Assumptions, barriers and lessons: Establishing a locally led training course at Nanyuki District Hospital

“We trained trainers…then for a long time, nothing seemed to happen”: lessons learned on

the road to establishing a locally led training course at Nanyuki District Hospital, Kenya.

In 2012 the South Devon Healthcare NHS Foundation Trust – Nanyuki District Hospital, Kenya health partnership received a Large Paired Institutional Partnership (LPIP) grant from the DFID funded Health Partnership Scheme for a three year project to improve the management of trauma patients at Nanyuki District Hospital. Given the longstanding relationship between the South Devon and Nanyuki partners, the South Devon team felt they had a good understanding of Nanyuki Hospital and their capacity development needs; staff were trained in primary trauma management, orthopaedic surgery, and GRASPIT, which aims to improve patient safety on the wards by training multidisciplinary staff in better recognition and assessment of sick patients.  Crucially, the GRASPIT course includes a training of trainers component that aims to create locally led, ongoing GRASPIT training. The course content was reviewed by Kenyan clinicians to assess its relevance for Kenya and it was accredited by the National Resuscitation Council of Kenya.

As the project progressed, it became clear to the UK team that locally led GRASPIT was not happening as planned: “We trained trainers. We observed them training other staff [during the training visits]…It all went fine; we had no idea it wasn’t fine. Then for a long time, I don’t think anything happened.” (Kerri Jones, Improvement and Partnership Lead).

This case study explores the reasons why the partnership was not initially able to establish locally led GRASPIT training at Nanyuki District Hospital and the lessons that the partnership learned along the way. (In another part of the GRASPIT story, Kenyatta National Hospital has become Kenya’s centre of GRASPIT training, home to 22 experienced “Master Trainers” who have trained over 1,100 health workers in the hospital and more across the country. For more information on the GRASPIT course see www.graspitkenya.com .

The frank accounts of Kerri Jones, Ellie Gregory, a long term volunteer from the UK, and Timothy Panga, Chief Officer for Health for the county government of Laikipia, were gathered by semi-structured interview, conducted over Skype and face-to-face, April to May 2016. This account nonetheless presents mainly a UK perspective, reflecting both the greater ease of the writers in speaking to the UK partner, and the more significant change in the UK partner’s understanding of the partnership work.

Analysing the interviews, four key themes were identified: stakeholder engagement, importance of monitoring and evaluation, the need to address assumptions and the qualities of a good partnership. These themes will be described in the following sections.

It took time for the South Devon team to understand the cultural and practical barriers to people attending training and continuing to deliver training. For the Nanyuki staff who were interested in becoming a trainer, their individual working patterns and responsibilities prevented them from doing so:

“…we hadn’t checked out at all what was realistic. I think people’s work patterns make it quite hard…one of the more enthusiastic of the trainers is a clinical officer in anaesthetics… his work pattern is that he works a week of days – in theatre all the time – a week of nights and then he’s away for a week.  So when do you fit the training in?” (Kerri Jones).

Other reasons for the lack of locally led GRASPIT training were surfacing which pointed to hospital hierarchies and their influence on individual’s engagement with GRASPIT:

“Once we began to understand people’s pre-existing commitments, roles in the hospital and realistic availability, we were much more able to select [training] committee members who would be in a position to push things forward.” (Ellie Gregory, long term volunteer)

Nanyuki Hospital had a committee responsible for health worker training, and the partnership was keen to engage with it, but this turned out not to be straightforward. Training responsibilities, as an approach to empowering staff, is common in the NHS but it was met with significant push back in the Nanyuki context. Ellie continues:

“Initially we focused heavily on the involvement of clinical officer interns, since they often had more time than nursing or medical staff.  However we had overlooked their junior position in the hierarchy of the hospital and the fact that a training session run by a clinical officer intern was unlikely to get much respect from a senior nurse or medical officer.”

Why was it then that the partnership had not anticipated these barriers before they began implementing training of trainers?  To understand this, we need to look at the partnership’s approach to assessing need at Nanyuki Hospital and how they kept track of their progress in developing locally led training.

Project stakeholders are all those implicated, not just those with the authority to give the go ahead

The partnership’s process of developing and implementing the course was quite informal. In designing the LPIP, the South Devon team liaised with the most senior staff at Nanyuki – the medical superintendent and the hospital lead for nursing – and understandably the offer of training to improve patient care was met with much enthusiasm.  While the South Devon team proceeded to discuss the training concept with clinical staff at Nanyuki Hospital, in hindsight these stakeholders should have had a more central role in the development of the course from the outset.  The South Devon team assumed that this enthusiasm from senior staff and a handful of stakeholders would be translated into action further down the line

It’s all very well discussing ideas with the senior management, but actually drumming up enthusiasm from busy ward staff to take part and be trainers is a whole different ball game.” (Ellie Gregory)

This experience underlines the importance of doing a thorough stakeholder analysis and consultation to get as rich an insight as possible into the context for implementation.  A more wide ranging stakeholder consultation at project design phase would have revealed more of the potential barriers to progress, helping the partnership to determine the feasibility of its plans.

The value of regular monitoring, evaluation, and learning

Volunteers from South Devon visited Nanyuki on short term visits, during which they delivered further training in GRASPIT and other partnership activities. For some time it was reasonable to think that the project was going to plan: participants were available; the training was well received; and there was appetite for training. However, the partnership did not have a monitoring and evaluation plan in place that carved out time for adequate review and. This meant that the lack of local training came to light late in the project. “When we looked back and we realised that it [GRASPIT training] wasn’t happening outside of the project activities…it was really quite disheartening.” (Ellie Gregory).

The realisation about GRASPIT prompted further evaluation of other areas of the project such as the surgical and emergency department strands to assess the sustainability of those too.  Although some of their findings were disheartening, the partnership benefitted immensely from this process of questioning and understanding what had actually been achieved, as Ellie Gregory explains:

“When setting up an orthopaedic project in a new hospital we tried to learn lessons from the data we hadn’t collected in Nanyuki. We began with a week of data collection, most importantly we asked staff ‘what do you want from an orthopaedic project and what do you need?’ Identifying these as two different things.”

Evaluation is an opportunity for joint reflection and review of the partnership’s objectives, as South Devon – Nanyuki learned and in this vein Timothy Panga, Chief Officer for Health in Laikipia County, has advice for other health partnerships: “Be flexible when objectives change along the way so long as there is a sound basis for the change of objectives.”  For the South Devon – Nanyuki partnership, their learning led them from emergency care and orthopaedic projects to a stronger focus on patient safety.

Use evaluation findings to improve your approach

The partnership really used the data coming out of the LPIP project to improve their approach to the next phase of their work, rolling GRASPIT out to other hospitals in Laikipia County:

“GRASPIT changed its design as a result of the work in Nanyuki.  This began with developing a training needs assessment, putting the focus on not making assumptions and ensuring early course discussion with a variety of stakeholders…Most importantly, after presenting the course history and outline to the stakeholders we would stand back and ask, ‘are you interested?’” (Ellie Gregory).

Since 2015, GRASPIT training has been rolled out to four further healthcare institutions in Kenya by South Devon NHS Foundation Trust and their new partner the National Resuscitation Council of Kenya (NRCK). Central to this project is the collection of data that will help them to identify the critical factors for the successful introduction of a locally delivered GRASPIT course.

The partnership reports that Nanyuki District Hospital and Nyahururu District Hospital (an training additional site) have “spontaneously recommenced GRASPIT after dormant periods”, which is a very positive outcome although the reasons for this are still being explored.

So far, we have learned that gaps in the partnership’s needs assessment meant that the barriers to having locally led GRASPIT were not thorough considered before implementation, and the lack of regular monitoring and evaluation meant they came to light late in the project.  Now we look at some of the reasons why these processes were not given sufficient attention.

Attitudes towards being a trainer may differ between partners

The GRASPIT course was very well received by staff at Nanyuki Hospital, as reported by the partnership.  The crucial objective with GRASPIT was to hand the training over to local trainers so it continued independent of any UK volunteers’ involvement.  Yet without doing an inclusive consultation with Nanyuki staff, the South Devon team were designing the project with an assumption that Nanyuki staff viewed the opportunity to become a trainer in the same way as UK NHS staff. The view that being a trainer is good for professional development forms a large part of the motivation for UK staff to embrace opportunities of this nature:

We assumed that people would have similar attitudes to the UK with regard to being part of the faculty” (Ellie Gregory).

The partnership was correct in thinking that there would be much interest from Nanyuki staff to attend the courses, as attendance and motivation were high.

Where this assumption fell short was that the new trainers would continue to deliver GRASPIT without UK involvement:

The next assumption was that people would be interested to become trainers…But in Kenya it was completely different and actually it was quite a burden to expect people to come away from the workplace and deliver training…” (Ellie Gregory).

Later experience showed that when senior management are committed and give staff the time to do training, staff are keen to join the cohort of trainers, spreading the burden of training more widely.

Understand staff’s existing training obligations

The team from South Devon made an assumption about who had overall responsibility for training at Nanyuki Hospital and it was some time before they learned that responsibility was officially held by one of the consultants.  Although they were not offered this information by their partner, they still felt that they had “…failed to find out where overall responsibility lay; we were just talking to the medical superintendent…” (Kerri Jones). Given the lack of prominence of this individual it seems unlikely that if they had consulted with the training lead they would have had more success in embedding GRASPIT but a discussion with the consultant responsible for training would at least have given them some context and helped the UK team see how GRASPIT could fit within the wider training environment at Nanyuki Hospital.

GRASPIT was just one of multiple trauma pathway trainings that the South Devon – Nanyuki partnership were implementing, with activity happening in the emergency department, and orthopaedics too: “There was such a lot going on when you think that the whole hospital staff is only about 135, so you can see why they might have got slightly fed up with us.”  (Kerri Jones).

As Timothy Panga describes:

“There are local trainings in the hospital, educational trainings, several times a week, once [or] twice a week. Then there are national government organised trainings and seminars and workshops. Sometimes that is quite destructive because you get many staff always in some form of training all the time and some of our local trainings are postponed because of lack of people.”

The UK team had made an assumption about staff’s capacity to take on more training on top of existing programmes.  On reflection, the South Devon team learned that offering new training to staff who were already stretched at work, in addition to undertaking their own CPD activities such as long distance learning qualifications and mandatory government training, had increased the risk of training fatigue and contributed to the lack of locally led GRASPIT.

Formalising a partnership with a memorandum of understanding

The partnership between South Devon Healthcare NHS Foundation Trust and Nanyuki District Hospital, Kenya, emerged from the activities of UK charities Exploring Global Health Opportunities (EGHO) and Medical and Educational Aid to Kenya (MEAK).  It was based on informal structures for about two years until the UK team decided to formalise the relationship because the UK and Kenyan teams were working together to deliver activities but without any documentation as to roles and responsibilities, which made all stakeholders feel uncomfortable.

Despite having no prior knowledge of a Memorandum of Understanding (MoU), Kerri drew one up and tentatively shared it with the team at Nanyuki.  It transpired that they had been feeling equally uncomfortable about the lack of formality in the partnership and so the MoU was welcomed. It served to strengthen their relationship:

It was much more explicit. People like to know what their roles and responsibilities are as there are uncertainties otherwise.” (Kerri Jones).

Signing the MoU brought greater transparency to the partnership.

The value to the project of investing in the partnership  

Ellie Gregory has spent a significant amount of time in Nanyuki since 2011 including a six month placement to support monitoring and evaluation activities in the LPIP. Her investment in forging relationships with colleagues at Nanyuki Hospital revealed barriers to achieving locally led GRASPIT courses.

For health partnerships that can to place a long term volunteer with the overseas partner, the opportunities for greater collaboration, understanding and joint learning will be hugely beneficial.  For those that cannot, the message is to focus as much on human aspects of the partnership as you do on the delivery of your objectives.

We learnt a lot more when Ellie was there as the long-term volunteer. She got under the skin of the staff a lot better than any of us had zooming in and zooming out again. She was talking more to a slightly different cohort of people whereas when we would go, we’d have meetings at the beginning and end of projects with the med sup [medical superintendent], the director of nursing, the people we felt we should speak to, get permission.  And they would be saying ‘yes’.” (Kerri Jones)

It is important to think carefully about where a long term volunteer could have most impact. They might be able to connect with levels of the hospital where senior staff would struggle or with key staff who might not be empowered to discuss the relevance of a training programme in more formal settings such as among senior colleagues.

Different cultural perspectives may be difficult to manage but could greatly influence progress

The possibility of cultural expectations affecting the relationship between the South Devon and Nanyuki teams had not been acknowledged sufficiently.  As Ellie describes, Kenyan partners were often reluctant to say no and it took years of relationship building to start having open conversations:

“I think people feel like they need to be really polite since our teams have come all the way from the UK and are eager to offer something. It took four or five years for me to start having really frank conversations with partners in Nanyuki about what training was wanted and/or needed.” (Ellie Gregory)

In response to this learning, the partnership has adopted a buddy system to link each UK volunteer with a member of staff at Nanyuki of the same cadre and seniority level, allowing for support systems at all levels of the partnership: “If the nurse in the emergency department has an opinion on the project, (for example a part of the course being irrelevant to the Nanyuki environment) and she doesn’t have a good relationship with the med sup, how will that message get back to the course organisers?” (Ellie Gregory).

A health partnership is as much about developing trusting and transparent relationships as it is about delivering tangible project outputs, and South Devon – Nanyuki is an example of this; as the partnership developed, so did their understanding of the strengths and weaknesses in design of the project. This is an example of how the principles of collaboration in project design, consultation with staff responsible for delivery, and division of project management responsibilities between partners, improve the likely success of a project and the sustainability of its results; the project will have local buy in and leadership, and will be embedded in the institution’s structures and processes.

An improved approach for future partnership work

Based on findings from the partnership’s evaluation of the LPIP project, they made some significant changes to their approach such as agreeing a clear memorandum of understanding that outlines each institutions’ role; securing the release of trainer time to deliver training locally; and identifying GRASPIT champions across the cadres of nurse, clinical officer and medical officer.  The partnership has also adopted the Kenyan process of ‘sensitisation’. With sensitisation, the first step is to make all stakeholders aware of the project, the partnership, and what is entailed; and the second step is to ensure that all parties have a common understanding of the aims of the project, the need for it, and the problem that it is addressing.  Sensitisation was implemented as a result of the partnership’s lessons about setting the foundations for successful work before getting the project under way: “What we tended to do was respond to need or suggested something around a course. We’ve run that and then we’ve trained trainers and got them to run another course. And then you hope that it will continue.” (Kerri Jones).

The new approach is based within a quality improvement framework in which local staff identify for themselves the issues that need to be addressed, the goal, and the steps that need to be taken to make the goal not only achievable but also sustainable long after South Devon’s involvement has ended. The UK Partner has now designed a ‘SPRINGBOARD’ course that teaches quality improvement methodology and leadership, an approach that is proving to be popular with Nanyuki staff.  In the future, all partnership interventions will follow this approach (subject to current ongoing evaluation confirming its effectiveness).

With further research into the barriers and enablers for sustaining locally led training, we could understand the impact of context on GRASPIT; given the cultural and institutional factors at play, would it ever have been possible to embed GRASPIT at Nanyuki Hospital as part of the LPIP project?  What is the relative importance of individual motivation and an enable environment to sustaining a local training programme? What triggers a resurgence of locally led training at an institution where it has been dormant for some time? A transparent, equitable, learning partnership will be best placed to answer these questions and build an effective training programme.