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Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 60-65 Surgical Training Human Resource Development in Rural Surgery: Developing the Paramedic Training Programme Shipra Banerjee Rural Medicare Centre, Khasra No. 242, Village Saidulajalb, P. O. Box-10830, Mehrauli, New Delhi-110030. Paper received: July 2002
Code Number: is03012 INTRODUCTION The population of India is more than one billion. More than seventy percent of the population still lives in rural areas, or small town on slums. These areas are economically backward and lack in infrastructure development, including electricity, proper housing sanitation, health facilities, educational facilities and trained manpower. It is in such situations that many rural surgeons have set up their practices and have started small hospitals.1 They provide appropriate care that is affordable to the people and try to use the resources efficiently and innovate if necessary. The paying capacity of the people is very little, there is no social security, and private insurance agencies do not cater to people with such an uncertain financial status. It is very important that the services these doctors provide should be cost-effective despite lack of infrastructure development and shortage of trained manpower. In India there is an acute shortage of trained registered nurses. Whereas, the recommended ratio is 3 nurses for 1 doctor, in reality it is only 3 nurses for 4 doctors.2 Since there is a scarcity of nurses they easily get employment in city hospitals and many migrate to Arab countries for better salaries. Like the doctors of modern medicine, these nurses are trained in modern nursing based on the curriculum, which is followed in the west. They learn the skills, attitudes and practices of western countries. As a result the common rural people have difficulty in understanding the culture of these nurses and very often they do not feel free while interacting with them. The nurses also fail to understand the behaviour of the common people and try to avoid interactions that depend on the behavioral aspects of the patient. Generally, basic nursing as well as physical care and emotional support to the patients are supposed to be provided by the nursing aids or sweepers. Planning and teaching the patient and his family about restoration and promotion of health as well as prevention of disease is generally not done. Most of the rural surgeons in India have not been able to motivate the registered trained nurses to work in their hospitals. Since the hospital services cannot be run without nurses, many of these doctors have trained local people to work as paramedics / nurses in their institutions.3,4 This strategy also helps to provide useful employment to the rural people. The training is generally based on the needs of the rural hospital as well as its clients. In this paper, the training programme that has been conceptualized and conducted at the Rural Medical Centre, Mehrauli, Delhi is presented. Most rural surgeons conduct similar programmes with some variations. The Rural Medicare Centre is a 25 bed hospital run by a voluntary organization, Rural Medicare Society, providing comprehensive health care including second level surgical care to the people living in rural, periurban areas and in the urban slums of Delhi. It was started in 1976 with the intention of providing need based health and surgical care to the community at a price affordable to the people. In the beginning some qualified registered nurses were employed but their attrition rate was very high and it was difficult to provide nursing care to the patients. The institution, therefore, started employing people from the community and training them as paramedics for nursing care and day-to-day management of the hospital and it has been successfully providing services to the community ever since. DEVELOPMENT OF THE PARAMEDIC TRAINING PROGRAMME IN THE INITIAL PHASES It was necessary for our institution to define the role of the personnel to be trained so that we could develop a meaningful and flexible training programme which could be modified after evaluation. In this context it is important to define the role of nurses in rural areas. Service to the mankind is the primary role of the nurses and paramedics. The nurses must know their patients, their problems in the context of the socio-cultural, economic and emotional aspects and should be able to interact and communicate with them, and most important, should be able to identify with the community. So besides the conventional role of nurses, we emphasized on the following local needs : a) Helping patients and their relatives to
use various facilities in the hospital with which they are not familiar.
TRAINEES IN THE PRELIMINARY PHASES Initially when we started the training programme, the criterion was to admit any person who was willing to learn to provide care in the hospital. We got the following categories of people: a) boys and girls who had finished schooling
This assorted group of people were bermed paramedics. INITIAL PROCESS OF TRAINING With the help of a trained registered tutor nurse we trained everybody in practical basic nursing. We found that the whole group learnt the procedures quite well. After 2-4 months of intensive training and supervision there was not much difference in the performance of the illiterate women, literate boys and girls and the girls with different categories of training in nursing. Alongside the training in basic nursing, we started training everybody in certain basic skills like drug administration including setting up of drips, intramuscular injections, steilisation, autoclaving of linen, bandages and gloves, familiarisation with operation theatre techniques like knowledge of basic instruments, their maintenance and sterilization, maintenance of the operation theatre, baby bath, monitoring of labour cases, care of the normal new born baby, etc. We noticed that most of the different categories of trainees learnt all the skills equally well. But the illiterate women very often could not remember tasks in the proper sequence and in the proper context. These were tasks that needed recording. We segregated them and decided to use them as nursing aids or to work in the outpatients under the direct observation of doctors. Besides practical education at the bedside, in the operation theatre, outpatients, office, etc. some didactic training in the local language (Hindi) was also given. At this point we decided to have two categories of paramedics, junior and senior. Those who were literate and were willing to advance in learning all categories of skills including office work could be gradually promoted as senior paramedics with better pay scales and prospects. Those who did not show any inclination to learn to write proper records remained as junior paramedics with a pay scale which was lower than senior paramedics. Thus, over a period we have developed three types of curricula for the paramedics : A. Common curriculum for junior and senior paramedics
Duration : 2-3 Hours per week for 3 months. B. Curriculum for senior paramedic nursing
Duration : 3 Hours per weeks for 3 months. C. Curriculum for working in Administration
Duration : 3 Hours per week for 3 months or more PRESENT TRAINING PROGRAMME (I) Paramedic Training Programme All training is on the job training. Trainees are from the Rural Medicare Centre and / or are sponsored by other organizations. Trainees a) Junior paramedics consisting of nursing aids, sweepers and porters. Candidates must preferably be literate. If not they have to undergo training in functional literacy b) Junior paramedics (nursing) : Junior secondary school or senior secondary school or nursing with B grade or A grade diplomas. c) Junior paramedics (technicians) : Senior secondary school preferably with training in laboratory sciences or radiography. d) Junior paramedics (administration) : Junior or Senior secondary school e) Senior paramedics (administration) : Graduates with training in typing, computers or accounts. f) Senior paramedics (nursing, technicians) : All categories are given 'on the job' training. Every individual has to follow curriculum A. Category (b) has to have initial training in curriculum B as well. Categories (d) and (e) have initial training and continuing education in curriculum C. All the categories have continuing education after evaluation. Method of Teaching Curriculum A Since many of the students are unable to take notes because of low levels of literacy, participative learning in various ways is practiced. Audiovisual methods are used quite frequently. Introduction to the topic is provided by the instructor and the lesson is developed with the help of the learners. Strictly didactic lectures are not used. Simple tasks based on a topic are given to the learners which they have to present in the class the next day. Group work and workshops are commonly adopted for management topics. Problems are identified and discussed in groups with the help of the moderator. Solutions are presented by the different groups and later discussed together. Feasible solutions which are accepted by all are adopted for practical implementation. Practical 'on the job' training is provided for topics like basic nursing, sterilization and autoclaving, maintenance of equipments, material management, resuscitation and first aid, and administration of drugs. Corrective supervision is provided by the trainers. Curriculum B Didactic lectures on various topics are provided by the respective specialists. Free use of models, charts and other audiovisual aids is encouraged. Practical 'on the job' training is provided for the various procedures required to be done by the nurses. Correctives supervision is provided by the doctors concerned. For Reporting and Record-Keeping, group work and participative training is provided by the trainer. Practical training is provided at various locations. Corrective supervision is provided during practical work by the doctors. Curriculum C Topics are introduced in the form of lectures with participation of the students. Workshops and group work are organized to train and develop innovativeness. Practical training along with corrective supervision is provided by the trainers and the managers in charge of stores, accounts and administration, etc. (II) Training of Patient's Relatives Whenever a new patient is admitted, he or she is accompanied by relatives. It is a socio-cultural behaviour pattern of the Indian masses that they must accompany the sick relative, empathise and sympathise with the sick and help them in whatever way they can, including financial help. We initially found it difficult to deal with them. Then we discussed with the people and with the paramedics about the kind of role relatives could play in nursing the patient. The paramedics thought they could be involved in monitoring the intravenous drips, and could watch serious patients with regard to colour, falling back of tongue after anaesthesia, any abnormal behaviour or convulsions, etc and report to the paramedic concerned so that immediate attention, could be provided. We decided to evolve a strategy of telling the people about the consequences of overcrowding, noise and the unhygienic conditions that may result in the hospital and we pleased with them to cooperate with us to provide the best service to the patient. Instead of allowing all of them at the same time, we allowed one relative at a time with each patient. The rest of the anxious relatives could wait in the open lounge outside the hospital. The paramedics started teaching the relatives in the areas already identified. With this involvement, relatives became more responsive and amenable to other suggestions like prevention of overcrowding, stopping smoking, observing hygiene and silence in the hospital, etc. Gradually the relatives also started taking an interest in helping to clean the patients, turning them, helping them cough and breathe with the aid of paramedics and helping them to use the toilets as well. We found that they were also training relatives of new patients with regard to hospital behaviour and the role the relatives must play. Another cultural aspect which we took advantage of was concerned with food. The relatives liked to bring some kind of nutritious food for patients and they always asked the doctor about the kind of food that should be brought for the patient. The doctors guided them to identify a proper nutritious diet, including high protein diet and vitamins and to avoid beverages like aerated drinks. They were also told about the harmful effects of smoking and alcohol. However, there is no fixed course for relatives. Instinctive and socio-cultural values are respected and used to make the relatives participate in the treatment of the patient. TRAINERS Initially for training in nursing we got the help of a nursing sister tutor who taught the doctors and the assorted group of paramedics, basic nursing. Later on when she left, the doctors did the training for some time. Later they selected committed and efficient paramedics to provide initial practical training under the overall supervision of the doctor in charge of training. EVALUATION In the beginning we laid much stress on a written examination with objective type of questions following completion of each topic. The trainees generally scored poorly but improved in performance and were willing to do better. So we decided to change the pattern of evaluation. The following methods were adopted : (I) Curriculum A and C Immediate Evaluation-(Graded and A, B and C) Assessed by the trainer Criteria assessed were as follows : a) Active participation by students in developing the teaching programme b) Participation during the teaching process c) Presentation of group work and self-assessment of group work d) Developing schemes to improve the performance and environment e) Willingness to implement schemes developed Evaluation on the job-(Graded as A, B and C) Assessed by the doctors and administrator Criteria assessed were as follows : a) Improvement in performance b) Clarity in understanding and explaining procedures c) Interest in work d) Enhancement of team spirit e) Implementation of schemes developed in the workshops with innovativeness f) Patient's satisfaction and relative's satisfaction (II) Curriculum B Immediate Evaluation-(Graded as A, B and C) Assessed by the trainer Criteria assessed were as follows : a) Participation during the teaching process b) Written examination at the end of the topic (III)Evaluation of the training of Relatives Immediate evaluation and long-term evaluation were conducted. The following criteria were evaluated, again using a scale of A, B, C Immediate evaluation a) Patient's and relative's satisfaction b) Interest to observe the rules of the hospital c) Observation of hygienic principles d) Avoidance of overcrowding e) Improved nursing care Long-term Evaluation Assessment in community and hospital with interviews using questionnaires. Certain guidelines which could be obtained from this approach are : a) Awareness of the community about patient care, nutrition and environmental hygiene b) Satisfaction with the care provided in the hospital c) Hospital infection rates d) Patient turnover rates e) Cost-effectiveness f) Community participation in hospital care and health-related programmes in the community. Depending on the evaluation, content and approach to training were modified. CONTINUING EDUCATION We have observed that even after initial training, with the passage of time, the paramedics start doing work mechanically and the performance tends to fall. So every year the course is repeated with modifications depending on the evaluation. Continuing 'on the job' training is provided with corrective supervision. OUTCOME OF THE PARAMEDIC TRAINING PROGRAMME By developing the locally available manpower, preventive care in surgery has improved. There is more involvement of the community in early detection of surgical cases, including acute abdomen, cancer breast, cervix, cellulites and complicated fractures, infected wounds of labourers and farmers, complications of pregnancy, etc. 3,5 Length of hospital stay of surgical patients has diminished considerably and there is an early recovery in patients because of the participation of relatives in the treatment.6 VARIATIONS In many Rural Hospitals regular annual courses may not be conducted. But paramedics selected from the community are provided continuing education and on the job training with corrective supervision till they become experts. Any new concept or method introduced in the hospital is also explained and taught to the nurses / paramedics. CONCLUSION It is indeed important to adopt nursing practices according to the social and cultural practices of the community as a part of the total appropriate health care amongst developing communities. By adopting such an appropriate training programme, Rural Medicare Centre as well as the rural surgeons in India have developed the required manpower, culturally acceptable to the local community to provide need-based care in hospitals and in the community. References
Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com |
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