Executive Summary
Evaluation of Preservice Midwifery and Nursing Reproductive Health Training in
the Philippines
Jhpiego Technical Report FCA-23 (September 1996)
Introduction
In 1993, Jhpiego initiated two new programs with the Association of Deans of
Philippine Colleges of Nursing (ADPCN) and the Association of Philippine Schools of Midwifery (APSOM). These programs
responded to the need to institutionalize clinical reproductive health/family planning (RH/FP) training, to
develop a sustainable, decentralized national clinical training network for RH/FP services and to develop
standardized training materials. This network was intended to increase the number of skilled graduating nurses and
midwives available to meet the needs of the country.
Objective
This evaluation was planned to determine specific outcomes of the APSOM and ADPCN
projects. The study assessed the following outcomes in the project-affiliated schools of midwifery and colleges of
nursing: institutionalization of FP training, quality of training (both classroom and clinical) and quality of
services in the project-affiliated clinics. The plan also included an assessment of the institutionalization of RH/FP
and the use of project training materials by all schools of midwifery and colleges of nursing.
Methods
Over the past two years, APSOM and ADPCN project staff collected baseline and
followup data on 27 project-affiliated schools of midwifery and colleges of nursing. The project staff
developed Philippine-specific quality of care data collection tools for use in the evaluation.
Cross-sectional data were also collected on the RH/FP clinics affiliated with these schools and colleges during
the summer of 1995. An institutional-level questionnaire (project survey) was returned by 53 of 198 schools of
midwifery and 21 of 176 colleges of nursing.
Data Analysis
In order to measure the outcomes of the projects, this study used operational
definitions of institutionalization, quality of training and quality of services using selected indicators.
Statistical analyses (Chi-square, Fisher and t-tests) were used to compare two complete pre/postintervention data
sets for 13 project-affiliated schools and colleges. In addition, the cross-sectional data, collected during the
summer of 1995, were analyzed. A separate cross-sectional analysis (derived from the midwifery project survey) was
conducted to assess the use of the curriculum, anatomic models and training materials.
Project Interventions
To date, 27 schools (13 nursing and 14 midwifery), primarily private sector
institutions, have been selected to participate in the APSOM and ADPCN projects. Both projects began with the
refurbishment of the RH/FP clinics at project-affiliated schools. Two faculty members from each school of midwifery
and college of nursing enrolled in the first year of the project were trained in FP service delivery, clinical
training skills and in the use of the standardized RH/FP curricula.
The projects also included extensive training materials development to satisfy the
nationwide demand for up-to-date RH/FP clinical reference manuals, curriculum modules and lesson plans tailored
specifically for nurses and midwives. Finally, support was provided in the form of training models (pelvic, uterine,
breast and condom models) and FP equipment to schools throughout the Philippines.
Results
Institutionalization
Data analysis (standard t-test) revealed a significant positive difference in pre/postinstitutionalization
scores for participating schools and colleges. The introduction of standardized training materials and new
clinical training methods in the project-affiliated schools aided in promoting sustained competency-based
training.
The current projects have addressed the need for trained faculty members able to
teach FP. Following the interventions, 20 of the 27 project-affiliated schools and colleges have at least two
faculty preceptors standardized in clinical RH/FP service provision. In addition, faculty members in all 198 schools
of midwifery and 176 colleges of nursing have access to specific guidelines outlining a standardized content and
length of time for both the classroom and clinical RH/FP components of the curriculum.
In the new midwifery RH/FP curriculum module, the recommended amount of instruction
is 34 hours of classroom instruction and 54 hours for clinical RH/FP practice. The total number of clinical
hours devoted to FP significantly increased in project-affiliated schools and colleges.
Following the introduction of the midwifery module, results show that of the
nonproject-affiliated midwifery schools that responded to
the survey, 11.8% have incorporated the minimum
recommended number of clinical training hours (54) and
25.5% have increased their clinical instruction time to 80
to 96 hours. The remaining 62.7% of these schools conduct
between 16 and 48 hours of clinical RH/FP practice for
their students.
Results also indicate substantial numbers of midwifery faculty members and
midwifery students need new or refresher training in clinical RH/FP training skills. There is a need to
strengthen the use of the anatomic model in nonproject-affiliated midwifery schools as a primary component of
competency-based training for IUD insertion.
Quality of Training
Based on the quality of training indicators, project-affiliated schools exhibited
statistically significant improvement in classroom and clinical training. The average number of classroom hours
devoted to RH/FP, while not significant, has increased by nearly 40% while the average number of clinical RH/FP
instruction hours has significantly increased (p=0.017) by 48%. Each project-affiliated school has not only a
training clinic for RH/FP, but the clinic also has at least two trained faculty instructors standardized in RH/FP
skills and clinical training skills, representing a significant improvement as compared to baseline measures.
Results indicate that the lack of a sufficient caseload for training purposes
remains a challenge for new clinics. The greatest proportion of clients visited midwifery clinics for
counseling only, followed by pill and condom acceptors. In nursing clinics, pill acceptors were nearly half of all FP
clients, followed by natural family planning (NFP) clients. Although most of the project-affiliated clinics
have very few IUD clients, students continue to receiving hands-on practice on the models using the IUD checklist.
Quality of Services
Quality of services was assessed at both the individual (provider) and
institutional levels. An evaluation of provider IUD skills (including counseling and IP practices) shows that
overall, the selected providers have maintained their IUD skills over a period of approximately two years since
their initial training. Separate analysis of the individual tasks, however, reveals a significant decline
in the ability of faculty members to perform post-IUD insertion tasks. Skills that were most commonly
problematic were handwashing and the proper disposal of used gloves following the procedure.
The institutional level assessment of quality of services was limited to a
comparison across schools and colleges rather than pre/postintervention. Three of the clinics successfully completed all 42 quality
of service tasks with perfect scores. The perfect scores indicated consistently correct performance across all
areas of service provision. These three clinics are three of the four sites developed as "centers of
excellence."
Results also suggest that half of the 10 project-affiliated nursing and midwifery
schools from program year one had lower scores than the other half in quality of service indicators. The three
task areas that appear particularly problematic are handwashing, counseling and record keeping. The
performance of faculty members in IP clearly needs improvement.
Conclusion
Analysis of the data revealed that the nursing and midwifery projects have
helped preservice institutions take important steps toward improving institutionalization of sustainable RH/FP
training and human resource development. Training of 38 faculty members and 1,993 students has been conducted
during 1994 and 1995. Training of students and faculty members in the project-affiliated clinics will serve two
important purposes in the long term. First, affiliation and training fees from nonproject-affiliated schools and
colleges will help support recurrent costs of the clinic and the continual provision of quality RH/FP training.
Second, the ability of the clinics to support this training demonstrates several indicators of progress:
sufficient clinics exist that have been designated for clinical practice at the project-affiliated schools,
clinics are adequate for training purposes and RH/FP trainers have the ability to transfer RH/FP knowledge
effectively to other faculty members.
These indicators mark the beginning of a sustained, decentralized preservice
clinical FP training network. The training network is expected to yield additional faculty members trained in
clinical training skills and an increased number of graduating nurses and midwives capable of providing FP
services. These advances are particularly important as the Philippines faces a greater demand for skilled midwives
and nurses to deliver RH services under the system of devolution.1
Recommendations
- Project staff should monitor the nonproject-affiliated schools
of midwifery that have not incorporated the minimum number of clinical RH training hours to assess whether
exposure to RH/FP clinical practice continues to increase over the next 12 months, after faculty
members from their school have completed RH/FP training.
- In future programs, APSOM and ADPCN should provide
refresher training in IP practices for faculty members and the site development coordinators should monitor
IP practices after the training courses.
- Project staff should monitor the use of training materials and
adherence to the standard RH/FP module, especially among the faculty members of nonproject-affiliated
schools of midwifery and colleges of nursing who have recently received training under APSOM and ADPCN
projects.
- Counseling skills were weak in the five clinical sites with lower
quality of service scores. Additional training should be considered for these faculty members.
- The quality of services and training at three of the
clinics is excellent. Site development coordinators should devote more attention to monitoring the
development of and the quality of services provided by the remaining 24 clinics.
1 Devolution is the
delegation of authority for the provision of health services to local
government units.
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