This study demonstrates that a 5-day BEmONC workshop supplemented by peer-to-peer facility-based simulation practice using peer learning cards and periodic, focused, structured clinical mentorship visits by referral facility clinicians is feasible and effective for improving knowledge and skills in rural Tanzania. Furthermore, this simulation package shows retention and an observed increase of BEmONC knowledge and skills 6 and 12 months following 5 days of initial BEmONC training.
The low scores on knowledge and skill prior to BEmONC training in healthcare providers working on the frontline supports calls to improve BEmONC capacity amongst rural healthcare providers if SDG maternal and neonatal targets are to be met. Baseline (T1) MCQ scores ranged from 60–75% and OSCE aggregate scores from 32–38%. This suggests some foundational knowledge but significant skill gaps. Based on the theory of skill acquisition, that knowledge precedes skill application20, study participants were well positioned to benefit from BEmONC training and practice.
Improved BEmONC knowledge and skill post workshop training, especially when HMS/HBB modules are used, is consistent with what has been previously reported from other areas of Tanzania, 21–25 East Africa,26–30 West Africa,31–33 and globally, in low resources settings.34–37 The inclusion of BEmONC cross cutting themes as ‘mini modules’ in our initial workshop was novel. These were added with hopes that participants would implement the new learning in their day-to-day practice. Although we did not specifically assess outcomes related to these topics, we believe these mini modules contributed to significant knowledge/skill improvements and early qualitative input suggests they were effective in overcoming implementation barriers.
Findings of skill and knowledge retention, and the observed skill improvement scores at 6 months and 12 months were associated with access to the peer-to-peer facility-based components of the simulation package. This reinforces the importance of providing ongoing facility-based practice opportunities to support skills retention after initial BEmONC trainings. In this study skill decay was observed at the 6-month assessment across ANC, ECLB and ECEB in Cluster B, which was the Cluster with delayed access to facility-based practice. It is impossible to say exactly when decay occurred because of assessment timing. In other studies, skill decay has been reported as early as 1-month post HBB training especially with ventilation skills in Tanzania,23 Honduras38 and Ghana.32 Skill decay post initial BEmONC training has been reported 6–7 months in Uganda27 and at 8–10 months in Tanzania.22,24,25 According to the theory of skill acquisition complexity of a skill and frequency of clinical exposure and use play key roles in identifying practice thresholds; the more technical or complex a skill (bag valve mask), or rare in terms of clinical exposure or application (oxytocin), the more practice is required to achieve and maintain competency.20,39 Skill decay suggests compromised maternal and newborn care and this is alarming. Importantly, skill decay was not observed in the Cluster accessing peer to peer facility-based simulation practice after initial training. Furthermore even delayed access to the facility-based components in this study was effective for improving the skill decay noted at 6 months. These findings are supported by literature on the inclusion of structured LDHF practice opportunities post-training with peer-to-peer learning, mentorship and/or supervision. Studies including this type of ongoing facility practice report better retention of skills over time. A study in Peru documented knowledge and skill retention post-HBB training at 6-months after initial training following frequent and structured facility practice with peers and/or mentors before every shift, weekly in-service case practice scenarios and supervised monthly peer to peer LDHF training.34 In Nepal, daily bag mask skill checks and weekly supervised practice resulted in measurable improvements in newborn resuscitation using bag and mask ventilation and HBB knowledge.36 In Nigeria, participants attending simulation based LDHF BEmONC training, complemented by mobile mentoring, demonstrated greater improvement in knowledge and skill and retention when compared to traditional stand-alone BEmONC training.33 In Ghana, weekly case LDHF simulation practice sessions for skilled birth attendants as well as workplace coaching and mobile mentoring resulted in retained knowledge and skill after 1 year and a sustained decrease in newborn mortality.31 It is important to note that in all of these studies, there was a high reliance on the use of the clinical expert for supporting ongoing practice. This can be challenging to sustain in low-resource environments due to high workloads of all clinical experts.40 In the present study, the simulation package only required a clinical expert visit every 3-months (3-visits in total over 12-months). The concept of clinical mentorship, a relatively new concept in low-resource countries, has been recognized as a key strategy for improving competence in the workplace. The challenges of clinical mentorship often reside in staffing shortages, high demand for clinical experts in home institutions, lack of monetary incentive, lack of equipment for training and time constraints.40 The model of clinical mentorship is powerful and had been associated with improved clinical skills in high-resource settings.41 Gaps identified by mentee healthcare providers can form a basis for meaningful dialogue to help overcome skill and implementation barriers. A strong mentor/mentee relationship facilitates a more open and safe space which may further promote learning and reflection and is less stressful for both the mentor and mentee.41 Stressful learning contexts can detract from information sharing and thus participant learning.11,41 Additionally, mentorship can be an informal approach to providing on the spot refresher training, as the mentor is expected to help the mentee identify and provide the expected standard of care.11,41 In this study the structured mentorship visit supporting the facility-based peer to peer learning at 3-month intervals was sufficient for retention of skills.
These results contribute information about the value of using peer to peer learning and peer case cards. In this study, peer-to-peer learning with the peer case cards was the main component of the ongoing facility-based simulation practice sessions. This approach negated the need for mentees to leave one’s facility, and for expert clinicians to attend every practice session. Peer learning is grounded by both experiential learning theory7 and mastery learning.8,9 The team developed peer-learning cards to facilitate easy engagement in practice. The cards acted as a cognitive aid; covering all key knowledge, skills and information. This is easily accessed on the card making it possible for a peer to help another peer to provide the right management. To our knowledge, we are among the first studies29 to use these types of cards. Peers were able to effectively use these in their facility practice sessions which we suggest contributed to retention and improvement in skill scores. Although, the concept of peer-to-peer learning is increasingly being used and studied in low resource countries, there is paucity of literature on the value of using case cards with mentorship to facilitate peer to peer learning. In Uganda the use of peer cards with helping babies survive training resulting in higher HBB and ECEB skill scores at 1 year.29 In Tanzania, Drake et al reported improved HBB skill retention when participants used an on-the-job guide to facilitate both self-learning and peer to peer learning and were supported by a clinical expert champion visit every 4–6 weeks.23 Further research is needed to better understand the use of peer-to-peer learning with peer cards in combination with mentorship in low resource settings.
The simulation package used in this study led to retention and observed improvement with both HMS and HBS skills (aggregate OSCE scores). Additionally, this study contributes information about effectiveness of our simulation package for improving the skill set of those demonstrating decay at 6-months post-initial training. In this study, Cluster B was able to achieve almost as high skill scores after accessing the additional facility-based components at 6-months. Twelve months aggregate OSCE scores were 89 and 90%; the Cluster receiving the simulation package over the entire study time achieved one percentage point more than the Cluster with delayed access. Although skill decay is concerning, our results suggest that facility-based practice sessions using peer learning, peer cards and one mentorship visit may provide a low resource education option to improve and retain knowledge and skill in rural Tanzania settings.
This studies limitations include a small sample size, which limits power; further; the small dataset did not allow for analysis such as linear models which could more critically consider time and dosing and enable more reliable “over time” conclusions. Additionally, resource and time limitations only enabled OSCE testing for select modules; more extensive testing could enable a full curriculum revision and review. The de novo ANC module should be reviewed to ensure practice sessions align, as results at T4 were generally lower compared to other OSCEs.