Model for Cesarean section OPERATIVE EXPERIENCEwww.operativeexperience.com

Model for PPH management: MamaNatalie LAERDALwww.laerdal.com

Model and equipment for newborn resuscitation:Helping Babies Breathe (HBB) model NeoNatalie

LAERDAL GLOBAL HEALTHwww.laerdalglobalhealth.com/neonatalie.html


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DESCRIPTION SOURCE

Lumbar puncture trainer/simulator for spinalanesthesia

GAUMARD SCIENTIFICTel: 001305-971-3790www.gaumard.com

KYOTO KAGAKUwww.kyotokagaku.com

Airway management trainer with stand SIMULAIDSwww.simulaids.comTel: 800-431-4310Fax: 001845-679-8996E-mail: [email protected]

8. VIDEOS AND PRESENTATIONS

The following videos and presentations are useful in EmONC training to reinforce the key

components of each skill being taught. Learners can view them at their own convenience during andfollowing training as needed to refresh their knowledge.

DESCRIPTION SOURCES

Active Management of the ThirdStage of Labor: A Demonstration

ACCESS Programwww.accesstohealth.org/toolres/amtslweb/amtsl.html

Vaginal Breech Delivery andSymphysiotomy

WHO Reproductive Health Libraryhttp://apps.who.int/rhl/videos/en/index.html

Manual Vacuum Aspiration IPASwww.ipas.orgView video at http://youtu.be/I0daZ8dLXdY

Vacuum Extraction WHO Reproductive Health Libraryhttp://apps.who.int/rhl/videos/en/index.html

Vacuum-Assisted Delivery: A BriefSummary of Key Principles

Clinical Innovations, Inc.http://www.clinicalinnovations.com/kiwi_video_vad.htmTel: 888-268-6222 or 801-268-8200To order video, go to:http://www.clinicalinnovations.com/vacca.htm#dvd

Steps to Overcome ShoulderDystocia


Caesarean Section Evidence-Based Surgical Techniques


Spinal Anesthesia www.operationalmedicine.org/ed2/video/spinal.mpg

Labour Companionship: EveryWomans Choice



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9. JOB AIDS

A full list of resources, including job aids, can be found in the Essential Obstetric and Newborn Care

(EONC) Toolkit, forthcoming in 2012 on the Knowledge for Health website (visit

http://www.k4health.org/publications-and-resources). The followingjob aids are especially useful

during training. If possible, each facility represented at the training should have copies of them.

Job Aids in the EONC Toolkit (forthcoming at www.k4health.org):

Positions for Labor (drawings of positions in labor and squatting position for birth), by Victor

Okello (artist); from GOAL, Uganda

Steps to Perform AMTSL (poster)

Steps to Perform MVA (poster)

Algorithm for Management of Preeclampsia/Eclampsia (poster)

Dilution and Mixing of MgSO4 (poster)

Algorithm for Management of PPH (poster)

Other Job Aids:

Positions for Laboring Out of BedTear Pad

Cascade Healthcare Products

www.1cascade.com/ProductInfo.aspx?productid=2937

Action PlanPoster

Helping Babies Breathe Action Plan

www.helpingbabiesbreathe.org/docs/ActionPlan.pdf

Large laminated WHO Modified Partograph

(Facilitators can make this by enlarging a printed partograph to about 1 meter x 1 meter and

laminating it.)

Wall chart to demonstrate cervical dilatation

(Facilitators can make this on flipchart paper by drawing circles from 1 cm to 10 cm in diameter.)

10. DOCUMENTATION OF ACTIVITIES

Training in EmONC is an important component of many maternal mortality reduction programs,

and documentation of activities is needed to monitor the impact of training. You will need a system

for collecting data on facilitators, learners and training events so that you can report on activities and

evaluate the program. The system can be solely paper-based or web-based or a combination of both.

Appendix F shows the Training Information Monitoring System (TIMS) Data Recording Form, the

paper-based reporting system developed by Jhpiego for tracking training activities. The data

collected can be entered in a simple Excel spreadsheet.


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APPENDIX A: ORGANIZATION OF MATERNITY

SERVICES

Listed below are the components of maternity services that should be assessed and targeted for

improvement in the clinical sites that are used for EmONC training. Included are points that should

be highlighted during the discussion of woman-friendly services on the first day of training andthroughout the training.

1. Staffing

Services should be available 24 hours/day, seven days/week.

Staff with BEmONC skills should stay at the site during their assigned shifts. Staff with

CEmONC skills should be easily available by phone or other means, and able to be at the

site within 20 minutes of being called.

2. Woman-friendly and family-friendly care

Women and their families should always be greeted kindly and with respect, no matter howbusy the service is. Every woman should feel as though she is receiving the highest quality

care, even if labor and birth proceed normally.

Women who present for care should undergo immediate rapid assessment and be triaged

according to the findings of the assessment.

Women have a right to (1) privacy (curtains, if not a separate room); (2) know who is taking

care of them (i.e., the providers name and qualification); (3) consent to care by a student;

(4) the presence of a family member/companion; (5) information about what is happening

and answers to their questions; (6) information about all procedures and informed consent

for each; (7) ambulate and eat/drink as desired if there are no contraindications; (8) assume

the position of their choice for the birth; (9) breastfeed immediately after the birth; and (10)remain with their baby throughout their stay at the facility.

3. Equipment/supplies

A designated staff member on each shift will be responsible for checking/restocking all

emergency equipment and trays per established guidelines and checklists. All staff members

should have access to emergency equipment at all times (e.g., adult ambu bags and masks, IV

solutions and administration sets, and medications such as oxytocin and magnesium sulfate).

4. Responsibility for client care

To ensure continuity and increase accountability for each clients care, every client is assigned

to a specific staff member (midwife, obstetrician, nurse), and that staff member is responsible

for coordinating all care. This includes maintaining the partograph and other documentation

(i.e., delivery register, referral forms, operative notes, and so on).

If the staff member cannot care for the client (because he or she is assisting at another

delivery or an emergency arises), the clients care should officially be turned over to another

staff member.

Midwifery, nursing and medical students are not counted as regular staff.


30/38


Each student must be assigned to a regular staff member.

Each staff member should supervise no more than two students at a time.

Students can provide direct care to the woman/newborn, but only under the direct

supervision of a regular staff member.

If a physical assessment shows the client is progressing normally, staff can instruct family

members about assisting with ambulation, nourishment and other comfort measures. Staffshould continue to assess the woman and maintain the partograph and other documentation

as needed.

5. Documentation

The partograph will be used for every client once active labor has begun. Students may assist

in gathering information for the partograph under the supervision of a regular staff member.

If a client is not in active labor, a chart will be established and updated at least every four

hours or more often if the clients condition warrants.

Specific documentation will be undertaken for women with complications. For example,

documentation for pre-eclampsia/eclampsia includes vital signs (with respirations andreflexes), presence of convulsions, state of consciousness, presence of headache and

abdominal pain, fetal heart rate and use of medications (time, dose and route).

6. Specific procedures

Routine procedures such as cervical exams, rupture of membranes and normal

birth/newborn care/repair of minor lacerations should be carried out in the same room/bed

throughout the clients care.

Procedures such as MVA should be carried out in the labor ward, not the operating theater,

so as to expedite the womans care and counseling and keep the operating theater open for

urgent cases.

7. Newborn resuscitation

At least one resuscitation corner will be readily accessible to all delivery areas. It will be set up

for immediate use at all times. It should include a table with a clean cover, exam gloves, a

radiant lamp or other means to warm the newborn, oxygen if available, clean towels/cloths to

dry the newborn, suction device, an ambu bag and newborn and premature-size masks, a

clock with second hand and a wall chart for newborn resuscitation (e.g., the Helping Babies

Breathe job aid).

8. Hand-off at end of shift

Providers leaving at the end of their shift will ensure that all materials, supplies and

medications are replenished before they leave and that the newborn resuscitation corner is

ready for use.

Incoming providers will meet with the outgoing staff and receive client assignments and an

update about the status of each client, using the partograph and/or other documentation as a

guide.

Incoming providers will immediately introduce themselves to clients.


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APPENDIX B: EQUIPMENT AND SUPPLIES LIST

The list below shows the standard equipment and supplies that are needed for training courses, both

in the classroom and in the clinical setting. Learners will need basic supplies to simulate what they

will find in the hospital, and these items can be kept and used for future training courses. After

assessing the clinical site, facilitators may want to donate certain equipment, supplies and

medications to the facility so that learners are able to care for clients according to global standards.

ITEMSNUMBERS NEEDED

Learners Facilitators Facility* Total

Examination

Adult sphygmomanometer 1 per team 2

Adult stethoscope 1 per team 2

Thermometer 1 per team 2

Tape 1 per team 2

Fetoscope 1 per team 2

Delivery

Delivery Kits 1 per team 35

Instrument tray

Cord scissors

Hemostats (2) to clamp cord, or cordclamps

Sponge forceps (2)

Galipot bowls for cotton/antiseptic forperineal cleansing; placenta bowl

1 per model

35

Plastic sheet to place under mother andclean cloths for draping

34 permodel

5

Clean cloths to dry and cover baby 34 permodel

2 dozen

Plastic apron 1 per team 5

Head covers 1 per learner 100

Masks 1 per learner 100

Glovessterile 6 pairs perlearner

3 dozen,varioussizes

Glovesnon-sterile 2 boxes perteam

10 boxes

Barrier goggles 1 per learner 1 perfacilitator

Gauze4-inch x 4-inch squares in giantpackage, non-sterile and not individuallywrapped

4 packagesper team

6 boxes

Oxytocin vials 1 per team 50


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ITEMSNUMBERS NEEDED


Syringe and needle (3 cc syringe with 20 or21 gauge needle)

1 per team 50

Amniotic hook or Kocher clamp 1 per team 35

Episiotomy

Sponges (foam blocks) of upholstery quality(8 inch x 4 inch x 4 inch)should not teareasily when thread pulled through. Pleasetest!

3 per learner 2

Suture needlesreusable, round body,half-circle suture needles either with suturealready attached or with an eye so suturecan be pulled through eye.

50

50

Rolls/spools of regular sewing thread (goodquality so goes through practice spongeeasily). Needed only if suture needles donot have suture attached.

10rolls/spoolsper team

Episiotomy/laceration repair kitsincludemetal tray or container with needle holder,episiotomy scissors, non-toothed dissectingforceps, towel clips, stitch scissors, sponge-holding forceps, long straight artery forceps

1 per team

3

10 cc syringe with 1.5-inch needle (pretendfilled with 0.5% lidocaine); or lidocaine 1%and sterile water for injection, for dilution to0.5%.

1 per

50

Infection Prevention

Plastic buckets 3 per team 6

Large steamer pot with lid (for steaming/boiling)

1

Plastic bucket for chlorine solution 1 per model(childbirth

andnewborn)

6

Heavy cleaning gloves 2 pairs

Toothbrush 6

Puncture-proof container for sharpsdisposal

1 perchildbirth

model

6

Plastic bucket for paper disposal 1 per model(childbirthand

newborn)

0 6

Bottles of alcohol and glycerin gel for handcleansing

1 per station 0 6

Dish/liquid soap 1 perclassroom

0 5

Individual towels 12 per 12 per


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ITEMSNUMBERS NEEDED


learner facilitator

PPH, PE/E and other EmONC Management

Foley bladder catheter 1 per model 0 5

Condom idem 0 5

Suture idem 0 5

IV fluids administration set idem 0 10

Adult ambu bag with mask 1 0 1

Oxytocin 10 IU idem 0 50

Cesarean tray, if CEmONC 1 per 46learners

0 3

Vacuum extractor 1 per 46learners

0 1

MVA kit 1 per team 0 1

NeoNatalie kits, including models, ambubags/masks, and mucous extractors; orseparate models and equipment

1 per 46learners

0 1

Antihypertensives 0 Based on# of casesat training

sites, ifstockouts

areanticipated

Magnesium sulfate 0 idem

Antibiotics for treatment of maternal andnewborn infection

0idem

Chlorhexidine 4% for newborn cord care 0 idem

*Numbers needed for each facility will depend on what is found during the clinical site assessment; some facilities arewell-equipped while others will have no spare equipment for use by learners.


34/38


APPENDIX C: PRACTICUM LOGBOOKS FOR

DOCUMENTING SKILLS PERFORMED WITH CLIENTS

Practicum Logbook for Nurses/Midwives and Obstetricians (to be filled out during EmONC training)

DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8

Partograph

Normal delivery

Active management ofthird stage of labor

Episiotomy and/orrepair ofepisiotomy/laceration


Vacuum-assisteddelivery

Manual vacuumaspiration

Manual removal of theplacenta

Bimanualcompression of theuterus

Compression ofabdominal aorta

Condom tamponade

Cesarean section*

Laparotomy for extra-uterine pregnancy*

Laparotomy for uterinerupture*

*For obstetricians only


35/38


36/38


APPENDIX D: SAMPLE ACTION PLAN FOR

LEARNERS

Learner Name:

Country of Residence:

Training Attended:

Name of Facility:

Date:

Based on what you learned during this training, please write down three things that you wouldlike to change at your facility over the next year:

Goal #1

Goal #2

Goal #3

List the actions/steps needed to achieve the goal, along with the date that each activity iscompleted. Include the names of colleagues who will assist you and list the specific tasks theyare assigned.

Goal #1

ACTIVITIES/STEPS DATEPLANNED

COLLEAGUES WHO WILLASSIST AND THEIR ASSIGNED

TASKS

DATECOMPLETED

Goal #2


COLLEAGUES WHO WILLASSIST AND THEIR TASKS

DATECOMPLETED

Goal #3


COLLEAGUES WHO WILLASSIST AND THEIR TASKS

DATECOMPLETED


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APPENDIX E: TRAINING EVALUATION

QUESTIONNAIRE

PLEASE EVALUATE THE

FOLLOWING STATEMENTS

STRONGLY

AGREE

AGREE UNDECIDED DISAGREE STRONGLY

DISAGREE

1. For the work I do, the trainingwas appropriate.

2. Training facilities andarrangements weresatisfactory.

3. The facilitators/teacherswere knowledgeable andskilled.

4. The facilitators/teacherswere fair and friendly.

5. The training updated myknowledge and skills.

6. Training objectives were met.

7. Teaching aids were useful.

8. Practice in the clinical areaswas important and helpful.

Please answer the following questions. Use the back for more writing space if needed.

1. What was the most useful part of the training course for you?

2. What, if any, part of the training course was not useful to you?

3. What suggestions do you have for improving the training course?

4. Other comments:


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APPENDIX F: TRAINING INFORMATION MONITORING

SYSTEM: DATA RECORDING FORM

Documents

Guidelines for Basic and Comprehensive InService Final (1)