TABLE 4

Top Ten Subthemes for Lessons Learned From HBS Trainers

Themes and SubthemesDefinitions and ExamplesSelected Quotesa
SupportCategory definition: broadly, any effort intended to facilitate the successful implementation and adherence to the planned (or newly introduced) HBS project.
 Local contactsConnecting with local providers, MOH officials, and others necessary to introduce and nurture HBS in-country.“Do an assessment before you go to teach. Work on developing a strong in-country partnership in order to create a sustainable program.”
“Must identify a local champion prior to the training…after [the training] must continue to communicate with the local champion…local champions can gather data, share with trainers.”
“Trained 6 Master Trainers on day one and two. Then, those trainers taught with us for 8 days, teaching 36 providers each day…The Master Trainers truly understood the working of the program and… have gone on to continue teaching since then.”
Mentor new trainers in putting on a course or training others before your team leaving the area or country.
“It’s vital to have the in-country Hospital administration, MOH and key players buy off on the training. We have been going for five years and are well known and have MOU with the hospital at the training clinic we built, but it took a long time.”
 CommunicationPre-planning discussions; dialogues with in-country partners; post-training follow-up and other methods of communicative support (coaching, supportive supervision, etc).“After the training there needs to be a plan in place as to how the participants will practice skills. This can be through the use of a skills corner that is equipped, where health care workers practice at the beginning of each shift.”
“It is difficult to sustain HBB skills over time, and continued refresher trainings are needed.”
“Return again and again to continue to mentor. Let them contact you with questions and stories of successes. Help them set up QI systems and check to be sure they are continuing to use the systems. Check in with those in charge of QI and hold them accountable.”
“Provide training materials way in advance.” Give participants the provider guide at least 2 to 3 days in advance to study.
HBB Champions wear a different color scrubs “and are known as the HBB teachers.”
 Hands-on practiceProviding opportunities to use equipment (NeoNatalie, ventilator, flip chart pages, etc) and peer-to-peer learning for mentorship in how to train others.“Summarize what was learned with a ball of yarn. Stand in a circle and ask each learner to say one thing they learned or that they will do differently, then toss the ball to another, etc. At the end, the string formed a ‘spider web’ and we put the manikin on it to show how we could now “support” the baby with our new knowledge.”
“Train and re-train and leave a baby (Neonatalie) where health care providers can practice between deliveries etc”
“Then we have 5 active resuscitations with the staff in the labor ward, real live, before they are deemed competent.” Teaching at the bedside and in labor ward.
Local contextConstruct definition: any of the qualities or characteristics of the local environment that can influence training and sustainability.
 Demonstrate successIllustrating utility of HBS, “winning over” skeptical stakeholders, successful resuscitation by participants and providers after training.“Go for it! Engage your students by telling stories of your experiences and encouraging them to tell stories of theirs.”
“It was also helpful to have non-clinical participants who had leadership roles in the health care center/hospital to understand what the course was about and how important it is.”
“Create benchmarks for institutions to determine when they’ve integrated the skills into their protocols effectively. We saw a dramatic reduction in newborn death, but it took about two years.”
At each table, consider “having two instructors (one experienced mentor, one newer teacher)” - builds the capacity of facilitators while building capacity in the learners as well.
 LanguageIssues related to language barriers, interpretation, literacy, etc.“Allow yourself enough time to go through the material slowly. Some participants may not have any experience, English is their second language and need you to speak slowly to understand, or you may need to use an interpreter.”
“We didn’t know most of our audience was illiterate and spoke a native language (not Spanish) …We didn’t know our students wouldn’t be able to read/write.”
 Gaps in care or practiceDeficiencies in knowledge or applied practices with regard to providing care or implementing and sustaining change.“Afterwards, the trainers must debrief the course and review participant evaluations.”
“Know your audience. I always want to know what they don’t have so I can work with what they do have. Understand they will not be able to perform as if they work in a US hospital. It will be different, but they have the talent and desire to do a good job for their patients. Help them figure out the work-arounds. Give them the gift of confidence that comes with knowledge. Love them.”
Training midwives, nurses, and physicians helps to break down barriers, create bridges between roles.
“Understand ethnic conflict in your area and common biases.”
“Don’t assume what you teach in a classroom will translate into active ward care.”
PlanningConstruct definition: the purposeful efforts to address the fundamental steps in implementing an HBS program. This includes the development of timelines, securing resources, making necessary connections, and overseeing the program from concept to training and sustainability or follow-up. Anything related to preparing for the introduction and perpetuation of an HBS program.
 TimeThe amount of time needed to procure resources, provide adequate attention to providers, or achieve buy-in from key stakeholders. The component always underestimated by well-intended HBS trainers.“More time. There is never quite enough time. Making them come back a separate day is almost impossible in most venues.”
“Doing the course over two days to have more time to practice.”
“Give yourself grace and schedule a follow-up session for what is left incomplete.”
“Consider a stipend for participants, especially those travelling from a great distance, to offset that cost.”
“Determine beforehand what time the course must end for participants to be safe travelling home.”
 UnexpectedThe myriad challenges of implementing a project in low-resource environments. Examples: differentials in punctuality, higher than anticipated number of participants, inadequate training space, providers being called away for work duties.“I had been told by funding organization I would be teaching ECSB but when I arrived, local organizers had been told I was to teach ECEB. I had not been given any materials for ECEB, but because I knew the course well, I did teach it. It was an unpleasant surprise, but knowing the coursework well saved the day.”
“We had miscommunication regarding it being a 2-day program and we had to cram in one day. We concentrated on the keeping the baby warm and delayed cord cutting and how that applied directly to their practice.”
“Difficulty downloading the HBB resuscitation video that is so impactful. I was not prepared for how weak the Internet access was in a city of 70 000 people. This would have been completely avoided if we would have downloaded it in the states prior to take-off.”
The doctors had to go and cover the wards during breaks and lunch, so “we allocated one trainer to catch them up if they missed any of the training.”
 AdaptingFlexibility, creative solutions, and other actions necessary to address unexpected challenges in the planning, implementation, and sustaining of HBS programs.“Plan, plan, plan, and then plan some more. Anticipating every possible struggle or complication is what helped my team survive. Having team members with critical thinking skills is a MUST.”
“I was still surprised by HOW resource poor some places were: no running water, no electricity, no cord clamps or ties, etc. Talking with people about what they do and what they do have available was critical, and then catering training to use what they can access.”
Being “willing to change table [assignments] if it became apparent that a participant was struggling once the course had started.”
“Smaller numbers and more frequent courses” meant “more time for practicing and more focused support from the trainers.”
 EquipmentAny supplies or materials necessary for implementation of HBS program and its subsequent sustainability. Examples: NeoNatalie, resuscitation equipment, printed learning materials, other necessary items.“Continual hospital renovations that interrupted training and ability to localize/maintain training and clinical supplies.”
“Host country did not have enough equipment for program to be sustainable in rural outlying health care centers.”
“Provide posters, [workbooks], NeoNatalies to leave in country”
“Learners will not be able to sustain the program if they have 5 bag/masks in the entire hospital.”
There is a tendency to try and teach 10 or even 20 learners with just one NeoNatalie because the skills are so sought after. One trainer eliminated this barrier by “scheduling different times for each pair to practice with the mannequin.”
  • a A few quotes were paraphrased for length or clarity.