bag-valve-mask questionnaire

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Gathering the evidence for the work we do, both for funders and to inform our direction of travel as an organisation, is not at all easy! Alison has been working with Grace in Cameroon to collect information from health clinics about their use of bag-valve-masks which NICHE International provided them with a few months ago.

3 out of the 5 units who had the questionnaire responded which doesn’t give us statistically robust information but does give us a fascinating insight into the obstetric services at these centres, the numbers of deliveries, trained staff and how many babies were born in a bad enough condition to worry the newly trained personnel.

preliminary results from the BVM questionnaire

There are a couple of things to learn from here:

1.) The very positive free text comments at the bottom that all units feel that having the bag-valve-mask over the last 8 weeks has potentially saved lives.

2.) The disappointing comment from Bafoussam that people have been reluctant to use the BVM because they can’t attach it to the oxygen supply is a reminder of the need for on-going training and refresher courses. Babies born at 32 weeks gestation and above should be resuscitated in air. The new 2021 guidelines suggest that babies between 28 and 32 weeks can be resuscitated in air to 30% oxygen. Only the very small ones, most of which do not survive in resource poor areas of the world, should be resuscitated in 30% oxygen from the outset. It is recommended to increase to 100% oxygen in any situation if the baby requires cardiac compressions.

We are looking to return to Cameroon at the end of April 2022 to train more instructors and begin training some of the Cameroonian instructors to be instructor trainers themselves. Well done to Grace and team for keeping the Neonatal Care Course training going throughout the Covid pandemic and thanks to the Cameroon Baptist Convention for continuing to fund the programme.

Teaching again after the pandemic

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It is great to be back teaching face-to-face again, albeit still only in the UK. UK NICHE instructors have to teach on a certain number of life support courses per year to maintain their instructor status. Julia was teaching the UK Resuscitation council Newborn Life Support (NLS) course this week in her home hospital in London.

Scenario teaching – unexpected preterm baby delivery

There are some differences when stabilising a preterm delivery at birth. The 2021 guidelines suggest that babies born under 32 weeks gestation should be put into a plastic bag at birth and placed under a radiant heater to stop them getting cold and dehydrated. Just their heads should be dried.

In most other respects, and if there is no radiant heater available, they should be stabilised the same way one would stabilise a term baby. Here the learners are demonstrating the 2-handed BVM technique with Julia checking that the chest is actually rising!

2-person technique of bag-valve-mask use at a simulated preterm delivery

Neonatal resuscitation training in Liberia – also june 2021!

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Not to be outdone, Kola has been busy in Liberia with neonatal resuscitation training at the same time as the Cameroonian course was running. WhatsApp was alive with photos coming in for a couple of days – heartening stuff to our NICHE team still unable to leave the UK to train more instructors.

Neonatal technicians in Liberia lecturing on Newborn Life Support during a resuscitation training session, June 2021

Today is International women’s day

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Dr Alison Earley

It’s a day for dressing up in much of the world, a day to celebrate the work women do to make the world go round, a day of empowerment. The picture here is of Cameroonian women on International Women’s Day in 2018, learning how to resuscitate babies dressed in their International Women’s Day material that they make into powerfully beautiful dresses every year. We should make more of it in the UK really.

There are many achievements to celebrate on International Women’s Day, but we mustn’t forget that in resource poor areas of the world, maternal mortality (death related to pregnancy and childbirth) is still 5 – 10 times higher than in richer countries.

Many mothers still give birth in unclean or unsafe places, and without skilled help or adequate facilities.   This has a direct result on the survival of their babies; two of the leading causes of neonatal mortality are infection and intra-partum related events.

Education for healthcare workers and sustainable improvements in maternal and newborn care are the key to improving this situation.   NICHE International has a mission to improve the care of newborn babies, by the training we give and by supporting nurses, doctors and midwives to maintain their skills and improve the care they give to mothers and babies.

Training (predominantly female) nurses and midwives to be instructors on the Neonatal Care Course (NCC) empowers them to “Choose to Challenge” and make changes to their own healthcare systems from the bottom up.

Miller’s hierarchy of learning

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Dr Jarlath O’Donohoe

To truly know whether our learners are achieving what we want them to achieve we should assess them in the setting that we expect these skills to be delivered.

Miller’s pyramid depicts four levels of learning which a student of a subject must pass through to truly perform: “knows”, “knows how”, “shows how” and “does”.

In the Neonatal Care Course, our novice learners gather facts and take an MCQ paper to “show that they know”. Workshops, discussion groups, skills sessions and simulations get them to the orange and green levels. The local champion and trained instructors then take over from NICHE for the “Performance Integrated into Practice” level at the top of the pyramid, completing the trainees’ journey from novice to expert.

I would like to see time better represented in this model. International NICHE instructors can skim the surface of the first 3 bands in one course but to achieve the competence and automacity inherent in the blue band at the top of the hierarchical model requires time, experience and supervised practice that only a local faculty can contribute to.

Maintenance, booster and refresher training

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Dr Jarlath O’Donohoe, always in pursuit of the Holy Grail – a solution to the “skills decay” problem….

Resource: Sullivan, Anne & Elshenawy, Summer & Ades, Anne & Sawyer, Taylor. (2019). Acquiring and Maintaining Technical Skills Using Simulation: Initial, Maintenance, Booster, and Refresher Training. Cureus. 11. 10.7759/cureus.5729.

Learning Curve: shows a relationship between the amount of practice / experience of a skill and the degree of competence achieved.

Forgetting Curve: the relation between the decay of a learned skill and the time elapsed since the skill was learned.

Experience Curves: combines the learning and forgetting curves.

Activities to overcome skill decay can be qualitatively classified as maintenance , booster or refresher, according to the diagram below:

Note the amount of time spent “deficient” with “refresher” activities. An example of this is paediatricians in the UK re-certifying in APLS every 4 years. “Booster” training is possibly achieved by statutory mandatory training paediatric basic life support every year and keeps the average paediatrician “proficient”. Would lower intensity but more frequent “maintenance” activities do a better job eg. weekly simulation training sessions?

Here is Kola delivering his “booster” training sessions in neonatal resuscitation to nurse technicians in Liberia this week, using equipment left by NICHE after the first batch of instructors were trained in 2019.

Kola (centre) teaching neonatal resuscitation in Liberia, February 2021

How often does he need to run these sessions to make this maintenance training and not refresher sessions? The quest continues….

Zooming to Cameroon

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Local Cameroonian instructors, who are now organising their own Newborn Care Courses, ran an NCC last week in Yaoundé, Cameroon.  Some NICHE Instructors joined them for parts of the course via zoom from UK, to try out the technology and assess the feasibility of remote training.

We were able, remotely, to:

1. Demonstrate how to run a simulation (this was management of a baby having fits).  NICHE Instructors from their homes in London and N. Ireland did this on zoom at the request of Cameroonian Instructors who watched.

2. Deliver one of the lectures on the NCC course via zoom

3. Join the faculty meetings in Cameroon at the end of each day.

4. Join the candidates for certificate presentation at the end of the course.

This was a useful exercise as we are thinking about the practicalities of training online, in particular delivering ‘Instructor Development Days’ for Cameroonian NCC Instructors, which before the pandemic, we had hoped to be able to do in person in November.

There are some technological improvements to make, but generally it was successful.

It was a pleasure to see our Cameroonian colleagues, who keep going despite pandemic and political difficulties.

Some comments from candidates on the course:

  • The training was an impacting one with lots of skills and knowledge acquired.  I could have wish that all health personnel around the world be train if possible to augment care of neonates.
  • I am confident now that I can take care of a newborn very well as compare to what i was doing in my station, especially resuscitating asphyxiated babies immediately after delivery.

Feedback from mboppi course

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“This course was very resourceful, I have gained more skills and will transmit the knowledge gained to my colleagues so that together we can improve the neonatal care outcome in Cameroon“

Grace and Dr Ngu Ernest, paediatrician in Douala, have just completed a Neonatal Care Course in Mboppi Hospital, one of the Cameroon Baptist Convention Heath Services institutions. 21 candidates attended and all passed the course. The programme used was the ALSG/MCAI one that NICHE instructors have used in the past. It was nice to see that Grace had also included an update for everyone on presentations from the 2nd African Neonatal Nurses Conference in Kenya that she attended with NICHE’s help in November 2019. We are proud to be associated with such an energetic campaigner for newborn care.

“Presentations were wonderful and work stations so interesting“

“Care of the newborn in Cameroon will improve greatly if health care workers are knowledgeable and only such training can help.  I wish such trainings could be open to other health facilities for awareness“

“I am more and well equip now than before on how to care for baby’s who will not live long“

“More time should be allocated for workshops“

“Care of newborn in CBCHS [Cameroon Baptist Convention Health Services] is very high than in other services, so I plead if this course can be extended out to other facilities, we will actually reduce the death rate of neonate in Cameroon“

“The practical were very educative and interesting“

See the blog post below for some images from the recent course delivered by 6 Cameroonian instructors with no input from UK-based NICHE instructors. New definition of sustainability – the excitement experienced when one puts oneself out of a job.

Peer to peer review and mentoring

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Medical and nursing staff in the UK now have to undergo annual appraisals, usually with a peer who coaches them through their appraisal paperwork, discussing issues and highlights of the year with them and helping them to develop themselves as a health professional.  Although there’s always a mad rush at the end of the year to get all the relevant bits of paper uploaded to one’s appraisal file in time for the allotted meeting, the process if done well encourages the health worker to focus on their goals for the next year, helps to prevent burn out and allows us all the space to reflect on our own practice.

Agnes, instructor in Liberia

This process is in its infancy in Liberia and Cameroon.  Jarlath has put together a draft form which gathers information about skills and confidence decay, provides a method of assessing someone’s on-going competence and allows a structure for peer mentoring.  We are not quite sure how this will work in the field but will be rolling it out over the next few years in Cameroon while we work out how to help support local instructors in the long term.

Click here for a preview.

 

Breastfeeding workshop

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The Neonatal Care Course (NCC) is an educationally robust product.  We teach about the four main areas that the World Health Organisation identifies as contributing maximally to neonatal mortality rates: resuscitation at birth, early breast-feeding, keeping babies warm and early recognition and management of sepsis.  https://www.who.int/maternal_child_adolescent/topics/newborn/enap_consultation/en/).  Our feedback forms show increased confidence of learners in all 4 of these areas. Increased clinical confidence correlates with increased performance over time.

Here is Grace, a one time NCC learner and now in-country NICHE champion and convener of their own independent NCCs, delivering a workshop on breastfeeding to local midwives.  This is what empowerment of local health professionals does.  This is our legacy and we are proud of it and very grateful to all who donate time, money and expertise to our charity.