Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
Paper 1. Aimed at quality improvement or O and G journal
Education and quality improvement in Obstetric and neonatal care in Malawi.
Potential authors TBD
O’Hare JP
Simkiss D
Mhango C
Chipwete S
Eloundou G
Quenby S
Gee H
Peile EB
Summary
Many sub-Saharan African countries depend on clinicians who are not doctors for much of the delivery of
obstetric and neonatal care. It has been estimated that 97% of caesarean sections performed in Malawi are
carried out by non-physician clinicians (NPC’s). The two year basic clinical education for NPC’s in Malawi
aims to ensure proficiency through mastery of the science and skills needed for clinical practice in urban and
remote rural areas.
As in many sub-Saharan African countries, maternal and neonatal mortality and morbidity has remained at
unacceptably high levels in Malawi despite a strong emphasis on service improvement in that country and
despite audit findings that show NPC’s operating to similar complication rates as the medically qualified
surgeons. This paper describes a project to deliver ‘empowering education’ to NPC’s with the objective of
simultaneously up-skilling them in the craft obstetric and neonatal skills, and educating them in clinical
service improvement skills and the leadership of change.
Learning advanced clinical and surgical skills by means of ‘drills’; extending and updating knowledge of
relevant clinical science, and simultaneously learning about clinical leadership, clinical service improvement
tools, clinical teaching and values- based practice appeared to work well in helping the clinicians to take a
broad view of their professional work which includes a responsibility to act as change agents. An important
component of the education was work-place based technical mentoring support from UK obstetric
specialists.
This paper explores the educational rationale for this project and looks at emerging pointers to
effectiveness.
Keywords: Clinical audit; continuing professional development; non-physician clinicians; clinical service
improvement; Maternal mortality; neonatal mortality; clinical leadership; Values-based practice
Introduction
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Non physician clinicians in Malawi – rationale, development, basic education,
Pre-ETATMBA Audit findings, maternal and neonatal morbidity and mortality in Malawi
ETATMBA project, sustainability
Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
Obstetric and neonatal education and experience
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Coverage of the basic diploma education in obstetrics and neonates
Experience of clinical officers on the job : supervision, CME opportunities, working situations
The educational intervention
o
o
o
o
Clinical teaching
Advanced clinical education with drills
Other CSI, Clin Leadership, change management, V-BP refer to Paper 2 for more details
Warwick degree to Malawian degree refer to Paper 2 for more details
Baseline data
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Synopsis of David Ellard data (refer to Paper 4)
Extending the power of audit
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Teaching about audit cycles refer to Paper 2 for more details
Early pointers to impact
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Interview data conclusions Refer to Paper 4 (Ellard and Griffiths ) for more details
Audit
 Abortions
 Infection (HIV; Neonatal Infection; puerperal sepsis)
 Anaemia of pregnancy and antenatal care.
 PET and Eclampsia
 Intrapartum care (Use of partograph and vacuum extraction)
 Postpartum haemorrhage
 Neonatal care
Discussion
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Differences in educational approach – CME that builds on learner experience and empowering NPC
learners to make changes in their own clinical practice and improve care through working with
others
Clinical drills and skills opening the door to less familiar learning
Low cost manikins and other resources available in resource poor settings.
Working together with peers especially important when workplaces isolated
Importance of clinical supervision in the workplace (Seleya and Gregory)
Audit as a learning tool refer to Paper 2 for more details
Professionalisation
Conclusions Take home message 1: In order to fulfil the potential of the job role, NPC’s working in O & G
need CME and upskilling which takes account of their experience working in remote and rural practice
Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
Take home message 2: In the continuing professional development of NPC’s is enhanced when their craft
learning about the surgical and clinical skills of obstetrics and about neonatal care takes place alongside
learning about topics such as clinical service improvement, leadership, , change management and values
based practice.
Paper 2 Intended for education journal ?? the Network, K Interprofessional care or others incl EPC
Empowerment Learning: Audit and learning about leadership helps Non-Physician Clinicians to develop
their own practice and improve local clinical services
Peile EB
Davies D
O’Hare JP
M’Hango C
Summary
Basic clinical education for non-physician clinicians (NPC’s) in Malawi aims to ensure proficiency through
mastery of the science and skills needed for clinical practice in urban and remote rural areas.
Clinical audit has long been used in Malawi to assure acceptable performance in the clinical workplace.
Individual NPC’s whose delivery of obstetric services has been tracked over a number of years in terms of
morbidity and mortality data, commonly demonstrate stable performance or small increments. This may
indicate that clinical experience can compensate for erosion of scientific knowledge over time, when NPC’s
working in remote locations have suboptimal opportunities for continuing medical education.
In this context we demonstrate the untapped potential of ‘empowering clinical education’ based around
completed audit cycles. Moving from didactic teaching methods to facilitated experiential learning in this
project has led to improvements in short-term audit results which suggest significant clinical service
improvement is underway. We combined extended learning in the clinical domains of obstetrics and
neonatal care with teaching and learning about clinical leadership, clinical service improvement tools,
cascading clinical education and values- based practice.
Keywords:
Clinical audit; continuing professional development; non-physician clinicians; clinical service improvement;
Maternal mortality; neonatal mortality; clinical leadership; Values-based practice
Introduction
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Non physician clinicians in Malawi – rationale, development, basic education, CME opportunities,
working situations
Audits carried out prior to ETATMBA, maternal and neonatal morbidity and mortality in Malawi
Baseline data refer to data collected by David Ellard
ETATMBA project, sustainability
Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
Empowering education
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The educational intervention
o Advanced clinical education with drills
o Clinical Service improvement
o Clinical Leadership and change management
o Values based practice
o Clinical teaching
Developing education which Malawi can own
o Warwick degree to Malawian degree
Parallel process in Tanzania
Extending the power of audit
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Teaching about audit cycles
Project based teaching
Accountability and responsibility - What are You going to do about it?
Re-audits and project development
Results refer both to Paper 1 (O and G learning) and Paper 4 evidence from interviews
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Abortions
Infection (HIV; Neonatal Infection; puerperal sepsis)
Anaemia of pregnancy and antenatal care.
PET and Eclampsia
Intrapartum care (Use of partograph and vacuum extraction)
Postpartum haemorrhage
Neonatal care
Discussion
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Empowering learners to make changes in clinical practice
Clinical drills and skills open the door to less familiar learning refer back to Paper 1
Working together with peers
Audit as a learning tool
Professionalisation
Conclusions Key message 1 Empowering education works well when broad range of clinical skills and
knowledge covered including skills for service development alongside surgical and medical topics
Key message 2 Audit works well in education intended to facilitate clinical service improvement
Key message 3 Empowerment leads to professionalization.
Key message 4 Strong circumstantial (but not measurable ) evidence that empowering education can
impact on mortality and morbidity
Paper 3. ? European journal of person-centred care
Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
Values- Based Practice: impacting on quality improvement in obstetric and neonatal care in Malawi.
Davies D
O’Hare JP
Mhango C
Ellard D
Peile EB
Summary
As part of a European Union project to develop empowering education for non-physician clinicians (NPC’s) in
Malawi, course materials on values-based practice were developed and delivered.
Much of the education was based on audit projects, which over the course of two years were developed by
the NPC learners from basic quality assurance on morbidity and mortality through to completed audit cycles
demonstrating impact of their learning on clinical service. NPC’s are crucial to service delivery of obstetric
and neonatal care in many of the urban and remote rural areas of Malawi.
As there was little formal assessment of the learning about values-based practice on this course, we were
interested to trace what was the ‘unpressed’ mention of its influence and impact on this course.
Values- Based practice appears to have played a significant role in humanising the clinical decision-making
practice of some learners. Others show little evidence of impact even when it might have been appropriate.
Keywords:
Values-based practice; Clinical audit;
clinical service improvement;
continuing professional development; non-physician clinicians;
Introduction
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Values-Based Practice
Non physician clinicians in Malawi – rationale, development, basic education, CME opportunities,
working situations
Audits carried out prior to ETATMBA, maternal and neonatal morbidity and mortality in Malawi
ETATMBA project, sustainability
Empowering education
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The educational intervention refer to Paper 2
o Relationship of values to Clinical Service improvement
o Relationship of values to Clinical Leadership and change management
Developing education which Malawi can own
Audit mentions of V-BP
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Accountability and responsibility - What are You going to do about it?
Re-audits and project development (refer to Paper 2)
Results – where was V-BP mentioned and where were omissions surprising?
Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
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Abortions
Infection (HIV; Neonatal Infection; puerperal sepsis)
Anaemia of pregnancy and antenatal care.
PET and Eclampsia
Intrapartum care (Use of partograph and vacuum extraction)
Postpartum haemorrhage
Neonatal care
Interview mentions of V-BP (Refer to paper 4 Griffiths/Ellard)
Discussion
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Empowering learners to make changes in clinical practice
Values awareness, values communication and values reasoning
Values and Partnership working in Malawi
Values in Clinical Decision making
The role of values in Professionalisation
Conclusions
Take home message 1 It has proved possible to adapt VBP teaching to local context in Malawi
Take home message 2 VBP has an important role in learning and teaching for experienced clinicians as it
works well alongside developing clinical skills, leadership roles and professionalism.
Paper 4
David and Frances to detail
Preliminary discussion document re Who/what/how/where early
stage ETATMBA papers
Paper 5 Possibility for J Interprofessional care or the Network
Realist evaluation of education to improve clinical service in two African countries: what works for whom
and where.
Davies D
Peile EB
Pemba S
Patel V
O’Hare JP
Summary
We report experience from a project to develop advanced education for non-physician clinicians (NPC’s) in
Malawi and Tanzania. In both countries NPC’s have graduated from a basic clinical education and the
clinicians we were working with had professional experience which ranged from little or no operative
practice to an extensive logbook of clinical experience.
Of necessity, the education which was developed in Malawi differed substantially from that developed in
Tanzania and evaluations have been reported separately (refer to Papers 1 ,2 , 4 and Pemba paper.)
Here we use realist evaluation techniques as we reflect on what works for whom in what circumstances. We
derive recommendations to assist development of further education for non-physician clinicians in similar
circumstances.