“Two deliveries today with some issues breathing and just with positioning, the babies picked up and are presently on S2SMC [Skin to Skin Mother Care] thanks for the knowledge from Neonatal care work shop“
This is a quote from one of the healthcare workers Grace and her team trained last week in Bamenda. They were a group from Life Abundance Primary Care Staff who are healthcare practitioners working in remote, hard to reach areas of Cameroon.
The Neonatal Care Course normally has a limit of 24 per course but Grace was asked to teach 42 at once! Experienced people working in very difficult circumstances in anglophone Cameroon at the moment, desperate to learn.
The Cameroonian faculty still delivered effective training for this group, opting to miss out the final exam and the oxygen concentrator session “since they have no oxygen and no concentrator”. The group work sessions were a bit crowded but the instructors stayed late to ensure everyone got a go at the simulations.
An amazing feat to have run the course with almost double the number of learners as usual, and credit to Grace and the other instructors for being so adaptable for the good of the babies these people will go on to help. Feedback like that quoted above empowers the team (and us at NICHE International) to continue with the programme.
NICHE International’s programme manager Grace is now the Maternal and Child Health Services supervisor for Cameroon Baptist Convention Health Services, our partner in Cameroon.
In this capacity she has been visiting various health centres to look at their newborn care facilities and offer support if necessary.
Bonaberi is a district of Douala with a rapidly growing population and severe poverty. Internally displaced people from the Cameroonian regions where there is civil unrest have moved to Bonaberi and added to this problem.
In the health centre she visited in Bonaberi, she found a range of difficulties. On reviewing neonatal deaths, she recognised the need for training particularly in resuscitation of the newborn.
Grace and other instructors trained by NICHE International have just finished running a training course in Douala and 5 staff from the Bonaberi Health Centre have attended it to improve their skills.
Grace and her colleagues are now experienced Neonatal Care Course Instructors. They can assess need and respond with appropriate training.
NICHE International wants to ensure that the learning which candidates acquire when they attend a Neonatal Care Course, is put into practice in their workplaces.
One way of doing this is to encourage peer to peer learning, which can be led by the health workers that have qualified as Neonatal Care Course Instructors and carried out in the health clinics and hospitals where they work.
There is evidence that short informal teaching sessions can embed good practice and reduce skills decay.
An award from BMA Giving is enabling us to buy new neonatal manikins to distribute to hospitals and clinics in Cameroon, to help midwives, nurses and doctors to practise neonatal resuscitation which saves babies lives.
On 31st July we ran our first Information Webinar for potential volunteers. We were delighted to see many keen people and some Cameroonian colleagues in attendance.
The best questions in the webinar were ‘How do we maintain the standards of the Instructors?” and ‘how do we know that what is taught on the course is incorporated into practice?”. Both of these issues remain a challenge, and are linked to the Holy Grail of skills retention.
NICHE has a well developed structure of training, based on educational approaches that are used in resource rich countries for clinical training. However it is clear that there is a significant loss of skill and knowledge in the few months following a training course, wherever in the world that course is delivered. To help trainers keep up to date and to develop, NICHE has recently begun facilitating Instructor Development days for established overseas faculty members.
In high income countries attempts to overcome the loss of skills by practitioners principally revolve around repeat attendance at the training course, usually at an interval of years (often 4 years). The 4 year gap is for financial reasons principally because the forgetting curve (see diagram above) is pretty much at the bottom of the graph by the time people redo their provider courses. For practical and educational reasons, it may be worth trying to identify other techniques that practitioners could use to retain skills.
Various modifications of training technique have been suggested to help with skill retention and programme scale-up. These include discussing things with an inanimate object (a rubber duck is the example given) which has been recommended in the world of computer learning. “Simply talking about it will lead to enlightenment” Thomas D and Hunt A wrote in The Pragmatic Programming. Pearson Education Inc. 20th Anniversary Edition.
For those not keen on talking to inanimate objects a closely related technique is the Feynman technique which has 4 stages. Imagine you are trying to teach something to an 10 year old child. Write down your description of what you are trying to learn. Identify the gaps and lastly find ways of filling in those gaps. This is Lernen durch Lehren, German for Learning by Teaching.
Mental imaging and rehearsal: athletes and surgeons often mentally rehearse their technique before implementing it. Instructors of life support courses practice exactly what they are going to demonstrate before teaching it. Results indicate that the more complex the teaching activity is, the more opportunities there are to learn by teaching. NICHE encourages the incorporation and extension of practices that provide opportunities for instructors to continue to learn by teaching their peers, peer tutoring and/or peer assessment (Duran, D. (2016). Learning-by-teaching. Evidence and implications as a pedagogical mechanism. Innovations in Education and Teaching International, 54(5), 476–484. https://doi.org/10.1080/14703297.2016.1156011). We have recently successfully fund raised for extra manikins to be sent to Cameroon faculty members for on-going microteaching sessions in instructors’ own healthcare facilities.
The forgetting curve and prevention of skills decay could be one of the discussion topics in the next Instructor Development Days.
Health centres run by the Cameroon Baptist Health Convention, our partners in Cameroon, share their maternal and neonatal mortality data with their Health Districts. They aim to learn from incidents. Grace and her colleagues were invited to Nkoabang Baptist Health Centre, Nkoabang Village on the Eastern edge of Yaoundé this week to deliver 2 days of training to the staff as one of the outcomes of a neonatal death review.
The topics covered are resuscitation at birth, new born infections, convulsions, and fluid and electrolyte balance.
Three experienced nurses who have trained as trainers with NICHE are leading the training.
This is a good way of learning from incidents and sharing the knowledge, and is vital to saving babies’ lives in Cameroon.
Health workers who have done the Neonatal Care Course, use a confidential WhatsApp group to seek advice about clinical problems of babies they are caring for, and also to talk about neonatal deaths that have occurred in their own health facilities.
This information enables midwives and nurses to support each other in their work, and is valuable in indicating where further training might be useful.
While the international instructors were on their way home after a successful but frankly exhausting week of instructor development and training, Grace was busy preparing to teach 24 healthcare professionals on their next NCC. This course will take the number of nurses, doctors and midwives trained in newborn care in Cameroon to nearly 400. 2 extra people turned up from the local government facility, having heard on the grapevine that the course was going on.
All the instructors also teach resuscitation skills to staff in their own healthcare facilities. As Grace says “before, when there was a sick baby born, people were running in all directions [to get away from it]. Now people run towards the delivery area to try and resuscitate the baby.” As Jarlath says (Irish retired paediatrician and senior instructor with NICHE), “give people the confidence to give something a go, and the competence will naturally follow” because people have a driving need to do things better.
Motivational model with expanded “growth needs”
Maslow opined that humans would want to develop themselves and move on up his pyramid if the lower levels of needs were satisfied. That certainly seems to be the case in Cameroon.
Dr Leslie, trained as an instructor last week, teaching on convulsions on this week’s NCC
The somewhat incongruous paper strawberries hanging from the ceiling in a lot of the pictures from the last fortnight are left over from the teaching facility having been used for a party last month! We had a similar situation in Liberia in 2019 when we taught under a ceiling full of withered brown and yellow balloons and didn’t really notice until the photos came out. They don’t seem to detract from the learning.
Alison gave out the certificates of achievement at the end of the 2-day generic instructor course. 2024 marks her 20th year as a volunteer in Cameroon, initially with MCAI charity and for the last 7 years with NICHE International. This is probably the last time she will come in person to Cameroon and we thanked her for her long service to the country – from overseeing the building of a playroom in Bamenda which enticed the children with HIV into their clinic, to the establishment of a breast milk bank in the same hospital, to the training of healthcare professionals in newborn care and now the support of a 28-strong Cameroonian teaching faculty. Alison continues as the lead trustee of NICHE International in the UK.
Alison at the centre of the Instructor Development Programme faculty with Mboppi Hospital Administrator
Graduates of the second Instructor Development Programme with their end of course certificate
16 healthcare professionals have just completed 2 days of Continuing Professional Development facilitated by 5 UK faculty who are in Cameroon to support the local Neonatal Care Course faculty and train 12 more instructors on the GIC at the end of the week. One of the 16, Ethel (second from the left, back row), is a nurse educator and is shadowing Ferenc, one of the European Resuscitation Council’s senior educators (sixth from the left, back row), and learning how to be a GIC educator.
It was an intense 2 days, mainly of educational updates but we had also been asked for some neonatal clinical updates so the material was interspersed with talks on jaundice, seizure management and CPAP, skills workshops on umbilical venous catheterisation and intraosseous needles as well as an evidence based discussion on the merits and dangers of cooling babies with ischaemic encephalopathy (early brain injury due to being without adequate oxygenation for an extended period around the time of birth) in low- and middle-income countries.
These professionals are the front line workers who will drive change in their health care facilities; they are driven by a need to make things better for new born babies in their country and to reduce neonatal mortality. Training and encouraging them as instructors of the Neonatal Care Course empowers them to initiate new practices at the coal face and hopefully effect long term changes for the good of the families they serve.
