February 2007 - Volume 1, Issue 1

DEVELOPMENT OF PROFESSIONAL MIDWIFERY SKILLS: AQUISITION, TRAINING AND ASSESSMENT

	Dr Thamer.K.Yousif, Prof.College of Medicine, Iraq Dr Maysa Ameeer, PhD Pediatric
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INTRODUCTION

The provision of skilled care for pregnant mothers during their pregnancy, delivery and post partum period as well as for the newborn infant, stands as the most important move towards reduction of maternal and infant mortality rates (1). Training of local women to become midwifes is a cost effective approach to the provision of such skilled attendant care. In planning for such a midwifery education program that allows them to work in the field as well as in the clinic, one must review the educational approaches that can be used in such a program in view of the local health needs, and the available resources of the university and the country.
EDUCATIONAL VIEW

Professional skills development for health care providers involves the development of good communication and physical examination skills, the ability to solve problems and make decisions, and competence in practical procedures. The educational approach to any curriculum is determined by the educational philosophy behind it. At least three major educational philosophies are determining three common educational approaches: The behaviorist, the cognitive and the constructivist approach (2). The behaviorist approach is based on the stimulus response principle (S-R), and considers learning as a change in behavior, gives the teacher the main responsibilities in the learning process, and relies on psychomotor tests to assess the achievement of the behavioral outcomes. Both the cognitive (structure of the discipline) and constructivist approach considers learning as development of the mind, and gives learners the main responsibility in learning. In the cognitive approach, learning is based on providing the students with the fundamental principles of the discipline, and then the students build on these principles through the process of inquiry according to the scientific methods the scholars follow. While in the constructivist approach, students learn, through authentic tasks, problem solving and social experience. These educational approaches were extensively tested in practical situations and through research in learning of factual knowledge. Learner centered models have gained wide popularity and were adopted by many medical educational institutes in the learning of factual knowledge. However, there has not been a similar shift in the methodologies behind teaching and learning of clinical skills, except the published Evans-Brown model "A constructivist model for learning clinical skills" (3). Although this model seems tempting, rewarding and worth trial for medical students, yet, in a training program like the' midwifery local project", where the participants are women from the local community, and the program is mainly vocational, A Competency Based educational program based on the behavioral assumptions in skills training but meanwhile utilizing the constructivist approach to facilitate the development of problem solving skills and decision making through the use of authentic tasks seems the most appropriate for achieving the goal of the project. Competency Based Training (CBT), is the training based upon achieving the participant's ability to demonstrate attainment or mastery of clinical skills performed under certain conditions to specific standards (The skills then become competencies). (4)

Competency based training programs are characterized by the following (5):

1. Competencies are carefully selected
   
2. Supporting theory is integrated with skill practice.
   
3. Detailed training materials are keyed to the competencies to be achieved and designed to support acquisition of knowledge and skills.
   
4. Methods of instruction involve mastery learning.
   
5. Learning should be self-paced
   
6. Flexible training approaches using variety of methods.
   
7. A variety of support materials including print, audiovisual and simulations (models) keyed to skills being mastered.
   
8. Satisfactory completion of training is based on achievement of all specified competencies.

Assessment of achievement is done by psychometric tests using checklists.

In order to achieve competency in performing clinical skills and procedures, it is now agreed upon that the students or trainees need to practice such skills in a safe and controlled environment. The classical apprenticeship model with learners' training done exclusively during clerkships on patients is not considered any more the proper environment for achieving competency in clinical skills. The patient's acceptance of being a passive, uninformed participant in medical education- a situation which was present in the past- no longer exists. There are global changes in health care practice, increased consumerism and increasing student' numbers. This together with the increasing identification of core skill curricula and outcome objectives which mandates mastering of the skills and assessment of achievement of competency, makes the need for clinical skills centers, and the use of models and simulators, appear particularly attractive(6,7). Furthermore, models and simulators are used extensively in CBT Courses (4). However, it is to be borne in mind also, that although clinical skills centers offer a panacea for clinical skills teaching, yet, it is important to consider the cultural aspects of the medical education which should differ from country to country. Medical education systems in some of the developing countries try to adopt not to adapt western curricula and teaching and learning methods, and because of this may fail to meet the needs of the individual health care systems and cultural norms. Furthermore, it is not appropriate to transfer the model wholesale to medical and health care schools in the developing countries. The capital cost of setting up a clinical skills center may be far in excess of the local budget. Even if the problem is overcome by outside funding, several obstacles still exist. These include:

1. The purchase of the equipment and manikins requires foreign currency
   
2. Long delivery time for replacement parts.
   
3. Local unavailability of the consumable supplies
   
4. Culturally unacceptable equipment

Once set up and equipped, the maintenance and running costs may prove prohibitive in the long term (7)

Accordingly, to establish the Midwifery educational program in rural areas, on a competency based approach, we must think of an alternative way that enables the participants to practice the core clinical skills till they achieve the required competencies in a safe and controlled environment without the need of a full clinical skills training center, in a way that does not overwhelm the restricted resources of the country, while being culturally acceptable, easy to maintain and to be run. The modified model suggested by Stark & Fortune (7) is a good option. Key manikins only will be purchased. Those include: simple child birth model (pelvis and infant dummy can suffice), a pelvis model for examination and IUD insertion, and a neonatal resuscitation model (face and mask resuscitation). In time, some locally developed manikins can also be produced similar to the experience we had in Iraq, where the undergraduates' students have fabricated from cheap locally available pieces of sponge and cloth, a model for suturing a perineal tear. Other clinical skills will be practiced in the MOH primary health care centers, the university outpatient department and delivery ward. To ensure equitable training, standardized teaching and feedback, methods can be applied through the establishment of competency based training tools including learning guides and checklists. Widespread staff development in the clinical teaching areas is an essential part and this will be the main task of the enthusiastic educators who have been selected to run the various parts of the curriculum. Assessment will be based on psychomotor tests were participants will be asked to perform the clinical skills while being observed by a tutor who fills a standardized checklist. For assessment of complex skills of problem solving and decision-making, objective written exams with problems (real or structured) will be administered.

CURRICULUM BLUE PRINT
A Competency - Based Midwifery Training Program for local women in Rural areas.

Goal:
The aim of this program is to provide the chosen women with the knowledge, skills and attitudes that enables them to carry the tasks of midwifery services including caring of women during pregnancy, delivery, initial care of the neonates after birth, helping the mother and child to establish and sustain breast feeding, as well as identifying life threatening and emergency conditions, with proper initial management and referral to specialized health facilities.

Objectives:
By the end of the program the participants will acquire the following knowledge, skills & attitudes:

1. Communication skills:
The participants will be able to communicate with the mothers and their families and counsel them on a culturally accepted methid and using a simple understandable language to provide health information about pregnancy, delivery, child nursing, common STDs, as well as family planning.

2. History taking skills:
This includes all relevant data about the present and past pregnancies, children's conditions, socioeconomic status, medical diseases and conditions that might affect the pregnancy or delivery .

3. Physical examination skills:
Assessment of vital signs, diagnosis of pregnancy, assessment of fetal position, diagnosis of stages of labor, detection of high risk pregnancies, diagnosis of common complications, assessment of new born at birth, diagnosis of common breast feeding problems.

4. Practical skills:
Management of normal delivery, performing and suturing of episiotomy, and repair of simple perineal tear, provision of emergency first line measures for pregnancy and delivery complications, stabilization of patients for referral, neonatal resuscitation, assisting mother and baby for breast feeding, insertion of IUD, use of hygienic and antiseptic measures.

5. Attitudes:
Support of mothers and families during stressful situations related to pregnancy and delivery, adoption of ethical rules when facing conflicting/ethical dilemmas, insuring privacy of patients' information.

6. Problem solving and decision making:
Interpretation of data of patients' history, physical examination to reach a diagnosis, ability to differentiate uncomplicated from complicated pregnancy and labor, with proper decision-making about when to refer, and what must be done before referral.

Instructional strategies:
The program is aiming at achieving competence in the selected midwifery skills, and is based mainly on the behavioral perspective, and uses techniques of mastery learning approach whenever possible. Theory will be integrated as introductory mini lectures with various illustrations to explain the basis, and the steps of performing the skills. Development of intellectual skills will be facilitated through small group problem solving sessions, using real or structured problems.

For the development of clinical skills the participants will be given enough chances to practice the skills after initial demonstration, till they achieve competency. A variety of instructions will be used including role plays, demonstrations using AV aids, and tutor performance, repeated practice with feedback on available models for management of stages of labor, pelvic examination and neonatal resuscitation. The remaining skills will be observed then practiced on real patients, under close supervision of trained clinical tutors.

Venue:
The training program will be conducted in the following areas;

1. Mini lectures and small group discussions, role-play: Class rooms of area schools of medicine.
   
2. Physical examination and practical skills training:
   Class rooms of School of Medicine for communication skills and role play in small groups, Class rooms and/or available rooms teaching in clinical areas of the school of medicine for training on models (pelvic examination, child birth, neonatal resuscitation, and IUD insertion, manikins/models)
   
3. Primary health care centers (MCH, Family health care centers of MOH) for observation, then practice with real patients for antenatal care, delivery of uncomplicated pregnancies, episiotomy and suturing)
   
4. Delivery suite of Medical school for observation and practice on initial management of complicated/emergency deliveries)
   
5. Home visits (field work) for postnatal care and breast-feeding assistance, counseling, health education, for STD and family planning.

Participants assessment:

Formative assessment:
Regular feedback by tutors on performance of clinical and practical skills using learning guides.

Summative assessment:
1. Objective structured clinical tests using structured and real patients, and models. Assessment is based on standardized clinical checklists.
2. Objective written exams (MCQ, true false, extended matching questions and problem solving questions) will be used to assess reasoning and decision making skills.
3. Participants who fail to achieve the required skills up to the defined standards will be offered a remedial course.
REFERENCES

1. A joint statement by WHO, ICM and FIGO. Making pregnancy safer: the critical role of the skilled attendant. World Health Organization 2004:1-24
   
2. Posner GJ: Concepts of curriculum and purposes of curriculum study. In: Posner GJ (Ed). Analyzing the Curriculum. (3rd ed) NY: McGraw Hill, 2004: 2-32.
3. Evan D. A constructivist model for learning clinical skills. Master Thesis MHPE: 2005. Universiteit Maastricht.
   
4. Sullivan R. The competency -based Approach to Training. JHPIEGO Strategy Paper 1995: 1-10.
   
5. Foyester J. Setting to grips with competency based Training and Assessment. TAFE National Centre for Research and Development. Leabrook, Australia; 1990.
   
6. Bradley P, Postlethwaite. Setting up clinical skills facility. Medical Education2003; 37(S1) : 6-12.
   
7. Stark P, Fortune F. Teaching clinical skills in developing countires: Are clinical skills centers the answer? Education for Health 2003; 16(3): 298-306.