annual report gfatm 2010 11 - indian nursing...
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ANNUANNUANNUANNUANNUAL REPORAL REPORAL REPORAL REPORAL REPORTTTTT
SSSSSTRENGTRENGTRENGTRENGTRENGTHENING INSTHENING INSTHENING INSTHENING INSTHENING INSTITUTIONAL CAPTITUTIONAL CAPTITUTIONAL CAPTITUTIONAL CAPTITUTIONAL CAPAAAAACITY FCITY FCITY FCITY FCITY FOROROROROR
NURSING TRAINING ON HIV/AIDS & ARNURSING TRAINING ON HIV/AIDS & ARNURSING TRAINING ON HIV/AIDS & ARNURSING TRAINING ON HIV/AIDS & ARNURSING TRAINING ON HIV/AIDS & ARTTTTT
OctOctOctOctOctober 2010 – Sepober 2010 – Sepober 2010 – Sepober 2010 – Sepober 2010 – Septttttember 2011ember 2011ember 2011ember 2011ember 2011
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EXEEXEEXEEXEEXECUTIVE SUMMARCUTIVE SUMMARCUTIVE SUMMARCUTIVE SUMMARCUTIVE SUMMARYYYYY
The year, October 2010- September 2011, marked the successful continuation of the GFATM 7 project on
Strengthening the Institutional Capacity to train 90,000 in service nurses on HIV/AIDS & ART, into phase II.
The Annual Report of GFATM 7 on training of nurses on HIV/AIDS & ART, documents the detailed description
and analysis of its activities & performance on the various indicators & critical Service Delivery Areas.
It contains an update on the various sets of trainings of nurses (including those organized for the
trainers and GFATM project staff), throughout the year.
A total of 13,438 nurses were trained in a 6 day curriculum in 431 training courses across all states.
The 5 Regional Resource Centres, conducted Refresher trainings on the revised curriculum for their
respective zones. A total of 19 such 3 days programs were held during the year and all trainers participated
in the courses.
The SRs, under the project directives, initiated the monitoring of Training of Nurses (TONs) from this year
onwards. The supervision and support provided during these visits, have resulted in a marked
improvement in the quality of the training programs.
In the beginning of Phase II, the Training Curriculum was revised to incorporate the updated NACO
guidelines for the management of HIV/AIDS disease and the critical suggestions /feedback received
from the top 50 trainers, across the 5 zones and subsequently, all the master trainers and Trainers were
oriented towards the same. The details of the process and contents of revisions, have been described in
this report.
An important endeavor towards Quality Assurance has been the development of a 360° feedback on
the trainers and the training institutes and a Grading system for the SRs, SSRs and the Trainers. Appropriate
sets of criteria were developed to evaluate the performance of the institutes and Trainers. This has led
to a healthy competition and motivation among the institutions to excel in their performance.
The Institute of Nursing education (INE), Sir J J Hospital at Mumbai was judged to be the best Regional
Resource Center for this year.
The Manipal College of Nursing, Manipal was judged to be the best SSR followed by Govt. college of
Nursing Ahmedabad and AFMC College of Nursing, Pune.
The Training Management Information System (TMIS) of the project was expanded to feature new set of
activities and indicators for phase II. For easy and fast communicability among the Project partners, a
SMS Gateway has also been introduced.
The improvement in the delivery of services, provided by the trained nurses, is a significant indicator of
the effectiveness of the training program. To this effect, a Midline Assessment was carried out, where
approximately 200 PLHIV (Persons living with HIV) were interviewed to provide a feedback on the
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quality of services, received, from the trained nurses. The results showed that 58% of PLHIV were
satisfied with the services provided by the staff nurses in different hospitals.
Another initiative for the Phase 2 of the project has been the Supportive Supervision programs for the
staff nurses in different levels of health care. The supportive supervision intends to provide ongoing
training and support to the nurses as a follow up to the 6 day classroom training. It also ensures high
motivation among the nurses in their place of work.
A one day orientation program on HIV/AIDS and the nurses training was organized in the districts for all
Nursing Superintendents and matrons in different hospitals. This ensured the involvement of all nursing
personal in the HIV/AIDS program and updated guidelines of NACO.
The training of ANMs, posted at 24x7 PHCs is being planned and a curriculum is being developed to
accommodate the needs of the ANMs working in these centers.
The year 2010-11 also showed an increase in the number of refurbished training institutes involved in
this project.
The Financial Guidelines, under various training heads, have also been modified, keeping in view, the
revisions in the Training schedule, new targets & Indicators and in line with the increased costs of
various products and services.
The report also describes the Success Stories- the positive & enriching experiences shared by the PLHIV
and the nurses, who have been a part of the first ever, comprehensive training program, FOR the Nurses
and BY the nurses.
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CCCCCONTENTONTENTONTENTONTENTONTENTSSSSS
1. Achievements of Phase I 5
2. Success Stories 6
3. Background 8
4. Training of Nurses – An Update 10
5. Establishment of Regional resource Centres (RRCs) 15
6. Revision of Training Curriculum 19
7. Monitoring & Evaluation (M& E) and Training Management Information System (TMIS) 22
8. Midline Assessment 26
9. Sensitization of The Nursing Superintendents on GFATM Project 28
10. New Initiatives 29
11. Financial Updates 34
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1. ACHIEVEMENTS OF PHASE I
Indian Nursing Council is proud to announce that the third year ( October,2010) of the GFATM 7 projecton strengthening institutional capacity of 55 nursing institutes and training of 90,000 nurses in India, onHIV/AIDS & ART, also marks its entry into phase II (October ’10-September’13). A meeting of the CCM(Country Coordinating Mechanism) members of the Global Fund in India was held during the last quarterand after, critically scrutinizing, the performance of INC (Principal Receipt), on the all the key ServiceDelivery Areas(SDAs) granted approval for the same. Almost all the targets showed a hundred percentachievement and the project were awarded an A1 and A2 rating.
This would not have been possible, without the continuous and unfailing support and efforts of thevarious stakeholders, i.e. NACO, Futures Group, CBCI and last not the least, the GFATM staff, including theTrainers of the 55 nursing training institutes, where these trainings were conducted.
Some of the significant achievements of Phase I are:
• Total number of nurses trained was 46,474, against a target of 45,000 nurses• Total number of trainers trained were 699 as against the target of 615• 5 Regional Resources Centers for mentoring and cross learning established and equipped with
resource packs• A total of 25 nursing institutions (out of the 55) were provided funds in Phase 1 for the
refurbishment of the classrooms, library and hostel facilities for training programs.• The concept of E Learning was introduced and all nurses were provided with a CD, along with
the Nurses’ manual the after the training, which covered all aspects of HIV/AIDS prevention,care & treatment and would strengthen nursing care for PLHIV
• The average Pre training score was 56.5% and the average Post training score was found to be78%.
• Most trainers were appreciated by the participants for their knowledge, technique and skills,and have received quite high ratings( an average of 4/5)
• According to the findings of the Midline Assessment of the project,58 % of HIV positive patients,who access ART services, reported being satisfied with their service experience
• Pilot phase of the Supportive Supervision (first ever initiative for Indian Nurses) was commencedduring May- June, which highlighted a marked positive change in the attitude of in-servicenurses towards PLHIV and their families. Care was provided to them in a manner which displayeda high degree of sensitivity towards the social and psychological implications of the HIV disease
• The initial skeptism regarding the relevance/benefits of this training, have slowly been replacedwith appreciation and admiration. As a result, the Health facilities have readily started releasing/proposing the names of nurses, for the future training programs.
• Development of strong cadre of Nurse Trainers on HIV/AIDS.
During the 2nd Project Steering Committee meeting, NACO lauded the achievements of the GFATMproject and expressed a keen desire to bring the training of Auxiliary Nurse Midwives (ANMs) , postedat 24x7 PHCs, under its ambit.
Armed with such impressive feats, INC is confidently, geared towards, scaling the fresh challenges ofPhase II, besides continuing the efforts to meet the laid down targets of the previous phase.
One of the most important Service Delivery Areas has to revise the existing Training Curriculum to matchup with the updating national guidelines. The top 50 trainers were invited for the Cross Learning Workshopsheld at their respective zones, to share their Feedback, in terms of the Technical Content, Duration ofvarious Units, Restructuring of the slides etc.
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The Project Steering Committee has also sought to strengthen the Counseling unit, to enable the trainednurses to effectively counsel the PLHIV and their families. As a result, the training program has beenextended from 5 to 6 days.
The other key new Performance Indicators /activities, in this phase are :
• Grading of Trainers• Supportive Supervision• Orientation Workshops for the Nursing Superintendents, on the GFATM project• Training of ANMs, posted at 24x7 PHCs• Monitoring of TONs by the SRs
Apart from this, The MIS was also updated with the tracking of these new indicators. A new SMSGateway was also included in the MIS page for easy communication with all staff involved in thetraining project.
As INC forges ahead into the 3rd year of the project, it is convinced that the high levels of motivation andconfidence of the GFATM staff, will ascertain the realization of project goals /activities.
2. SUCCESS STORIES
The training project also brought forth some examples of a positive impact it had on trainers, staffnurses and PLHIV. Some of the success stories are discussed here.
2.1 Narrative by PLHIV, lauding the Quality of services provided by GFATM Trained Nurses at M.Y. Hospital,Indore
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“I am a HIV positive person, attached to an organization, as an Out Reach Worker. I work with HIVpositive people.
In the mean time, I was invited by Government College of Nursing, Indore, to deliver a talk on PositiveSpeaking ,during one of their Training of Nurses on HIV/AIDS.
Initially, I was scared of the fact that my HIV Positive status will be revealed to all the nurses and theywill misbehave with me. Despite this fear, I gathered my courage and talked about Positive Speaking atthe Training.
This has benefited me a great deal , the same nurses, who attended the training, provide all theassistance and guidance to me as well as to other PLHIV, who accompany me, at M.Y. Hospital, Indore”_ Vinod
2.2 Feedback from Staff Nurse
“The whole training programming was knowledge updating, interesting and timely. Each and everysession was conducted and explained very well. With each passing day it kept on increasing our knowledgeand we came to know many such things we didn’t know before.
Before coming to this training programme, it was our thinking that we knew everything and actuallydon’t need such training but just after the first session our thinking changed and we realized that wereally needed this training programme and so do other nurses. We didn’t knew the new guidelines andprinciples and many things.
But now after the completion of this training, we are much more confident and competent and we willsurely be able to deal and counsel with HIV patient more effectively as well as protect ourselves fromoccupational injuries.
Last but not the least we would like to extend our heartfelt gratitude to all the teaching faculty involved.They all were really very nice to us and made us feel comfortable and there subject knowledge andteaching art made the training interesting.
Thank you very much for running such a nice training programme for nurses.”
Miss Sheeba Mathai (Staff Nurse), Civil Hospital Ratlam (M.P.)
2.3 Feedback from Staff Nurse
With kind regards this is Mrs B V Ingle, Staff Nurse, Primary Health Centre, Dumala Tehsil, Newasa,Ahmednagar District who had attended the training programme on HIV/AIDs & ART at CON AFMC Punefrom 14.6.10 to 18.6.10. On the concluding day after ‘Unit 15 - challenges faced by nurses in HIV/AIDScare’, we were asked to formulate an action plan. So acting upon the instructions our group chalked outa plan which is being implemented at our Primary Health Centre in the following manner:
• We have contacted the under mentioned schools and conducted Health Awareness and Healtheducation regarding HIV & AIDs as well as Psychological support to PLHA.a. Rural High School, Vadala Bakirobab. New English School, Kharvandic. Rayat Shikshan Sansthan, Malichudhre
• We educate the womenfolk on the days of immunization as well as antenatal clinics and removetheir apprehensions, doubts and misunderstanding regarding HIV & AIDS. We also arrange forvoluntary HIV Testing Camps after Pretest counseling at Sub Centre levels by contacting labtechnicians from the nearby centres.
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• We also do Delivery Tracking and advise the Antenatal women to get admitted in PHC for safedelivery. This is done by post, Sangthan Sabha and through telephone.
• Our sincere efforts and our training are yielding considerable responses. Normally 7 or 8 deliverycases used to come to Primary Health Centre in a year. Now the number of deliveries havereached 28, within a span of five months. We hope the count increases in number in the future.
• We also follow the infection Control measure strictly. Bleaching Solution is prepared by us andwe use it to disinfect articles contaminated with body fluids or secretions. Blood spill is alsosprayed with 1% hypo chloride solution, covered for 20 mts and then mopped.
• All the women who come for delivery, insertion or removal of Copper T at PHC are given dueattention to minimize the risk of transmission of infection.
• Our action plan may have some drawback initially but I believe that one day it will turn out tobe a grand success.
• I owe to you / NACO/INC for giving me this opportunity.
Mrs Babynanda Ingle – PHC, Usthal Dumle, Ahmednagar Dist. Maharashtra.
3. BACKGROUND
3.1 The Global Fund
The Global Fund for AIDS, Malaria and Tuberculosis (GFATM) set up in 2002, is a unique global public/private partnership dedicated to prevent and treat HIV/AIDS, Tuberculosis and Malaria. This partnershipbetween governments, civil society, the private sector and affected communities represents a newapproach to international health financing. Global Fund financing is enabling countries to strengthenhealth systems by, for example, making improvements to infrastructure and providing training to thosewho deliver services. The Global Fund remains committed to working in partnership to scale up the fightagainst the diseases and to realize its vision – a world free of the burden of AIDS, TB and Malaria. Therehave been 9 rounds of funding by the GFATM for control of AIDS, Malaria and Tuberculosis to variouscountries including India.
Staff nurses form the backbone in provision of health care services from the tertiary to primary levels.From conventional nursing care to infection control, counseling and health education, nurses are requiredto multi task and provide a wide range of services. Though nurses, the primary care givers and at times,the only point of contact with the health care delivery system, play a pivotal role, in providing treatmentand support to the PLHIV, had not been comprehensively trained on the same and anecdotal evidenceshows that there is stigma and discrimination due to poor attitudes of nurses and doctors resulting inpoor care being provided to them.
The Phase – II of the project (2006-2011) aims to consolidate the gains made under the earlier phasesof project implementation, expand access to services, upscale critical interventions so as to ensure adecisive reversal in the spread of the epidemic and strengthen capacity of the existing health system toensure long term sustainability, a vital concern for this chronic disease, that has no cure.
Given this scenario, India, under Round 7 GFATM, has been chosen, as a first ever country, to havereceived funding for strengthening institutional capacity of 55 nursing institutions and training of 90,000nurses on HIV/AIDS &ART, within a period of 5 years (2008-2013). It is envisaged that with enhancedknowledge and skills, nurses would be able to deliver an effective and comprehensive HIV/AIDSprevention, care, support and treatment.
The project is being implemented by Indian Nursing Council (INC) in coordination with the National AIDSControl Organization (NACO) with the support of the management support agency, Futures Group
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International Pvt. Ltd. and Catholic Bishops Conference of India (CBCI). A total number of 55 NursingTraining Institutes have been identified from all over the country for this purpose.
The Indian Nursing Council is the Principal Recipient (PR) and 5 of the 55 nursing training institutes arethe Sub Recipients (SRs) and are also the Regional Resource Centres. Their task is to conduct the trainingsof the master trainers and monitor the other 50 nursing training institutes who are the Sub Sub Recipients(SSRs).
The Futures Group and the CBCI are the additional SRs, who support the Indian Nursing Council inimplementing the programme.
3.2 HIV/AIDS Update
The Joint UN Program on HIV/AIDS, UNAIDS has a new vision for the future of –
• Zero New Infections• Zero Discrimination• Zero AIDS related Deaths
This has generated tremendous enthusiasm among all stakeholders and people living with HIV infection.According to the UNAIDS annual report of 2011, an estimated 34 million people were living with HIVworld-wide. Though with improved access to antiretroviral drugs the mortality due to AIDS have reduced,we still have 1.8 million deaths in 2010. Overall, HIV incidence has fallen in 33 countries, 22 of them insub-Saharan Africa, the region most affected by the AIDS epidemic.
Supporting countries in the ongoing task of optimizing their responses through a clearer focus oninvestment has been embraced by major providers of international development assistance in AIDS.The investment approach is in the forefront of the new strategy being developed by the Global Fund toFight AIDS, Tuberculosis and Malaria, as well as the HIV prevention strategy recently issued by the USPresident’s Emergency Fund for AIDS Relief.
In addition to improving quality of life and reducing AIDS-related deaths, antiretroviral treatment is nowrecognized as preventing HIV transmission by reducing viral load and hence reducing the potential fortransmission. Coupling treatment access with combination prevention options is pushing new HIVinfections down to record levels.
In India, based on various studies and independent assessments, it is seen that the National AIDSControl Program III,is progressing steadily towards its objective of halting and reversing the HIV epidemicin India over the period 2007- 2012.
Though most infections occur through heterosexual transmission, emerging pockets of injecting druguse, male migrants and Men having Sex with Men are contributing to the epidemic in India, the 4 –pronged strategy under the current phase, have yielded good results in certain areas of the program.23.9lakh people are living with HIV as per NACO Annual report statistics at the end of 2009, with an adultprevalence of 0.31%. This makes India, the country with the third largest population living with HIV.
Another area of improvement, has been the provision of care, support and treatment services for PLHIV((People Living with HIV/AIDS) and improved access to free ART & 2nd line antiretroviral medicines.NACO is providing free treatment to around 3.5 lakh PLHIV in 2011. The ART centers have expandedacross the country to cover almost all districts. There are around 350 such centers in tertiary and districthospitals, besides, Link ART centers and Community Care centers (CCCs)
In mitigating the impact of HIV, support is also drawn from welfare agencies providing nutritional support,opportunities for income generation and other welfare services.
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Mainstreaming and partnerships are the key approaches to facilitate multi-sectorial response, engaginga wide range of stakeholders. Private sector, civil society organizations, networks of people living withHIV/AIDS and government departments, all have a crucial role in prevention, care, support, treatmentand service delivery.
With reducing stigma and discrimination in hospitals and ART centers, access to these centers haveimproved and more and more people are coming forward for HIV counseling and testing, PPTCT servicesand ART.
The findings of Midline Assessment, conducted, during February’ 11 and certain success stories, indicatethat the nurses, trained ,under the project, have been providing improved care, support and treatmentservices to PLHIV and their families. These findings have been discussed in detail, in the later chaptersof this report.
4. TRAINING OF NURSES – AN UPDATE
4.1 Training of Trainers
In order to ensure the standardized quality trainings for nurses, creation of pool of Master Trainers andTrainers, on an ongoing basis is must. It was also observed that many of the trainers, from the existingpool, were not available to participate in the trainings, for various professional or personal reasons.Also, at many training institutes, new Principal/ Training Coordinator, gets appointed, who need to betrained.
The 4 SRs organized one TOT each, in the last year and trained 117 no. of trainers. The total number ofTOTs conducted and trainers trained till September 2011 is 29 and 848 respectively.
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Zone wise No. of Training of Trainers Conducted
Zone No of Workshops No of Participants
North 1 29
East 0 0
North East 1 29
South 1 29
West 1 30
Total for the year 4 117
Cumulative Total (till end September’11) 28 816
4.2 Training of in-service Nurses
Conducting regular training of nurses, one of the key Performance Indicator, under the project, wassuccessfully carried out during the past year. The total trained was 59,920.
These trainings were conducted at 50 training institutes (From Phase II onwards,5 SRs were involved inMonitoring of TONs, being conducted at SSRs, within their region) across all the zones. Subsequent toNACO recommendation to strengthen the counseling skills of the nurses, the Counseling unit was revised,both in terms of theoretical contents and practical Exercises ( two rounds of Role Plays) .This resulted inthe increase in duration of training program from 5 to 6 days.
The training institutes invited the participants from all levels of Government health facilities (i.e. Tertiary,District and Primary ) from their mapped districts. Effort was also made to include maximum nursesfrom clinical areas like Medical , Surgical, Gynae/Obestritics OPD as well as Wards; Labor Room; OperationTheatre; ART /PPTCT Centres etc. It was also ensured that each workshop had optimum no. of participants(i.e. 25- 35)
On an average, each institute conducted 4-5 trainings per quarter.
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Zone wise No. of Training of Nurses conducted and No of Participants
Zone No of Workshops No of Participants
North 67 2009
East 55 1638
North East 32 1005
South 181 5799
West 96 2987
Total for the year 431 13438
Total since inception 1918 59920
Phase 2 Data Update
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4.3 National Consensus Workshop
A 2 day Consensus workshop was organized for all GFATM staff in the 55 Nursing Institutions. Thisprogram was organized in Vishakapatnam, Andhra Pradesh, on the 29th and 30th January 2011. Thiswas attended by the Principals, Training Coordinators, Finance officers, Data entry operators and stafffrom INC and Futures Group. In this program, the changes in the implementation of the Phase 2 of theproject was shared and discussed with the participants. The new operational and financial guidelineswere emphasized and all gaps identified in the first phase of the project were discussed and remedialmeasures suggested.
4.4 Orientation of the Master Trainers on the revised curriculum
Subsequent to the revisions in the Training Curriculum, as recommended by the project Core Committee& NACO experts, INC organized a 3 day Orientation Workshop (10th – 12th November, 2010 ) at NewDelhi, for the select Master Trainers, from all the 5 zones. The resource pool consisted of Core Committeemembers, Nursing Experts and experts from Futures Group. All the revisions and their rationale werediscussed slide/Unit wise and the subsequent queries, regarding the same , from the participants, werealso addressed.
4.5 Refresher Trainings for the Trainers
Once the Master Trainers from all 5 zones were oriented towards the revised curriculum, the 5 SRsorganized no. of Refresher Trainings for their respective pool of trainers. The Resource persons were theMaster Trainers and the technical experts from Futures Group.
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Total 13 such workshops, between December’10 – February’ 11, were conducted, in order to cover100% trainers, across all the zones.
4.6 Regional Workshops
The Regional Workshops were also conducted during August- September’11, by the SRs, with the aim oforienting the Training Coordinators and select Trainers , at the SSR levels ,towards the new set ofrecommendations, suggested by NACO and the concept of Supportive Supervision.
The Resource consisted of Nursing Experts, select Master Trainers and the Consultants from FuturesGroup. The revisions , mainly consisted of new Guidelines and updated theoretical contents, were discussedin detail, by the various Experts .
These workshops also heralded the initiation of Supportive Supervision, at the national level. Theexperiences and findings of Pilot phase (conducted during May- June’ 11 ,by RAKCON, New Delhi &WBGCON,SSKM, Kolkata) were shared with the participants, along with explanation of the relevance,process & plan for the same ,at the zonal level .
Till September’11 end, total 4 Regional Workshops had been organized by 3 SRs (i.e. RAK CON, NewDelhi, WBGCON, SSKM, Kolkata and CON,CMC ,Vellore )
4.7 Publications
Project documents
Following Project Documents were published during last year:
• Operational Guidelines
This Document has been developed to facilitate INC & the Nursing Institutes (SRs and SSRs) inconducting modular training of nurses in HIV/AIDS all over India in an uniform pattern by followinga set of standardized guidelines and procedures that would enable them to progress in a smooth,efficient and timely manner.
• Financial Guidelines
This is a standard and comprehensive document intended to help INC and the Nursing Institutes(SRs and SSRs) to conduct quality trainings of Nurses on HIV/AIDS according to the prescribedguidelines and budget.
• Monitoring & Evaluation Plan
This document is intended to provide guidance to the INC, the identified Nursing Training Institutes,and the Management Support Agency (Futures Group) on Monitoring &Evaluation of nursing training,especially in relation to indicators and targets as in the Round 7 GFATM performance framework.
• Quality Assurance Manual
The aim of this manual is to provide the required guidelines and procedures for INC, the ManagementAgency (Futures Group) and the Nursing Institutes (SRs and SSRs) to coordinate and conduct qualitytrainings of Nurses on HIV/AIDS in an efficient and seamless fashion by ensuring adherence tostandards in training delivery.
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Newsletter
Publication of the Newsletter, showcasing the achievements of the project , new developments inNursing profession, articles on clinical nursing, interview with an eminent Nursing Professional etc.,continued successfully. There has been an enthusiastic response from not only the GFATM faculty , butalso from nursing professionals, both from the clinical as well as academic field, to provide contributions.As a result, this has become an excellent forum, where the nursing community ,is able to connect andshare their knowledge/achievements, among each other.
The Newsletter is widely circulated among all Nursing School and colleges, major hospitals, healthdepartments, in the center and states and other UN and international agencies .
Handbook for Nurses on HIV/AIDS
It has also been proposed to publish a Handbook For Nurses on HIV/AIDS , under the project. ThisHandbook is meant for hospital based nurses, to provide, an updated information on prevention, diagnosisand treatment of HIV/AIDS cases. Subsequent to the 6 day training program, when nurses return to theclinical practice, it will act as a ready reference, during the course of day today management of HIV/AIDS patients and support appropriate referrals to an expert or a higher center for treatment.
The process for developing the contents of the Handbook has already been initiated by Futures Group.
4.8 E Learning
One of the important Performance Indicators of the GFATM 7 project is the development of Web basedmodule for the nurses for their continuous professional growth. E Learning provides:
• relearning ,post personal training
• motivation through appropriate use of interactive courseware, different from paper based learning;
• control to learners over when and where they study;
• individual feedback, for example—through computer assisted assessments, and positivereinforcement, if modules are customized;
• encouragement for collaborative learning and for taking responsibility for self-learning
• opportunity for conducting training sessions for trainees, particularly those working in remoteareas.
The e-learning modules consists of the textual content along with audio visual components to improvethe learning process. Interactive lessons along with multiple choice exercises are also to be a part ofthis.
The concept of E Learning has already been introduced, at the initial period of the project, by providingthe CDs of the Nurses’ Manual, along with the hard copy of the same. The nurses could refer to it ,duringthe course of their professional work .
The next step in this direction is, to upload the training module on the GFATM TMIS, for a wider access,to various categories of the Health professionals. For this purpose, the ground work has already begun,in the form of preparing the audio components i.e. scripting of the contents of training curriculum, bythe technical consultants of Futures Group.
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5. ESTABLISHMENT OF REGIONAL RESOURCE CENTRES (RRCS)
5.1 Introduction
The GFATM 7 project aims to strengthen 55 nursing institutions and train 90,000 in-service nurses overa period of 5 years (2008-13)
Given the scale of the programme, it is was a challenge for the Indian Nursing Council (INC), theproposed Principal Recipient(PR) ,to reach out to different parts of the country on its own. Also realizingthe ground reality of frequent turnover of key people in the positions, the Project before its closure,strives for developing and strengthening local resource centres , which can be accessed by the nursingschools and colleges beyond the Project period. This creates scope for sustaining and availability of localexpertise. Hence the INC selected five state level institutions, as Regional Resource Centres (RRCs)(alsotermed as Sub Recipients under the project ), which will co-ordinate and implement the project atregional level i.e. in South, North, East, West and North East zone. They are:
• College of Nursing, CMC Vellore – South Zone
• Institute of Nursing Education, Mumbai- West Zone
• Raj Kumari Amrit Kaur College of Nursing, New Delhi- North Zone
• West Bengal Govt. College of Nursing, SSKM Hospital, Kolkata- East Zone
• NEIGRIMS, Shillong- North East Zone
In addition Catholic Bishop Conference of India (CBCI) is another SR, whose role is limited to logistic,financial and administrative support for 10 institutions under its control.
Following criteria were used by the PR in the process of selecting these Regional Resource Centres:
• The size of the institute
• The quality of the past training programs conducted
• Number of nurses trained by these organizations
• Access to facilities of medical institutions for hands on training
• The minimum infrastructure facilities available in terms of class rooms, teaching equipments ,lab and demonstration facilities, hostel accommodation etc.
The Indian Nursing Council provides leadership, quality control, and accreditation and is responsible forFinance disbursement & training material development. It co-ordinates the work of all the RegionalResource Centres to ensure achievement of all targets under the project.
These institutes are provided with necessary resource packs, in addition to strengthened physicalinfrastructure—dedicated lecture rooms with all amenities including IT—computers and software, internetfacilities, projectors, screens, audio-video equipment, copier, scanner, as well as boarding/ lodging/travel arrangements for learners and faculty.
According to the Project guidelines, the 5 Resource Centres will also be a hub for a wealth of informationincluding best practices and lessons from the field. They are in charge of mentoring support, Crosslearning and are responsible for overall training/capacity building of about 4 to 10 nursing traininginstitutes in their region, working with them as implementers (designated as Sub-Sub Receipts-SSRs).
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5.2 The following table depicts the linkages (technical and financial) between INC (PR) and SRs/SSRs
Schematic for technical linkage
Schematic for financial linkage
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5.3 Description of roles and responsibilities of the Regional Resource Centres
• Conducting Training of Trainers (TOTs): One of the primary indicators of the project is the creation ofa pool of expert Master Trainers and Trainers, in order to ensure effective Nursing training. To thiseffect all the five RRCs/SRs have been actively involved in organizing TOTs, at their institutes, on aregular basis. Once INC approves the dates and list of participants, the particular SR is independentlyresponsible for logistics (i.e. arrangement of the accommodation, food, local transport/travel, TrainingHall & material etc.) and technical planning (i.e. identifying and inviting the Resource persons,PLHIV representative etc.) for the TOT.
A brief report is submitted to INC and Futures Group and the relevant data is entered in the TMIS.
• Conducting Cross Learning/Refresher & Regional Workshops: In order to impart quality training tothe nurses, it is imperative that they are provided with the latest knowledge and facts regarding theHIV/AIDS care. Thus, the training materials need to be revised accordingly and the trainers beperiodically updated/reoriented towards the same; also it is important to share good practices andlessons among trainers to promote professional growth. To realize this goal, the respective RRCsconduct Cross Learning/Refresher and Regional workshops for them at least once a year. Though,the Resource Persons for these workshops,are the technical experts from INC, Futures Group andselect master trainers, each SSR is charge of planning and executing the logistic aspects of theseworkshops.
• Monitoring of Training of Nurses (TONs) at SSR Level: As the project entered phase II, the role of SRsexpanded to include providing the technical support to their respective SSRs i.e. supervise thequality of TONs, being conducted at various training institutes ,within their region at least once in aquarter. Therefore a quarterly Monitoring Calendar is prepared and uploaded on the TMIS by eachSR. The monitors include the Principal Coordinator, Trainers and the Training Coordinator of therespective SR.
The two day, direct onsite assessment, is done on the basis of a standardized Supervisory Checklist,which includes ,not only assessing the operational aspects (i.e. Training Hall facilities, GFATM staff &Trainers etc.) but also evaluating the efficacy of Training Programs(i. e. the quality of teaching bythe Trainers, in terms of content as well the laid down process e.g. conducting the role plays/Demonstrations/ Energizers etc.)
The other aspects of supervision are checking the maintenance of records, registers and documentsrelated to at least last two trainings; the quality of data and grading of Resource Persons, participatingin the program etc.
The monitors are expected, not only to observe all these aspects, but also provide on- site supportand trouble shoot, as and when needed. A constructive feedback is provided to the PrincipalCoordinator & Training Coordinator, both in person as well as through E mail, at the end of supervisoryvisit.
Once the visit is complete, the monitor submits a written report to the parent institute, INC andFutures Group.
• Financial Monitoring of SSRs : Another important responsibility, assigned to SRs, is the Financialmonitoring and support to their respective SSRs. At the inception of the project, their role waslimited to transferring of funds to SSRs for conducting the TONs. The SSRs, in turn, have to submittheir Statement of Expenditure (SOE) on monthly and quarterly basis.
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Gradually, however, the Finance Officers (FOs) of the SRs also started to plan and conduct theFinancial Monitoring visits to the various SSRs, under them, at least once in a quarter. The visits areneed based , routine or as directed by INC. The FOs have to take prior approval from INC, beforehandfor the same.
The purpose of this exercise is to ensure the proper expenditure, according to the budget guidelinesand the corresponding authentic documentation of the same, in the format, as prescribed by theproject finance guidelines.
The FOs are also responsible for trouble shooting and/or providing guidance to the SSRs, regardingthe finance issues, on an ongoing basis.
After the completion of the visit , the FOs submit the report (in the designated format),along withtheir observations to INC.
• Facilitation of rotation of Trainers: As RRC, the SRs also play the role of Facilitators to the SSRs, intheir region. One key area, requiring such intervention, is the appropriate rotation of trainers invarious TONs. For the effective utilization of the large pool of resource persons, the project mandatesthat all them get an equal chance to participate (both as internal & external) in the TONs, held, attheir parent/outside training institute.
Some of the other rationale, behind this guideline, is the equal distribution of teaching load, breakthe monotony or fatigue, prevent favoritism/ exchange of good teaching skills / practices amongthe GFATM faculty etc.
To this effect, each SR prepares and analyzes a quarterly calendar of Trainers, participating in TONs(both as internal as well as external ) to be held at various training institutes. On the basis of this,the SRs facilitate their distribution across various SSRs, in an equitable manner, TON wise.Documentation of reasons for over/under utilization of trainers, is also maintained and shared withINC and Futures Group. In the absence of any valid reasons, for non/erratic participation in the ToNs,INC takes the final decision, to phase them out from the project.
5.4 Summary of Monitoring of TONs conducted by SRs (March- September’11)
SRs No of Monitoring Visits
College of Nursing, CMC, Vellore 32
INE, Mumbai 20
RAK College of Nursing, New Delhi 9
Govt. College of Nursing, SSKM Hospital, Kolkata 11
College of Nursing, NEIGRIMS, Shillong 4
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5.5 Summary of Various Activities conducted by SRs
SR Training of Cross Refresher Refresher FinancialTrainers (TOTs) Learning TOTs Workshops Monitoring
Oct’10- Cumu- Oct’10- Cumu- Oct’10- Cumu- Oct’10- Cumu- Oct’10- Cumu-Sep’11 lative Sep’11 lative Sep’11 lative Sep’11 lative Sep’11 lative
(2009- (2009- (2009- (2009- (2009-11) 11) 11) 11) 11)
College of 1 9 0 1 4 4 4 4 1 5Nursing, CMC,Vellore
INE, Mumbai 1 2 0 1 2 2 0 0 8 8
RAK College 1 7 0 1 3 3 1 1 3 3of Nursing,New Delhi
Govt. College 1 7 0 1 3 3 1 1 3 4of Nursing,SSKM Hospital,Kolkata
College of 1 3 0 0 1 1 0 0 2 2Nursing,NEIGRIMS,Shillong
CBCI - - - - - - - 13 29(Administrative& Financial)
6. REVISION OF TRAINING CURRICULUM
6.1 Background
The GFATM 7 project on training the nurses on HIV/AIDS &ART (2008-2013) aims at enhancing theknowledge and skills of nurses so as to enable them to deliver an effective and comprehensive HIV/AIDS prevention, care, support and treatment.
There exists a critical gap, in nursing care, due to the absence of an appropriate curriculum to enhancethe knowledge, skills and attitude of the nurses which would help them to provide effective and stigmafree service, at the medical institutions, to the PLHIV and /or their families.
As a result, one of the key Service Delivery Area (SDA) of the project was to develop Training Curriculumin consultation with stakeholders – NACO, INC, SNCs (State Nursing Councils) and experts from the fieldof HIV/AIDS to incorporate core competence and best practices in the field of HIV/AIDS care.
A national workshop was held in the beginning of the project to arrive at a consensus on the content,methodology and for standardizing the curricula for nurses training to be adopted at the differentinstitutions for different levels. As a process of carrying out this activity, the Nursing pedagogy and
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materials available nationally was reviewed. A complete training package was, then, pre-tested inselect institutions and based on the feedback, changes were incorporated and the final copy was circulatedfor wider adoption to all the 55 institutions.
The final curriculum of the Facilitator-led program, consists of 15 units, focusing on HIV prevention,treatment, care and support, with emphasis on the role of nurses in each of these areas . Each unit hasclearly defined objectives and session plans which include
• Lecture• Case Studies• Role Plays• Large and small Group Discussions• Worksheets• Brainstorming sessions• Videos• Clinical site visit• Interface with a PLHIV representative
The Training materials have been divided into two sections- Facilitator’s Guide and Nurses’ Manual.
The Facilitator’s Guide is meant for Trainers and Facilitators. It contains, for each training session, adetailed session plan with information on the content of the session, materials required, and plan withinstructions on how to conduct the session in a logical manner. The guide also includes ready to usePowerPoint presentations and specific step by step session activities which need to be conducted withthe trainees.
The Nurses’ Manual, meant for the participants, provides detailed background information on each unitin the course, work sheets, case studies, and other activities complementing the information providedby the Facilitator / Trainer during the session presentations. The manual can also be used as a desktopreference guide by the nurses, during the course of their clinical practice.
Evaluation forms to assess the trainee’s knowledge levels before and after the training, the courseitself, and to identify daily challenges and lessons learned for trainers are included as part of thetraining material. The training package also includes a selection of Ice breakers and Energizers, Referralsites, and the Glossary of terms.
6.2 Rationale for revision of Training Curriculum
According to the Monitoring & Evaluation Plan of the project, at end of phase I (September’11), thetraining curriculum/modules were reviewed and revised by the experts and key Stakeholders toincorporate new /updated HIV care guidelines, protocols and theoretical content etc. This is alsorecommended by National AIDS Control Organization (NACO) in order to ensure standardized and qualitytraining of nurses.
6.3 The process of Revision of the Training Curriculum is as follows :
• Feedback from the trainers: Top 50 trainers, across all 5 zones were invited in the Regional CrossLearning Workshops, with the view to elicit their feedback and suggestions on the Training curriculum.The focus areas were
� Technical Contents of the Facilitators’ Guide� Restructuring of the slides and the sessions� Duration of various units
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� Suggestions for further improvement the training program
• Review by Core Committee: A review and in-depth discussion by the Core Committee members,was conducted on each of the Feedback and Suggestions, received from these Cross LearningWorkshops. At the end of two day meeting, the committee approved of certain criticalrecommendations provided by the trainers.
• Review by Experts from National AIDS Control Organization (NACO): In the next round, few expertsfrom NACO were invited to examine the recommendations of the Core Committee. Apart from thissome of the vital HIV treatment guidelines & protocols were also assessed and the relevant updatesregarding the same were incorporated in the curriculum.
• Orientation of the Master Trainers on the revised curriculum: Select Master Trainers, from all the 5zones, were oriented on the revisions and updates in the Training Curriculum in a 3 day RefresherWorkshop. The resource pool consisted of Core Committee members, Nursing Experts and expertsfrom Futures Group. All the revisions and their rationale were discussed slide/Unit wise and thesubsequent queries from the participants were also addressed.
• Refresher Trainings on the revised curriculum: As a follow up to this orientation, several Refreshertrainings were organized by the 5 SRs i.e. College of Nursing, CMC Vellore (South zone) ; Institute ofNursing Education, Mumbai (West zone); RAK College of Nursing, New Delhi ( North zone);WestBengal Govt. College of Nursing, SSKM Hospital, Kolkata (East zone) and NEIGRIMS, Shillong (NorthEast zone) for the their respective trainers .The Resource persons were the Master Trainers of therespective zones and the experts from Indian Nursing Council and Futures Group.
• Review by NACO Experts (II): A second round of review by the NACO experts took place to incorporatefew updates on the HIV prevalence; treatment guidelines; detailed explanation of certain technicalconcepts etc.
• Refresher Trainings on the revised curriculum (II): Subsequent to the second review by NACO experts,another round of Refresher trainings were organized by the 5 SRs, for their respective Master Trainersand Trainers. The technical experts from Indian Nursing Council and Futures Group and select MasterTrainers participated, as Resource persons, to facilitate the training of GFATM trainers on the latestcurriculum.
6.4 Proposed key Revisions in the Training Curriculum:
• Duration & Schedule : The duration of the training has been proposed to increase from the original5 day (Phase I) to 6 day. This was, mainly, due to the fact, that extensive up gradation, in the theoryas well as practical session (2 sets of Role Plays) of Unit 4- Counselling for PLHIV (known as HIV/AIDS Counselling &Testing, in Phase I), required at least 5 hours for its completion. As a result, thiswas rescheduled for the 5th day. Few other units, similarly, were also rescheduled and extended interms of duration & teaching content.
• Evaluation Forms (Pre & Post Test Questionnaire): Some of the questions/statements of the Pre/Post Test questionnaire were replaced with new set of questions. The no. of questions remainedsame i.e. 20
• Restructuring of the slides: Many of the slides in various units were rearranged and restructuredaccording to the training content.
• Technical Contents:
� Modification and editing of title of many of the units
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� Updated prevalence rates of HIV/STIs/MTCT/ Pediatric HIV infection etc.� Latest guidelines on ART (MTCT, Pediatric & Adult) ,HIV Testing ( both Pediatric & adult),DOTS etc.� Revised STI Flow Charts� Revised Annexures in terms of contents and topics� Detailed theoretical content on Baseline Nursing Assessment, HIV & Law, NACO Testing strategies,
Counselling, ICTCs/ LAC/ART Centres/ PPTCT &Pediatric HIV, Infection Control & PEP, STIs,Complementary Therapies, Palliative Care , Challenges Faced by Nurses etc.
� Inclusion of WHO/NACO/MOHFW approved videos on HIV Replication & Role of ART, Hand Washingand Personal Protective Equipment (PPE)
7. MONITORING & EVALUATION (M& E) AND TRAINING MANAGEMENTINFORMATION SYSTEM (TMIS)
7.1 Introduction
Monitoring is a regular, systematic process of measuring performance against benchmarks in program/project implementation while it is ongoing. Evaluation periodically assesses current versus desiredperformance standards and seeks to analyze the gaps, bottlenecks so as to improve further performancein similar or different contexts.
Monitoring and evaluation (M&E) are the cornerstones of the project, looks at standardized measures oftraining performance, results, verifies whether activities are being/have been implemented as plannedwithin specific timelines; ensures transparency and accountability; detects any shortfall and/or constraint;provides valid and timely feedback to the decision maker(s), other stakeholders for informed planningand decision-making, need based resource allocation; as well as documents, disseminates empiricalevidence on ‘lessons learned’, thereby improving training effectiveness and efficiency.
7.2 Components of M& E
• Monitoring of Training of Nurses (TONs)- by INC, Futures Group & SRs• Grading of SRs & SSRs• Grading of Trainers
The detailed description of process of each of these ,is as follows:
� Monitoring of Training of Nurses (TONs)
One of the significant component of M& E, is the regular,on –site direct observation of 2 dayssupervision of the training course, based on standardized Supervisory checklist to assess the qualityof training. The supervision is done by faculty of the SRs, Futures Group and the INC officials.
The purpose of supervision is NOT to find faults ,but to build in the concept of Quality Assurance, atthe national/sub national levels.
The standardized Supervisory Checklist, used by the supervisors, captures various parameters like:
• Training Hall Facilities/Staff• Resource Persons• Training Sessions• Administration & Finance, M&E/ TMIS & Miscellaneous.• Any Noteworthy Observation• Additional Observations, Suggestions & Onsite Support Provided.
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Based on the observations, during the supervisory visits, the Checklist has been upgraded to includeadditional parameters, to make it even more robust and comprehensive .E.g.
• Trainings being conducted according to the prescribed Training Schedule• Adequate no of units, being assigned to the Training Coordinator• Improvement Observed since the last visit• Comments on the performance of Trainers• Supervisor’s Grading on the above mentioned parameters (Out of 10)
In addition to the above, the monitoring also includes, checking the maintenance of records, registersand documents relating to at least two trainings conducted by that Institute prior to the currenttraining, analyzing various feedback forms used during the training. Undertaking random checks onthe quality of data as well as coordinate with the identified agency/evaluators for QA for datavalidation/verification.
� Grading of Performance by the Training Institutes (SRs & SSRs)
Grading system for performance, another aspect of M&E, was developed and shared with theinstitutions, for the first time, during the National Consensus Workshop, held at Kochi, Kerala, inFebruary ’10. It consists of grading of Institutes and the trainers, based on various qualitative as wellas quantitative indicators.
The qualitative indicators are from the Monitors’ feedback (i.e. Comments On the Trainers- as a partof Supervisory Checklist), whereas the Quantitative indicators considered for the ranking of theinstitute are more extensive.
Grading of Training Institutes (SRs & SSRs)
The qualitative indicators are as follows:
1. No. of Govt. hospitals nurses trained by the Institute2. No. of Participants, attending training programs3. Average % rise in Post Test score4. Satisfaction of participants from the feedback scores
Grading of SRs
Grading of SRs is done by taking into consideration the following Parameters
1. % of SSRs Monitored by the SR
This is the % of SSRs that the SR has monitored for TON from the total No. of functional SSRs.Thenthe score is reduced to max score of 10.
2. % Retrained
This is the percentage of trainers who were retrained from the number of trainers in that zone. Thenthe score is reduced to a max score of 10.
3. % SSRs Monitored By F O
This is the number SSRs that the Finance officer has visited. The score is then reduced to Max of 5
4. No. of SOEs submitted within time limit
5. No. of SOEs that had errors
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6. A score of (-1) was given to SRs who had received the Funds for refurbishment but not competedthe task.
7. A score of (-1) was also given to SRs not having GFATM staff throughout the year
The top three institutions for this year were :
Institute of Nursing education J J at Mumbai was judged to be the best SR.
Manipal College of Nursing was judged to be the best SSR followed by Govt. college of Nursing Ahmedabadand AFMC College of Nursing Pune, being in the runners up positions. Year 2011
� Grading of trainers- Percentage of Trainers, who score 65% & above
This has been added as a new indicator for phase II, based on the 360° evaluation of the trainers.
They are graded on the basis of feedback given
• By the participant• By the Training Coordinators• Observers from INC and Futures Group.
The maximum score a trainer can score is 10 points, of which 5 points are on participant’s feedbackgiven to the trainer after each unit and average of these scores for a trainer is considered.
Ranking by the participants (1 to 5 ) under the following headings
1 2 3 4 5
i) Content covered
ii) Trainer’s Knowledge of subject
iii) Trainer’s Delivery of teaching
iv) Trainer’s Response to questions
v) Conduct of interactive sessions
vi) Effective use of teaching materials (slides, videos, exercises)
vii) Time management
viii) Module met expectations
Comments (if any)
Ranking by the Training Coordinator (1 to 3), based on
• Communication skills• time management• proper use of the training materials• involvement of participants• response to the participants queries
1 point is reserved for any extra positive comment given by the participants/ Training Coordinator/Supervisory Visitors from INC or Futures group. In case there is a negative comment for a trainer 1 pointis deducted from his total score.
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1 point is awarded to the trainer if he/she is involved in taking different units in the trainings in thequarter (this shows that the trainer is well versed and comfortable to teach any unit)
During the last year, there were 65% of trainers, who scored a grading of 65% & above (n-397)
7.3 Training Management Information System (TMIS)
TMIS is intrinsic to M&E to generate efficient & reliable training data collection, aggregation, analysissolutions and vital reports related to training/capacity building of nurses under the Round 7 GFATMproject, using state of art technologies to support the M&E requirements of the project.
Futures Group supported TMIS , was formally launched by INC President, Mr. Dileep Kumar, during theNational Consensus Workshop, held at Kochi, in February’10.
7.4 TMIS- Phase I
It contains the various reports about the training program, such as:
• Details of all 55 institutes• Database of Nursing Experts, Zone wise Master trainers & Trainers including their contact details
and present work• Training calendar• Details of Health facilities from where the nurses have been invited for training• Database of Nurses trained, including their contact details & present posting• Summary of various Workshops
7.5 TMIS- Phase II
At the onset of phase II of the project, the TMIS was revised and upgraded to include:
• New Performance indicators of phase II
� Number of Training Institutes refurbished with infrastructure and equipment� Number of master trainers and trainers trained and re-trained to provide ongoing training
to nurses� Number of Trained Nurses provided with supportive supervision
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� Number of Nursing Superintendents invited for annual meeting for implementation of nursingtraining
� Percentage of trainers who attained performance rating of 65% and above� % of HIV positive patients who access ART services who report satisfaction with their service
experience
• Navigation Sheet for the Data Entry Operators
• TON Monitoring Calendar
• PDF version of the Newsletters
• SMS Gateway for easy communication with all the GFATM staff
All data into the MIS get entered by the designated data entry operators positioned in each of the 55institutes within a week after completion of the training. In addition, a centrally positioned “Help desk”is available to support data management and data analysis.
8. MIDLINE ASSESSMENT
8.1 Rationale
Patient satisfaction has recently emerged as an important measure of the quality of health care delivery,right alongside the more traditional health status measurements and quality of life indicators. This isbased largely on the discovery that patients with higher satisfaction levels often make importantbehavioral changes, including:
• Maintaining more stable relationships with health care providers.• Complying more closely with medical advice and treatment.
Patients with higher satisfaction levels may also have improved health outcomes.
Measuring patient satisfaction helps:
• Strengthen communication and build relations with patients.• Assess the strengths and weaknesses of the ART centers from the patients’ perspective.• Bring focus to quality improvement efforts.
Taken together, these outcomes represent key opportunities to make and monitor the changes requiredto achieve some important goals: improving patient satisfaction and improving care overall.
The assessment is conceptualized to generate midline data for the indicator—‘Percent HIV positivepatients who access ART services who report satisfaction with their service experience’ in the performanceframework of the aforementioned GFATM Round 7 project. The premise for the midline assessment isanchored on the fact that it will provide evidence/ measure changes in the patient satisfaction againstthe baseline data (Baseline survey was conducted in Feb, March and April 2011). There are manyevidences indicating that as the services improve, more patients access the available services henceimproved uptake of/ adherence to prevention and treatment, ultimately impacting on the diseaseburden. As a part of one of the core Performance Indicators- “% of HIV positive patients who access ARTservices who report satisfaction with their service experience”, a Mid line Assessment was conductedseparately for trained nurses and PLHIV, in February to April 2011.
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8.2 Process
Sample :
This assessment included 20 districts selected at to cover all the 5 zones, high prevalent districts and alllevels of health care. The distribution of districts according to the zones is as under:
• North Zone (3) – Delhi, Punjab & UP• West (4) – Maharashtra (2), Gujarat & Madhya Pradesh• South (7) – Andhra (2), Karnataka, Kerala, Pondicherry & Tamil Nadu (2)• East (3) – West Bengal, Orissa & Chhattisgarh• North East (3) – Assam, Manipur & Mizoram
In each district, a random sample of 20 PLHIV from each of the ART Centre, at the Tertiary health facilitywere approached and offered enrolment if aged 18 or older This included 2-3 HIV positive pregnantwomen and who have accessed PPTCT services in the hospitals. Total of 432 PLHIVs including 18 HIVpositive pregnant women were interviewed.
Data Collection Tool
A Semi – structured questionnaire , consisting of sections on demographic details, services availed,satisfaction grading for the services availed, behavior of the nursing staff and health education, andservices at PPCTC facilities was administered by these students. The satisfaction level of the servicesavailed at the ART centers by the PLHIV was measured using 5 point Likert scale ranging from verydissatisfied with a score of 1 to very satisfied with a score of 5. Validity of the questionnaire was verifiedthrough content validity. A higher score indicates greater satisfaction.
Although the survey questionnaire was printed in English, the interview was conducted in vernacularlanguage for convenience and understanding of the respondents. All the forms have date, site andname of the interviewer.
Data Collection
M. Sc nursing students from Nursing Colleges, based in these districts were trained to conduct theassessment under the leadership of the principals of the respective colleges. For the purpose of thesurvey the PLHIV will be requested to provide feedback on services rendered by the (GFATM) trainednurses. Approximately 20 minutes were required for each interview.
A team supervisor supervised the interviews. Futures’ Group staff supervised a random 5% of theinterviews. The nursing colleges were responsible for collecting the duly checked questionnaire andthen sending them to Futures Group to be entered into the database
8.3 Findings
Following are some of the findings of the survey-
• Scores on correct knowledge about HIV/AIDS prevention, care and treatment was 76%• It ranged from 86% about understanding symptoms and signs to 58% on knowledge about
needle stick injury management.• Correct practices on Barrier nursing, maintaining confidentiality, education of patient among
other things• Attitude of nurses was positive towards PLHIV• Fear of getting HIV infected decreased, with more exposure to PLHIV• Isolation and labeling of PLHIVs were being contributed in certain instances• 58% of PLHIV survey expressed satisfaction with overall services provided
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• 90% felt the nurses’ behavior during care to be appropriate• 95% were satisfied with health education being provided by the nurses• 97% expressed their willingness and desire to come back to the same center for services being
provided by the nurses
9. SENSITIZATION OF THE NURSING SUPERINTENDENTS ON GFATM PROJECT
9.1 Nursing Superintendents & their role in HIV/AIDS Care
Nursing Superintendents are the one of the key stakeholders under the project as they are :
• responsible for deputation of nurses for the training programs• responsible for the deputation/posting the GFATM trained nurses, at the strategic clinical areas
(e.g. Labor Room, Skin OPD, ART Centre etc.) where they are most likely to be able to utilizetheir training
• responsible for facilitating the adequate availability of the Infection Control materials and supervisetheir effective management
• Facilitator for the effective implementation of the newly acquired HIV management skills, duringthe training program
• Internal Coordinator for successful execution of Supportive Supervision, for the trained nurses,attheir Health facility
9.2. Need for sensitizing the Nursing Superintendents on GFATM 7 project:
Keeping in view, the significant role of the Nursing Superintendents, towards the realization of theproject objectives, it has been decided to orient them, also, on critical issues on HIV/AIDS management.The Nursing Superintendents, on the other hand, motivated by the, evidence based, success of thetraining program, have themselves expressed a keen desire, to be a part of the same.
Since being at the senior administrative position, it is not feasible or desirable , for them to participatein the regular Training program for the staff nurses. Therefore a One day sensitization workshop,specifically, tailored to suit their needs, have been chalked out.
9.3. Focus Areas
The relevant topics covered for the one day sensitization workshops are:
• HIV/AIDS Update• National AIDS Control Program (NACP) III• Update of GFATM 7 project• Infection Control Practices• Supportive Supervision• Update on the state level HIV/AIDS scenario
The resource persons for these workshops are the officials from the SACSs, Experts from INC and FuturesGroup.
The first one day orientation workshop for Nursing Superintendents of various hospitals of Rajasthanwas organized by Rajasthan University of Health Sciences, Jaipur on the 26th February2011. A total of50 superintendents from different districts participated in this program.
Subsequently, College of Nursing, RIMS Ranchi organized one day workshop for the NursingSuperintendents of Jharkhand state on 15th May’10. The total no. of participants were 39.
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10. NEW INITIATIVES
10.1 Supportive supervision
• Background
Under GFATM 7 project, the need for Supportive Supervision is envisaged due to the uniqueness of theconcept & training content; sustaining soft skills like Counseling, that requires ongoing practice & guidanceand harnessing/sustaining the goodwill generated towards PLHIV. The training not only aims at buildingup the skills and knowledge base to care, support and treat HIV infected patients but also emphasizeson their actual transfer to the clinical settings. Supportive Supervision, of the trained nurses, provides anexcellent opportunity to supervise and reinforce these newly acquired skills , till they are internalizedand become an integral part of the quality care, provided to PLHIV, especially in crucial clinical sites like,OT, Labor Room, ART Centers etc.
It will also go a long way to maximize Nurses’ potential, sustain the acquired knowledge & skills,improve performance, motivate and build their self-confidence.
As one of the vital Performance Indicator, pilot phase of Supportive Supervision was initiated in thesecond phase of the GFATM project, in select Tertiary, District & Primary Health facilities, which hadGFATM trained nurses.
Supportive Supervision plan is the first ever large scale initiative for Nurses in India.
• What is Supportive Supervision?
Supportive Supervision is “monitoring, guidance and feedback on professional & educational matters topromote enhanced patient care. It deals with technical issues e.g. skills & knowledge. It is aimed atmotivating & supporting Health Care Providers to improve their work performance.”
“Supportive Supervision is a process that promotes quality at all levels of the health system bystrengthening relationships within the system, focusing on the identification and resolution of problems,and helping to optimize the allocation of resources”. Marquez & Keane, 2002
It is a key element in continuing education. It focuses on problem solving on the spot with the jointparticipation of the supervisee and supervisor.
Supportive Supervision in a nutshell combines three elements:
1. Impact
Supportive supervision supervises the knowledge, skill and aptitude of the GFATM trained nurses inthe Hospital Settings, It Is a Follow-Up on the Six Day GFATM Training Of Nurses.
2. Support
The Supervisors fill in any gap/problem/difficulty faced by the GFATM trained nurses in their careand treatment of PLHIV patients on the spot. Also they update them on any new technical guidelines/practices that are introduced from time to time.
3. Motivate
Sustain the motivation of high achievers and provide them further encouragement to realize theirtargets.
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• Supportive Supervision v/s Traditional Supervision
Supportive Supervision is different from Traditional Supervision which focuses on inspection and faultfinding rather than on problem solving to improve performance. Health workers often receive littleguidance on how to improve their performance; they are frequently left undirected with few or notargets to help assess their performance until the next supervisory visit. Motivation is hard to maintainin such an atmosphere.
On the other hand, Supportive Supervision works with health staff to establish goals, monitorsperformance, identifies and corrects problems thereby improve the quality of health service.
Together, the supervisor and health workers identify and address weaknesses on the spot, thus preventingpoor practices from becoming routine. Supervisory visits are also an opportunity to recognize goodpractices and help health workers to maintain their high-level of performance.
• Implementation of the Supportive Supervision plan
� Team:
All 55 Training institutes are the partners in implementing Supportive supervision process. The teamwould consist of Principal Coordinator, responsible for the implementation of the process, TrainingCoordinator, Supervisor as well as Coordinator and Trainers from the academic faculty; NursingSuperintendents/ Matrons/ Ward-in-charges to be the local coordinators, at the Health facilities.
� Process:
� Based on the availability of the trainers and the targets, Training Coordinator makes a plan forthe dates and health facilities to be covered, in a particular quarter. After the approval of thePrincipal Coordinator, the dates are uploaded on the Supportive Supervision calendar on TMIS.
� The Training Coordinator, coordinates with NS/Matron, at least 2-3 weeks, regarding the availabilityof the trained nurses, during the proposed visit
� The proposed Health facilities are the Tertiary hospitals (with ART Centre)/District Hospital(s)/CHCs/PHCs and Private Hospitals
� The main clinical sites, where the nurses are supervised, are Medical, Surgical Wards & OPDs/Obstetrics & Gynae Ward & OPD/Labor Room/ Operation Theatre/ART Center etc.
� Each visit involves a batch of 2 Supervisors for is for 2days; Each supervisor is expected tosupervise 5-7 nurses, across various clinical sites
� Supervisors follow a standardized Checklist (along with a Question Bank) , which is designed tofocus on the 5 Assessment components:
� Knowledge base� Clinical Skills� Interpersonal & Communication Skills� Infection Control Practices� Non Discriminatory Practices
� Following methods are followed to supervise the above mentioned Assessment components:
� Observation� Direct Questioning (Supervisory checklist)� Demonstration� Checking the patients’ record/medical file etc.
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� Once the assessment is complete, a brief remedial session is conducted, focusing on the weakskills (while highlighting the strong ones also)
� The same is discussed with the NS/Head of the facility; their comments,along with theirsignatures, are procured
� A brief report is submitted to INC/Futures Group, the respective SR and the health institutesupervised, consisting of:
� No. Of Nurses supervised� Clinical areas visited� Knowledge base & Skills Guidance/reorientation provided� Corrective measures taken
The data is also uploaded on the TMIS
• Pilot Phase of Supportive Supervision
The pilot phase of Supportive Supervision was initiated in May 2011 in the North and East Zone SRs,i.e. RAKCON , New Delhi and WBGCON,SSKM Hospital, Kolkata respectively.
The process was observed and supervised by the consultants of the Futures Group.
Process
Dates Dates
31st May & 15th June’11 26th-31st May’11
Health Facilities Health facilitiesTertiary Health Facilities Tertiary Health Facility• Safdarjung Hospital • SSKM Hospital• Ram Manohar Lohia Hospital District Health Facilities
• Howrah District Hospital• Gabberia State General Hospital• Uluberia Sub divisional HospitalPrimary Health Facility• BHPC, Jagdishpur
Clinical Sites Covered Clinical Sites Covered• Medical Ward • Medical Wards• Surgical ward • Surgical Ward• Operation Theatre • Operation Theatre (Haematology)• OPDs (STI, Gynae) • Intensive Therapy Unit• Casualty • Labor Room• ART Centre • OPDs (Post Partum Unit)
• Casualty
Total No. of Nurses Supervised Total No. Of Nurses Supervised14 40
No. of Supervisors No. Of Supervisors3 5
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FEEDBACK BY SRs
RAK College of Nursing, New Delhi WB Government College of Nursing, Kolkata
Time Duration Time Duration2 days 2-3 Days
Involvement of Nursing Superintendent/ Involvement of Nursing Superintendent/Nursing Staff Nursing staffUncooperative (in one hospital)/Reluctant but Cooperativelater cooperative
Checklists ChecklistsWere found to be comprehensive & effective OK
Finances FinancesThe supervisors felt there was a need for OKfinances to be shared among NS/DNS/ANSto ensure cooperation
Coordination/Cooperation by authorities Coordination/Cooperation by authoritiesNS/DNS/Nurses uncooperative in one hospital; Initially reluctant but cooperated andViewed the exercise as Intrusion; Unrelated to appreciated later ontheir job responsibilities
Other Issues
• Staff reluctant to demonstrate procedures • Infection Control Practices were observed to(in one case). Most nurses were happy to be not followed according to the norms-meet the supervisors and talk to them. Nurses wearing hand accessories/Waste
• Preparation of Bleaching solution done by bins not properly maintained/No supervisionGroup ‘D’ staff and Nurses do not consider for the Group ‘D’ staff while preparing theit within their responsibility to instruct/ Bleaching solution etc.supervise them. As a result, they do not • Wards over crowded; Nurses over loaded;really check whether it has been prepared Severe lack of Resourcesaccording to prescribed percentage or • Scoring could not done according to formatwhether it should be changed if the as the observations were individualized andcontainer is full of used syringes. not uniform
• Roll out of Supportive Supervision at the National Level
The suggestions &recommendations of the Supervisors and Observers of Futures Group were discussed,at length, during the Core Committee Meeting and the process of supervision was further revised.
The revised plan was rolled out in the North zone, during the Refresher Workshop, organized by RAKCON,New Delhi, in August’11.
Till September’11, 10 training institutes, across all the zones have initiated the Supportive Supervision,in the Health facilities, in their assigned districts. There have been a positive and encouraging response,both from the Nursing Superintendents and the nurses. Many of them have shared, this initiative, tohave a motivating effect and have helped them, to further sharpen their HIV Care skills.
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Zone Training Institutes No of Nurses Supervised
North RAK CON,New Delhi 2
CON,BHU, Varanasi 14
CON,CMC, Ludhiana 39
CON,LHMC 18
CON, Kanpur 4
North East Naga Hospital. Kohima 14
South CON, CMC, Vellore 3
CON, Manipal 22
CON, Anantpur 42
CON,Kadapa 18
Total 176
10.2 ANM trainings on HIV/AIDS
Under the Global Fund Round 7 project, one of the mandates is to train the Auxiliary Nurse Midwifepositioned in the Facility integrated ICTCs (FICTCs). These are mostly located in 24x7 PHCs. A total of4071 ANMs in these facilities need to be trained within this project. The target is 2000 by end of Marchand 2000 in the next quarter.
At present NACO is training these ANMs under a 5 day program being conducted by SACS. However, theANMs are finding it difficult to participate in any program for 5 days. NACO is keen that a new curriculumwhich is concise and covered within 2-3 days.
The new curriculum is being developed based on the existing ANM training module developed byNACO.
This will include topics relevant to the working of the ANM in these facilities and focus on :
• Basic Information on HIV/AIDS, including disease progression, diagnosis and ART• Prevention of HIV transmission• Counselling on Treatment adherence• PPTCT and EID• Infection Control• Positive Living• Stigma & Discrimination• Record keeping and reporting
The training materials will be translated in local languages.
The training will be for 2 and half days and will be conducted by ANM school trainers. These trainers willbe locally identified and trained by Trainers from the existing Trainers’ pool of the GFATM project. Thetrainings will be conducted in select SR/SSRs.
11. FINANCIAL UPDATES
The INC has developed comprehensive financial guidelines for the implementation and monitoring ofthe GFATM project. INC provides budget allocations and actionable targets and expected deliverables
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before the beginning of each quarter in respect of each Regional Resource Centre (SR) and in respect ofeach Nursing Training Institution (SSR). The quarterly budget and actionable targets are being conveyedto each Sub Recipient (for the Sub recipient and also for the Sub-sub Recipients) before the beginning ofthe quarter. Each Implementing Agency, viz. the Regional Resource Centres (Sub-Recipients) and theNursing Training Institution (Sub-sub Recipients) prepare a quarterly action plan indicating, inter-alia,the physical targets and budgetary estimates in accordance with the approved budgetary allocation byINC as per pattern of assistance under the Programme covering all aspects of the project activities forthe quarter.
The implementing agencies ensure that there are no deviations from the budget allocations and/ oractionable targets and expected deliverables provided by the INC while preparing the quarterly actionplans. Should there be any need for a deviation for any reason; prior approval is to be obtained from INCbefore including any deviation in the annual action plans.
As part of periodical reporting mechanism for financial management and project management and forsubmission of financial and programmatic information to Global Fund through the quarterly ‘PerformanceUpdate and Disbursement Request’, all SRs and all SSRs are required to submit quarterly financial andprogrammatic reports to Indian Nursing Council. The Sub-sub Recipients are required to submit thesereports to their Sub Recipients (with a copy to INC), who will consolidate the reports at the Regionallevel and submit the same to Indian Nursing Council. The quarterly reports are to reach INC by 8th of themonths after the end of the quarter. The SOE in Report III (programmatic and financial information ontrainings) is to be submitted immediately after the conclusion of each training program.
Summary of Expenditure from October 2010 to September 2011
Comparative position of budget allocation and expenditure incurred up to 30th September 2011 was asunder:
Implemeting Agency Budget allocation Million USD Expenditure Million USD
Indian Nursing council 0.47 0.42(Principal Recipient)
Disbursement to Sub recipients 5.87 3.74
Total 6.34 4.16
Variation from budget allocation ismainly on account of purchase ofequipment after September 2009and training of more local in-service nurses entailing lessexpenditure on travel andaccommodation. There was alsodelay in appointment of staff insome Institutions.