In-service training of midlevel providers in emergency care in Ghana: Challenges, successes, and lessons learned

Abstract

Background: Provision of emergency medical care is an increasingly important aspect of health care delivery in resource-limited settings. To meet the greater demand for skilled personnel in emergency medicine in Ghana, we developed an in-service course in basic emergency care for midlevel providers (physician assistants and nurse practioners) working in district hospitals. Midlevels were specifically targeted as this group cares for the majority of the rural population in Ghana. Structure/Method/Design: We held an initial "training of trainers" course for 22 physician assistants from district and subdistrict hospitals within three regions of the country. From this initial cadre of participants, 10 were selected as senior trainers who then received a refresher training course and continue to train colleagues within their respective regions. The course is organized in three parts: didactic lectures, structured case discussions with simulations, and skills stations. Evaluation methods include knowledge-based pre- and posttests, direct observation, case review, and simulation stations. Results (Scientific Abstract)/Collaborative Partners (Programmatic Abstract): Stephan Brenner, MD, MPH; Barbra Villona, MD, MPH & TM, DTM & H; SueLin Hilbert, MD, MPH; Beth Rubenstein, MPH, MBA; Rachel Moresky, MD, MPH Summary/Conclusion: All groups showed improvement in knowledge with average pre-test scores of 56% (SD 14.5%) and post-tests scores of 84% (SD 9.5%). Simulation cases indicate that the majority of the trained midlevel providers learned information sequentially, inconsistently used physical examinations for diagnosis, and rarely reassessed following interventions. Practical skills such as splinting and suturing were more easily acquired than skills in clinical decision making. Most participants felt that case discussions and simulations were the most helpful learning tools and identified symptom-based algorithms as useful reference tools for daily practice and teaching colleagues. The greatest successes of this program are increased awareness, knowledge and advocacy of emergencymedicine, more confidence in basic lifesaving skills, and the development of a focused introductory curriculum targeted to midlevel providers. For continued successful implementation of this program, facilitators must take ownership of teaching materials, knowledge gaps within the senior trainer group must be bridged, and appropriate long-term evaluation methods must be developed.