Strengthening the Pre-Service Nursing and Midwifery Education in India Learning Resource Package for ANM Faculty Training Participants’ Handbook March 2012 STRENGTHENING THE PRESERVICE NURSING AND MIDWIFERY EDUCATION IN INDIA LEARNING RESOURCE PACKAGE FOR ANM FACULTY TRAINING PARTICIPANTS’ HANDBOOK MARCH 2012 Copyright @ 2012 by Indian Nursing Council All rights reserved. No part of this publication may be reproduced, reviewed, abstracted, stored in a retrieval system or transmitted in any form or by any means including photocopying without the prior written permission of the Indian Nursing Council, New Delhi. Disclaimer: The names and situations used in case discussions in this manual are fictitious and does not bear any resemblance to any person alive or dead. Any resemblance is purely co- incidental. First Edition 2012 Printed March 2012 PREFACE Recent policies and programs of the Government of India focused on Maternal, Newborn and Child Health (MNCH) services including the Janani Suraksha Yojana (JSY scheme), Integrated Management of Newborn and Childhood Illnesses (IMNCI) and operationalization of 24/7 Primary Health Centers and First Referral Units. These efforts have put an increased emphasis on the role of the basic health worker in the provision of comprehensive Reproductive Health (RH) and MNCH services in the country, especially in rural areas. To respond to this need for development of a basic service provider who can provide quality RH and MNCH services at the grass root level, a comprehensive initiative to strengthen the foundation of pre-service education for ANMs (Auxiliary Nurse Midwife) is being undertaken by the Indian Nursing Council (INC). This book is part of the learning resource package for, ‘Strengthening the Pre- Service Nursing and Midwifery Education in India’ for ANM faculty training that is developed to prepare them to use the new Government of India guidelines for Skilled Birth Attendance, Integrated Management of Neonatal and Childhood Illness, Family Planning and Prevention and Management of Reproductive Tract Infections when teaching midwifery to ANM students. The package includes a ‘Facilitators’ guide’ and a ‘Participants’ Handbook’ that includes materials and exercises needed for this course. In addition, there are several other resources available to support training, such as reference manuals, Hindi versions of participant notebooks and the presentation graphics. This resource package has been endorsed by the Indian Nursing Council (INC) for use during the training of ANM faculty and further in pre-service ANM education. It is hoped that this learning resource package will help the ANM faculty to deliver quality competency-based clinical training that results in confident ANM’s able to deliver appropriate maternal and newborn care in communities and healthcare facilities throughout India. Dr. Asha Sharma Vice-President Indian Nursing Council ACKNOWLEDGEMENT The Indian Nursing Council (INC) is committed to improve and sustain quality in the pre-service nursing and midwifery education of India. In the national survey conducted by the INC, it was found that the quality of education in the ANM training schools was not up to the mark as the faculties of the schools were not updated in the recent advances in nursing and midwifery education and the guidelines of the Government of India. In order to fill this gap and to address the immediate need of the nursing faculty for updating their knowledge and skills, the INC embarked upon a national initiative to strengthen the pre-service nursing and midwifery education in the country. Through this initiative, five National Nodal Centers of excellence for Nursing and Midwifery Education have been established and the faculty of ANM schools from different regions of the country would be trained in these institutions for a period of 6 weeks. The curriculum for the 6 weeks training has been launched by the Indian Nursing Council. This curriculum would provide comprehensive training and updates for the faculty of ANM schools on Effective Teaching Skills, Skilled Birth Attendance, Integrated Management of Neonatal and Childhood Illness, Prevention of STI, HIV and Parent to Child Transmission of HIV, Family Planning and the Performance Standards for Nursing and Midwifery Education for Quality Improvement. The learning resource package, which consists of a Facilitators’ Guide and Participants’ Handbook, was pilot tested at the first 6 weeks training and was found feasible to be implemented throughout the country. It is envisioned that this learning resource package would help sharpen the skills of the faculty of ANM schools and that the quality of education at the ANM schools will improve dramatically and be maintained as per the international standards. I would like to acknowledge Dr. Bulbul Sood, the Country Director of Jhpiego and her team from MCHIP Dr. Somesh Kumar, Ms. Julia Bluestone, Dr. Rashmi Asif, Dr. Neeta Bhatnagar, Dr. Vineet Srivastava, Mrs. Abra Pearl and Mrs. Celine Gomes who were instrumental in the preparation and publication of this Learning Resource Package. I would like to thank the Nursing Education Committee (NEC) of the Indian Nursing Council and Ms. Surekha Sama for their technical inputs in this curriculum. I gratefully acknowledge the tireless efforts of Ms. K. S. Bharati, Joint Secretary, Indian Nursing Council who has not only provided inputs to the content but contributed to the coordination and compilation of this document into a quality training manual for ANM faculty. I Hope that this curriculum and the learning resource package would help strengthen the capacity of the faculty of ANM schools and thereby improve the quality of pre-service nursing and midwifery education in the country. Sh. T. Dileep Kumar President TABLE OF CONTENTS TRAINING APPROACH OVERVIEW ------------------------------------------------------------------- 1 Welcome---------------------------------------------------------------------------------------------------------- 1 Training Approach Used in this Course --------------------------------------------------------------- 1 Key Features of Mastery Learning --------------------------------------------------------------------- 2 Role of the Participant in the Course ------------------------------------------------------------------- 4 Components of the ANM Faculty Training Package ----------------------------------------------- 4 Using the ANM Faculty Training Package ----------------------------------------------------------- 5 Evaluation and Certification of the Participants --------------------------------------------------- 6 COURSE DESCRIPTION ----------------------------------------------------------------------------------- 7 Course Design -------------------------------------------------------------------------------------------------- 7 Course Structure ---------------------------------------------------------------------------------------------- 7 Specific Characteristics of this Course ----------------------------------------------------------------- 7 COURSE SYLLABUS ------------------------------------------------------------------------------------------ 8 Course Goals --------------------------------------------------------------------------------------------------- 8 Course Objectives --------------------------------------------------------------------------------------------- 8 Training/Learning Methods ----------------------------------------------------------------------------- 10 Duration of the Course ------------------------------------------------------------------------------------ 10 Learner Selection Criteria ------------------------------------------------------------------------------- 10 Suggested Course Composition ------------------------------------------------------------------------- 10 COURSE SCHEDULE --------------------------------------------------------------------------------------- 11 PRECOURSE KNOWLEDGE ASSESSMENT ----------------------------------------------------- 27 How the Results will be Used --------------------------------------------------------------------------- 27 Pre-course Knowledge Assessment Questionnaire ----------------------------------------------- 27 Clinical Experience Questionnaire and Personal Learning Plan ---------------------------- 30 SECTION I: EFFECTIVE TEACHING SKILLS AND PROFESSIONAL RESPONSIBILITIES----------------------------------------------------------------------------------------- 33 Handouts ----------------------------------------------------------------------------------------------------------- 35 Handout 1.1: International Confederation of Midwives (ICM) Code of Ethics for Midwives ------------------------------------------------------------------------------------------------------- 35 Handout 1.2: Teaching Clinical Decision-Making ------------------------------------------------ 38 Handout 1.3: Sample Lesson Plan Format ---------------------------------------------------------- 41 Handout 1.4: Job Responsibility of the ANM at the Sub-Center ----------------------------- 43 Checklists ---------------------------------------------------------------------------------------------------------- 48 Checklist 1.1: Effective Facilitation Skills ---------------------------------------------------------- 48 Checklist 1.2: Clinical Demonstration Skills ------------------------------------------------------- 49 Checklist 1.3: Clinical Coaching Skills --------------------------------------------------------------- 50 Exercises ------------------------------------------------------------------------------------------------------------ 51 Exercise 1.1: Write Course and Supporting Objectives ----------------------------------------- 51 Exercise 1.2: Create and Facilitate a Role Play --------------------------------------------------- 52 Exercise 1.3: Create and Facilitate a Case Study ------------------------------------------------- 53 Exercise 1.4: Create and Facilitate a Clinical Simulation ------------------------------------- 53 Role Plays ---------------------------------------------------------------------------------------------------------- 55 Role play 1.1: Responsibilities of an ANM based on her Job Description ----------------- 55 Role play 1.2: Partnership with TBAs ---------------------------------------------------------------- 57 Role play 1.3: Supportive Supervision ---------------------------------------------------------------- 59 Role play 1.4: Approaches to Managing People ---------------------------------------------------- 61 SECTION II: FAMILY PLANNING -------------------------------------------------------------------- 63 Pre & Post Course Knowledge Assessment Questionnaire ----------------------------------------- 65 Exercises ------------------------------------------------------------------------------------------------------------ 66 Exercise 2.1: Technical Overview of FP Methods ------------------------------------------------ 66 Exercise 2.2: MEC Chart: Hormonal Methods ---------------------------------------------------- 69 Exercise 2.3: MEC for IUCDs --------------------------------------------------------------------------- 70 Exercise 2.4: Infection Prevention for IUCD Insertion/Removal ----------------------------- 71 Handouts ----------------------------------------------------------------------------------------------------------- 72 Handout 2.1: Loading IUCD in a Sterile Package ------------------------------------------------ 72 Checklists ---------------------------------------------------------------------------------------------------------- 76 Checklist 2.1: Family Planning Counseling -------------------------------------------------------- 76 Checklist 2.2: Postpartum Family Planning Counseling in the Ward ---------------------- 79 Checklist 2.3: IUCD Counseling and Clinical Skills --------------------------------------------- 81 Role Plays ---------------------------------------------------------------------------------------------------------- 84 Role play 2.1: Demonstration and Practice: FP Counseling using GATHER Approach ----------------------------------------------------------------------------------- 84 SECTION III: INTRODUCTION TO STI, HIV AND PPCTC OF HIV ------------------- 87 Pre and Post Test Knowledge Assessment Questionnaire ------------------------------------------ 89 Handouts ----------------------------------------------------------------------------------------------------------- 92 Handout 3.1: HIV Disease Progression ------------------------------------------------------------ 92 Handout 3.2: WHO Clinical Staging of HIV/AIDS for Adults and Adolescents with confirmed HIV Infection ------------------------------------------------------------- 93 Handout 3.3: WHO Clinical Staging System of HIV/AIDS for Children with confirmed HIV Infection ------------------------------------------------------------- 95 Handout 3.4: Nurse’s Role in Referral, Linkages and Networking ------------------------ 97 Handout 3.5: Vaginal Discharge – What You Need to Know -------------------------------- 98 Handout 3.6: Checklist–How and What of History Taking with Patients with STIs 99 Handout 3.7: Hand Hygiene -------------------------------------------------------------------------- 100 Handout 3.8: PPTCT True or False Statements ----------------------------------------------- 101 Handout 3.9: Small Group Exercise: Patient Education ------------------------------------- 102 Handout 3.10: Replacement Feeding Checklist ------------------------------------------------- 104 Handout 3.11: Steps in Pre-test Counseling ------------------------------------------------------ 105 Exercises ----------------------------------------------------------------------------------------------------------- 107 Exercise 3.1: “We Know More Than We Do” ------------------------------------------------------- 107 Exercise 3.2: Clinical Staging Cases ----------------------------------------------------------------- 108 Exercise 3.3: Case Studies: Applying Syndromic Case Management ---------------------- 112 Exercise 3.4: Steps in Hand Washing Checklist -------------------------------------------------- 113 Exercise 3.5: Situational Guide-Cleaning up a Blood Spill on the Floor ------------------ 113 Exercise 3.6: HIV and Pregnancy Case Study ---------------------------------------------------- 113 Role Plays --------------------------------------------------------------------------------------------------------- 115 Role play 3.1: Typical Patient Questions ----------------------------------------------------------- 115 Role play 3.2 (a): Counseling Role Plays ------------------------------------------------------------ 117 (b): Counseling Assessment Checklist -------------------------------------------- 118 ANNEXURES --------------------------------------------------------------------------------------------------- 119 Annexure 3.1: STI Syndrome Flowchart – Management of Lower Abdominal Pain in Females --------------------------------------------------------------------- 120 Annexure 3.2: STI Syndromic Flowchart–Management of Inguinal Bubo ------------ 121 Annexure 3.3: STI Syndromic Flowchart–Management of Painful Scrotal Swelling -------------------------------------------------------------------------------- 122 Annexure 3.4: STI Syndromic Flowchart–Management of Genital Ulcers ------------- 123 Annexure 3.5: STI Syndromic Flowchart – Management of Urethral Discharge in Males ------------------------------------------------------------------------------------ 124 Annexure 3.6: STI Syndromic Flowchart – Management of Vaginal Discharge in Females --------------------------------------------------------------------------------- 125 Annexure 3.7: STI Syndromic Flowchart – Management of Oral & Anal STIs ------- 126 Annexure 3.8: Management of Anogenital Warts, Molluscum Contagiosum and Ectoparasitic Infection ------------------------------------------------------------- 127 Annexure 3.9: Personal Protective Equipment (PPE) ---------------------------------------- 130 Annexure 3.10: Guidelines for Disinfection and Sterilization-------------------------------- 132 Annexure 3.11: Factors Increasing the Risk of MTC HIV Transmission ----------------- 133 Annexure 3.12: Nurse’s Role during Pregnancy, Labour, Delivery, and Postnatal Period in the Care of HIV Positive Women ---------------------------------- 134 Annexure 3.13: Key Elements of Effective Counseling ----------------------------------------- 137 Annexure 3.14: Avoiding Counseling Mistakes --------------------------------------------------- 138 SECTION IV: INTRODUCTION TO PERFORMANCE STANDARDS FOR ANMTCS AND THEIR IMPLEMENTATION ---------------------------------------------------- 139 Handouts --------------------------------------------------------------------------------------------------------- 141 Handout 4.1: Standards-Based Management and Recognition of Health Service Delivery --------------------------------------------------------------------------------- 141 Handout 4.2: Change Management --------------------------------------------------------------- 144 Handout 4.3: Setting the Standards -------------------------------------------------------------- 146 Handout 4.4: Implementing Standards: Measurement of Actual Performance ----- 148 Handout 4.5: Scoring and Summary of Results ----------------------------------------------- 150 Handout 4.6: Feedback and Operational Action Plan --------------------------------------- 151 Handout 4.7: Key Implementing Teams Hand out ------------------------------------------ 153 Handout 4.8: Cause Analysis ----------------------------------------------------------------------- 154 Handout 4.9: Selection of Interventions --------------------------------------------------------- 156 Handout 4.10: Team Building and Operational Strategy and Planning ---------------- 158 Handout 4.11: Measuring Progress: Networking and Benchmarking ------------------- 160 Handout 4.12: Recognizing Achievements -------------------------------------------------------- 162 Handout 4.13: Resource Mobilization: A “Win-Win” Strategy ------------------------------ 164 Performance Standards of ANM Pre Service Education -------------------------------------------- 167 ANNEXURES ----------------------------------------------------------------------------------------------- 243 Annexure 1: Instructions for Facilitation Activities -------------------------------------------- 245 Annexure 2: Participant Assignment Sign-Up Sheet ------------------------------------------- 246 Annexure 3: Participant Assignment Sign-Up Sheet-Demonstration Skills ------------ 247 Annexure 4: Course Evaluation ----------------------------------------------------------------------- 248 References ----------------------------------------------------------------------------------------------- 250 LIST OF ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ANM Auxiliary Nurse Midwife BEOC Basic Essential Obstetric Care BEmONC Basic Emergency Obstetric and Newborn Care BP/CR Birth Preparedness and Complications Readiness CBT Competency Based Training CHV Community Health Volunteer CHW Community Health Worker DMPA Depo Medroxy Progesterone Acetate DOTS Direct Observation Therapy Short course ETS Effective Teaching Skills FP Family Planning FRU First Referral Unit GoI Government of India HBV Hepatitis B Virus HCV Hepatitis C Virus HIV Human Immunodeficiency Virus HPV Human Papilloma Virus ICM International Confederation of Midwives ICTC Integrated Counseling and Testing Center IEC Information, Education and Communication IMNCI Integrated Management of Neonatal and Childhood Illness INC Indian Nursing Council IP Infection Prevention IUCD Intra Uterine Contraceptive Device JSY Janani Suraksha Yojana LHV Lady Health Visitor LRP Learning Resource Package MCHIP Maternal and Child Health Integrated Program MCPC Managing Complications in Pregnancy & Childbirth MEC Medical Eligibility Criteria MNC Maternal and Newborn Care MNCH Maternal, Newborn and Child health NVP Nevirapine PEP Post Exposure Prophylaxis PHC Primary Health Center PID Pelvic Inflammatory Disease PLHA Person Living with HIV/AIDS PNC Postnatal Care PPE Personal Protective Equipment PPFP Postpartum Family Planning PPIUCD Postpartum Intra Uterine Contraceptive Device RCH Reproductive and Child Health