Background
High-quality care is crucial to reduce neonatal mortality and achieve sustainable development goal 3.2 [
1]. It requires robust pre- and in-service training, multidisciplinary teamwork, access to appropriate medical devices and professionals able to use and maintain this equipment.
A multidisciplinary team within healthcare is traditionally comprised of different types of clinical staff. However, when medical devices are essential for safe and effective care, such as in a ward for small and sick newborns, it is important to consider expanding the team to include a broader multi-cadre group (e.g., biomedical engineers and biomedical technicians). One of the biggest challenges to broadening multidisciplinary teamwork is that training typically occurs in professional silos [
2‐
6]. This inhibits collaboration, limits understanding of and respect for each other’s roles and drives a hierarchical system within the workplace [
2]. As collaborative practice “strengthens health systems and improves health outcomes” [
7], it is crucial to break down these divisions. One approach to this is through inter-professional education (IPE) [
2].
Undergraduate training (i.e., pre-service) is traditionally uni-professional, and though providing core knowledge, skills and attitudes required to deliver healthcare [
8], professional silos are retained. In-service training may be multi-professional, often focusing on a specific topic (e.g., neonatal care), but again maintains the silos. However, in-service training can be inter-professional. The purpose of IPE is “to learn with, from and about each other” [
8], thereby breaking down professional divisions. This leads to greater respect for each other and a better understanding of the contribution that each makes to the team, thus improving collaboration [
8].
Establishing new educational curricula, training, or material necessitates consultation with and inclusion of all key stakeholders [
9]. Performing a needs assessment is crucial to determining educational goals, identifying core content, ascertaining preferred learning formats, and ensuring local relevance. It is also a means of promoting stakeholder buy-in [
10]. Learning needs to be contextualised [
11], with opportunities for refresher training and ongoing support [
12]. As “medical education is in a perpetual state of unrest” [
13] it is important to ensure that educational material is adaptable in its format to enable wide integration into national educational programmes. Longitudinal training opportunities are better placed to strengthen communities of practice through use of peer-to-peer learning and mentorship. They improve teamwork and collaboration, with resultant behavioural change and transformation of practice [
14]. To cascade learning, many implementers train a large group of participants and select the best to become Trainers of Training (ToT). A ToT course ensures that trainers know the teaching topics; it does not show them how to deliver the training [
15].
This paper describes the feasibility and short-term outcomes of the approach used by NEST360 to introduce or revise evidence-based national neonatal training materials, with the inclusion of material on neonatal medical devices. The neonatal device training materials that have been developed are locally owned, adaptable in format, integrated into pre- and in-service training, promote interprofessional learning and have the overall aim of reducing neonatal mortality.
Discussion
A careful and considered approach was taken throughout the development and introduction of these NESTEd training materials, starting with an extensive local needs assessment, following the six steps suggested by Eliza Medley [
23]: 1. What skills do they/we have? 2. Are the skills needed? 3. Has any former training been done? 4. Who needs the training? 5. How accessible is this programme? 6. Is it a success or not? The key gap identified through the needs assessment was lack of educational materials on neonatal devices used to augment clinical care. In addition to identifying educational gaps, this assessment ensured that any training materials developed were culturally suitable and sustainable. Often in resource poor settings, brief educational training courses are created, introduced and delivered by visiting external experts, resulting in a transient ‘parachute effect’ with no long-lasting influence [
24,
25]. By undertaking a local needs assessment, we were able to mitigate this risk and ensure contextual and cultural suitability of the training introduced [
9,
26]. It also promoted stakeholder buy-in and enabled the core educational team to develop materials that met not only the needs of students and interprofessional healthcare teams but also of healthcare and academic institutions, national policymakers and Ministries of Health and Ministries of Education [
10,
27]. The inclusion of all key stakeholders promoted local ownership of the training materials, thereby promoting sustainability [
28].
Our materials reflected two key medical educational theories: constructivism and social constructivism. Constructivism builds upon prior clinical knowledge and experience to promote a deeper level of learning and subsequent translation into practice [
29]. This was achieved by collaborating with local partners and contextualising materials into the local clinical setting [
30]. The overwhelming premise of social constructivism is that learning is reliant upon interaction with others [
31]. This is fundamental to medical education as excellent clinical practice is dependent upon learning from one another in a team. Interprofessional learning was, therefore, the basis on which the NESTEd materials were developed. As the gap identified from the needs assessment pertained to medical devices, it was imperative to broaden the team to include biomedical engineers and technicians. The aim is to establish a community of practice where the use of technology is embedded within the clinical setting and learning is shared across disciplines to improve neonatal clinical care [
32]. Using educational theory to inform the development process helped ensure the academic quality of the materials [
33].
The core writing team comprised a small interprofessional working group with expertise in medical education, neonatal care, and communication strategies. Equally importantly, most of them worked within the clinical and teaching setting where the materials were to be used. This local knowledge ensured the suitability and relevance of the materials produced. Materials were developed through a collaborative writing process with reference to pertinent literature. Production of evidence-based training materials provides quality assurance for both teachers and learners.
Further quality assurance was ensured by having a robust review process. Draft materials were presented to the wider NEST360 education team within all four countries for consensus opinion, again ensuring local relevance. Following the incorporation of their recommendations, the materials were sent for internal review by key stakeholders, including students, educators, and Ministry representatives. The wealth of expertise of local reviewers enriched and improved the materials promoting local ownership and inclusion in local and national trainings and curricula. All these steps should encourage sustained use of the trainings. The final stage of quality assurance was through external expert review. External experts are neutral, bringing international experience and credibility to the process. All these quality assurance measures are important as it is well recognised that high-quality medical education is paramount to successful delivery of high-quality clinical care [
34].
The NEST360 education team recognised that the needs for pre- and in-service trainings may be very different. Therefore, a wide variety of materials were developed to ensure educators can access those most suited to their teaching environment. The modules are generic so that the Ministries of Health can adapt them for similar devices. Job aids are device-specific and can be used during mentorship sessions. Simulations are used during national neonatal trainings or within the pre-service setting. Videos can be used for personal revision or incorporated within pre- and in-service trainings. Skills labs enable students to refine their technical use of the equipment [
35]. Because the educational materials span the needs of pre- and in-service trainings, they have been accessed, used, incorporated into curricula, and embedded within national training programmes. This adaptability is crucial as the medical field is in a constant state of change as more advances in medical practice evolve [
13].
In striving for trainings of excellence, the importance of ensuring all instructors/educators were suitably qualified was recognised. Being an exemplary healthcare provider does not equate to being a good teacher, and it has long been identified that there is a significant gap regarding educational training of health professionals: “Teaching has been the Cinderella of academic medicine, as a stepchild it has garnered little respect in comparison with that accorded its sister tasks of research and patient care” [
36]. Teaching is complex and challenging, so it is essential that healthcare providers are equipped with the knowledge and skills to do this effectively [
37]. One of the most welcomed and significant educational trainings that NEST360 introduced was the generic instructor course (GIC). Being taught well improves learning, which will, in turn, translate into better clinical practice and improved quality of care.
A further strength of NESTEd materials was the emphasis on interprofessional education. Training in professional silos inhibits the development of interprofessional collaborative practice [
38,
39], so to avert the risk of inadequate clinical care, it is paramount that team members understand the expertise, functions, and roles that others bring to the team. The use of IPE has been proven to improve the quality of care, with examples including reduction of infections, reduction of need for supplemental oxygen and reduction in cost of care within neonatal intensive care [
40,
41]. Anecdotally the IPE approach adopted by NEST360, where biomedical engineers and technicians are included in the healthcare team, has successfully broken-down professional silos. It has been evident that there is wider appreciation of the expertise and value of skills that all parties bring to the team. There is also a greater understanding of the important role that BME/Ts play in delivering high-quality neonatal care.
Throughout the process, the NEST360 team strived to ensure the sustainability of the trainings. Inclusion of all key stakeholders during material development led to local ownership and inclusion within academic curricula and national neonatal training programmes. Embedding material in this manner and demonstrating the importance of exemplary training has ensured that high-quality interprofessional neonatal training is included within the national agendas for neonatal care of the four countries implementing with NEST360.
A limitation of this paper is that it simply provides a narrative and short-term evaluation of the approach used. A long-term evaluation is planned to ascertain whether our approach translates into long-term behavioural change. Additionally, we plan to publish more papers covering GIC, our mentorship approach, quality improvement initiatives and data for action components of the NEST360 education and training package.
Acknowledgements
We thank the Ministries of Health and Education and all the stakeholders for their active engagement and uptake of the educational materials. We thank all the training teams and health workers – clinical and biomedical alike – for their enthusiastic involvement in all the trainings and their commitment to improving the quality of care and outcomes of sick and small newborns. Especial thanks to the Communications Team at NEST360 and Picturing Health for making our materials so clear and attractive and the relevant administrative staff for their support.
We are immensely grateful to the following people who reviewed the manual to provide expert opinion and guidance: Aggrey Wasunna, Alexandra Pledge, Alfred Gest, Alick Vweza, Andreas Hansmann, Andrew McArdle, Anne Hansen, Antke Züchner, Audu Lamidi Isah, Bev Bradley, Carolyn Maclennan, Christabel Enweronu-Laryea, David Gathara, Edwin S. Palmer, Haika Mariki, Hamish Graham, Hans-Joerg Lang, Heloise Buys, Isa Abdulkadir, Jalemba Aluvaala, Jean Bowyer, Kate Goldberg, Kathryn Maitland, Kouya Francine, Laila Hassan, Louisa Pollock, Louise Day, Manjari Quintanar-Solares, Mary Waiyego Kariuki, Maxwell Kroon, Melissa Medvedev, Mustapha Bello, Mwanamvua Boga, Natasha Rhoda, Neil Kennedy, Odessa Omanyo, Ornella Lincetto, Peter Moons, Peter Olupot-Olupot, Priscilla Wobil, Quique Bassat, Rachel Musoke, Rashmi K. Kumar, Sara Loetz, Sarah Kiguli, Sarah Kotsias-Konopelska, Sarah Rylance, Simon Nguranyang Phemoi, Simon Pius, Tayo Olaleye, Tim Baker, and Victor Tumukunde.
We are also very grateful to fellow researchers and guest-editors who peer-reviewed this paper, and for the input from the managing editors at BMC and within NEST360 including Caroline Noxon, Sarah Murless-Collins, and Joy E. Lawn.
NEST360 Collaborative Education Authorship Group (additional, not named above)
Ahazi Manjonda (Muhimbili National Hospital – Upanga), Angela Okolo (Federal Medical Center Asaba, Nigeria), Caroline Noxon (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Catherine Paul (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Charles Osuagwu (APIN, Nigeria), Chinyere Ezeaka (Department of Paediatrics, College of Medicine, University of Lagos, Nigeria), Christina Samuel (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Danica Kumara (3rd Stone Design Inc., California, USA), Daphne Flowers (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Dolphine Mochache (Aga Khan University, Kenya), Ekran Rashid (Aga Khan University, Kenya), Emmie Mbale (Paediatric and Child Health Association, Malawi; Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Malawi), Esalee Andrade-Guerrero (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Evelyn Zimba (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), George Okello (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Georgina Msemo (Ifakara Health Institute, Tanzania), Grace Irimu (Department of Paediatrics and Child Health, University of Nairobi, Kenya), Grace Soko (Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Malawi), Harold Chimphepo (Ministry of Health, Malawi), Josephat Mutakyamilwa (Ifakara Health Institute, Tanzania), Karim Manji (Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Tanzania), Kondwani Kawaza (Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Malawi), Maria Oden (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Maureen Majamanda (Department of Nursing Sciences, Kamuzu University of Health Sciences, Malawi), Mustapha Bello (College of Medical Sciences, Department of Paediatrics, Modibbo Adama University, Yola, Nigeria), Nahya Salim (Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Tanzania), Olabisi Odosunmu (APIN, Nigeria), Olukemi Tongo (College of Medicine, University of Ibadan / University College Hospital, Ibadan, Nigeria), Opeyemi Odedere (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Rebecca Richards-Kortum (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Robert Tillya (Ifakara Health Institute, Tanzania), Sara Desai (Rice360 Institute for Global Health Technologies, Rice University, Texas, USA), Steve Adudans (Acanova, Kenya), Vincent Ochieng (Aga Khan University, Kenya) and William Macharia (Aga Khan University, Kenya).