 She should be all set now. Catherine. Oh, did you do it? Okay. Well, let me go ahead and introduce Portia She Portia Shanduka is an RN a registered midwife with a bachelors in nursing and I'm currently nursing advanced midwifery at neonatology She's a Zimbabwean, but she's working as a nurse educator and deputy head of the midwifery program at the Paris School of Nursing in a rural district in Lesotho, and she's also a counselor She has Many years of experience in clinical midwifery and as faculty member She's interested in midwifery education and practice sexual and reproductive health and women and girl child issues and she's working on a national framework for Strengthening midwifery knowledge translation She's worked with developing midwifery modules and reviews She's an examiner of midwifery final examinations. She has developed and administered midwifery e-learning platforms and she participates in an international confederation of midwives Delphi survey of the midwifery core competencies and Midwifery assessment tools as well as worked with the Lesotho nursing councils midwifery education practice standards and competencies and As with great pleasure that I turn the mic over to Portia to discuss with us the students use of the pardogram at a district hospital in Lesotho Hello, everybody Hello, everybody. Can you hear me? Hello Portia, you can go ahead. We can hear you very well Thank you Thank you for coming attending this presentation It's so exciting. It's evening. It's at night on my side Now my presentation is on the students use of the pardogram at a rural district hospital in Lesotho The Paris School of Nursing is the only nursing college at in the rural districts. We have other nursing colleges which are in the urban or in the The capital city, Marcel so Paris School of Nursing is part of them Paris Mission Hospital is a mission Institute So it is Paris School of Nursing and Paris Hospital where the study was carried out is and now one proprietor that Catholic mission So Paris School of Nursing is one of the next training institutions in Lesotho Comments the new curriculum, which is a competence-based curriculum in midwifery in 2014 and for Paris School of Nursing it was the Also beginning of this program We have the other program is general nursing Which is three years and the certificate nursing assistant Which is one year three months So in this curriculum The competence-based curriculum is focused on on the performance It's one of the government measures of reducing maternal mortality in the country Before the new curriculum they started increasing the recruitment of midwives through an increase in intake so as to increase the workforce and also improving the health facilities like the rural health facilities so that they can Offer maternity services to the mothers in the rural areas as well as the the equipment and on all the facilities through the the partner organizations so but still the maternal mortality is still in a problem as one of is the Millennium Development Goals in 2015 the Lesotho did not meet that target of reducing by 75 percent it was actually off track so one of the the recommendations for to first check the Millennium Development Goals was to increase the to improve the the workforce and the quality care and that included the use of the patogram so in this new curriculum the the patogram is one of the compact competencies in the labor module of of the middle midwifery so as you can see in this is the background the this black and white picture is just showing the student midwife attending to the woman in the clinical area the most of the time these they are alone there is a shortage of staff and they need supervision they need guidance and they need to apply what they have learned in the clinical area but most of the time they find themselves alone and they have the they have to meet the outcomes according to the new curricula and this picture of of the the student who is post-cultivating with a fitoscope that is the resources that are available and when you are alone and you have no nobody supporting you nobody supervising you the clinical confidence and competencies and competence is compromised so when you look at that picture you see that the fitoscope is pressing deep into the this pregnant abdomen so the purpose of this study was to explore the student midwife's application of the patogram competency in the clinical setting as I mentioned that it is the the competence in the new curriculum it's it is focused on performance so we are more concerned about the performance so that is what the the government thought of the reason of of introducing the new curriculum that they they thought they could increase the duration of midwifery training or even just increase the the number of midwives currently they are they are on compulsory midwifery after completing real training in general nursing they have to proceed and continue with compulsory midwifery training as a specialty it's also a major that is quantitatively increasing the workforce but the issue of the of the performance you're still to be addressed we hoping that this curriculum of competency based will address this issue of the knowledge the the practice the theory practice in congruence that was it has been it is a global issue and in in the suitu as you can we can appreciate that is a low resource setting the the practice area is quite different from the the the faculty and solar suitu is also included in the this issue of the clean power theory practice in in congruence so this the student in the new curriculum the students they they they leave the classroom after the theoretical capacitation and they go through simulation to practice those skills so that they transit to the clinical practice area to apply those competencies in the real on the real patients so and they have to add the evaluate on their evaluations of their learning both clinical classroom and simulation they expressed a a challenge especially in with regard to the use of the patogram so that is how the study was carried out the the focus it was a qualitative design focus group interviews were done with this current intake in in 2017 between november october and november so we had two focus group discussions for students of that same intake we have one intake per year a group of 10 ish and they they were interviewed by a trained interviewer and then the same data is was triangulated we had the to ask the same questions about how students apply their the patogram competence in the clinical area two faculty members a clinical instructor and an educator they had individual interviews and then we had one focus group discussion uh was one focus group interview of the student of the mid-rise the professional mid-rise who are supervising those students and it was for for the same purpose to to find out whether there are any challenges and any positive or negative experiences and any suggestions so this is the lisuto context as you can see it's a low resource setting the topography you can see that it's a mountainous area and it's high high altitude it's very cold and most of the places that is where the mothers are they are not accessible even when they have to be referred for to the referral center to the town they have to use helicopters Because the places are not accessible so that means a facility base is the only option that is available for them because they cannot be accessible if they have to have home beds and there's also HIV which is also a bedding and it's affecting in lisuto is the highest in the the age 15 to 49 years and that is the child bearing age it is impacting heavily on the women and also this maternal mortality rate and then the simulation setting when the government introduced the new curriculum across the all the training institutions we had also supporting organizations like navy they supplied the simulation equipment so it makes it easy for students to simulate to practice safe these skills before they get to the real the actual practice area and then in the clinical area when you get to the clinical area you find that is the basic in a the hospital where the study was carried out it is the labor ward actually has two two beds that can be separate that are separated by screens these curtain screens and then the rest of the beds are postnatal and antinatal wards age about 16 all in all and so these are the resources that are available everything is manual as you can see maternal observations they are done with this manual equipment fetal observations but general examinations abdominal examinations took our page for the contractions document everything is is manual is still in that context and then so as I said the study took the design of exploratory descriptive and contextual qualitative design the population is this 2017 28 2018 intake of 37 student midwives and there were papers simply sampled from all key holders so as to try and let the the the same data and we used a semi-structured interview guide analysis was done by the researcher because I could not interview my own students myself so I did the transcription and the analysis through open coding and then themes from those audited transcripts themes emerged so four major themes emerged from the from those quotes with three categories each the first one satisfaction with theoretical capacitation so both the midwives and the faculty and the students themselves they express that they are satisfied with the theoretical station of the students in relation to the patrogram before they get to the clinical area and then so under this satisfactory theoretical station the the were categories of the the knowledge about components of the patrogram the knowledge on how to blot and how to interpret it and also they had positive attitude towards the patrogram because they all knew the importance and the value of the patrogram and then the second theme on midwifery simulation it was shown to be barely close to a reality the students they express that yes they have the equipment in the simulation but most of the the simulators whether it's low fidelity or high fidelity they really mimic the midwifery competencies as you can and appreciate that most of the midwifery procedures involve the sense of touch so when they purpose the contractions on a simulator they don't get that confidence because when they get to the clinical area is in the real patient is a real pregnant woman is it feels different even doing the vaginal examinations on a simulator is quite different they was targeting the theater heart and so the categories that came under the stimulus those all those labor observations and monitoring they are not they are only feasible in to blot to do and blot when they are in the simulation settings and they said they leave the the the simulation with still without the the conf not fully confident and not fully competent though they are they have that knowledge and the value of the pathogram so it meant that this simulation is not rich enough it's supposed to be the bridge between the theory and the practice and then this the other theme of theory practice in congruence the this theory practice in congruence that they have been complaining about they found that the in in the pathogram when they get to the clinical area it's it's a school thing the pathogram is a student thing is not a labor monitoring tool they find that it's done only for the students because the students are there and when the midwives they are there to supervise them it's mainly to make sure that they do not overuse because when the midwives were interviewed they were saying the students like the pathogram so they they end up they're commencing it when it's not necessary and they said themselves they they use the pathogram when when they are free or when they are not busy so it it's because most of the time they are busy it's now it means it becomes as the thing for students or thing for school and also its application of the the knowledge and attitudes that they have when they are in the clinical area it's limited by time material and human resources and then also another category under this theory practice in congruence is the clinical confidence and competence is only developed after long practice exposure so if it's they are hardly supervised and they are they hardly utilize it appropriately so it means they will still need a long practice exposure on on using the pathogram because they've they've transited from through the simulation we we're still without that without full confidence and then we had suboptimal professional role modeling so since in the clinical area they found that the only professional practitioners who use the pathogram are the midwives they they say the doctors in other cadres they don't use the the pathogram so now the it means they depend on the professional midwives for the professional role modeling and and this professional role modeling is is hampered by poor supervision most of the time they are not supervised there is not satisfactory and then they say the experiences of of good bad outcomes without the use of the pathogram by professional midwives negatively influences their personal zeal and value of the pathogram so even if as much as they have the value when they leave the classroom they have the value of the pathogram and the knowledge enough to apply it but when they get to the clinical area they find mothers are giving birth normally and they don't see complications so they say ah it's it's it means you can do without so it now negatively influences their professional zeal and the value that they of the pathogram that they had when they left the classroom and also that they realize that the the midwives they also need support they are not supported because they find in in the clinical area they they come with the knowledge they seem to be up to date more than their supervisors who are the professional midwives and the professional midwives themselves they said we need to be updated we need we need support so and the student midwives they said this the midwives need to be supported they need to be they need to have incentives they need to be awarded and so that they teach us so they have the experience that that relationship for for proper professional role model we need those interpersonal relationships that are sound and some of the students they said the midwives are not interested in teaching us and they think they are not competent or they think they are they are just too busy for them while the midwives themselves they say some of the students are not interested and and they said we are busy we have we we support them when we are not busy so it was a matter of it depends so they would all say it depends on some the midwives will say some students they are motivated and we support them and the students will say some midwives they are not they are interested and they support us so it was the the issue of the the relationship so the conclusion now is that the students found that they face a limitation in using the patogram fully at the clinical learning settings from from the results of from the findings some students they said when even when we want to some sometimes we are limited by all this time in material resources and including the the human resources because they need to be supervised and all in after all this experience some of the students they said even us when we are we are using the patogram now because we are learning because we want to learn because it's a requirement of their curriculum in their curriculum they have to apply what they have learned in their assessed on the competencies it's unlike in the previous curriculum where they will just do their theory in class and then the practical is done it's not integrated in this done separately they would just learn the practical procedures but not as like the the competencies and then at the end of the year they would have just one final one or two final procedures clinical procedures for the practical assessment but in this case they have every module it has the at the end of the year they they have to do an oski of 10 stations which cover an integrated assessment of the whole all the competencies so now the students were saying we are using the patograph because we are learning we want to learn so when we are qualified we we might not also use the the the patogram if we are in the same working environment the same working conditions with this is like this professional midwife so it it meant that this is a challenge is challenging is a threat to the future because the students are the future of the midwifery profession so I recommend that the faculty is to strengthen the students clinical learning support starting from simulation now that we this challenge of in the clinical setting of of of shortage of midwives and shortage of resources they will always encounter a difference when they get to the clinical area so it is imperative that this to strengthen students support of clinical learning must start at the simulation to find ways of also of improving the midwifery simulation to be more authentic and to try and bridge the theory practice a gap and also the curricular reforms should also include the clinical area because when there's the new new curriculum was introduced the all the faculty in all the schools were capacitated and we are credited to and approved to to commence this new curricular but there is not much that was done on the clinical placement settings for their readiness for the the students so they have the experience despite the shortage of of resources human resources particularly they've experienced also a large number of groups of students who come at the same time who who need who are an extra load to them who need their supervision their guidance their coaching and in the future there is no we don't have that structure for clinical preceptorship and mentorship support for all clinical practitioners be it student practitioners or professional practitioners so we need them the studies and including action should be to collaborate between the faculty and the clinical area so I also recommend closer collaboration with the service to support midwifes who intend support and draw model of the students and improve to improve partogram theory practice gap so since the study is the the foundation of the smaller which hang for developing that framework for mid different knowledge translation in the suit so if we also forge that closer relationship of the support of midwifes then this study which it was an eye-opener on me because when I interviewed when I listened to the interviews for these midwives I found that they also need support yet we expect them to support our students so the question was who supports the midwives whom we expect to support our students they also need guidance they are no national guidelines for maternity for labor and maternity guidelines in the country so the question is who supports who guides the the midwives whom we expect to guide our students and who role models them if they also need mentorship who role models them since we expect as we expect them to role model their students and we expect them to coach our students who coaches them so these are all the questions that I came up with and I saw that these all these curriculum reforms for them to be success they must also start the the clinical area where we want the outcome the first out the the main outcome or the main target of the government to reduce maternal mortality if you want our mothers to benefit we must also support the midwives who support our mothers so now if the students they are like the clients they are in between the the the the the faculty and the clinical area so if they are trained as the study done at that at this institution of the professional role of the of the of the professional analysis in their clinical teaching it revealed that they have the experience role stream but they are resilient and their solution forecast so we need to support the midwives who support our students and at the end of the day our mothers are supported and then we will all achieve the same goal of reducing maternal mortality in the country so the pattern is it is the identified competence that it can be evaluated because on just random check you can check the utilization even on random observation you can just drop in and you see how it is utilized so it was chosen for this as a starting point for the mid different knowledge translation since they were not talking about only complaining about the pattern but they were saying especially the pattern is difficult to implement or to to practice or to apply everything that we learn at the at the school when we get to the clinical area it was mainly the outcrier was mainly of the pattern so they say practice makes perfect but I say provided it is perfect practice so if I don't want my students to do as Romans do which is imperfect practice I have to be part and parcel of changing wrong for my students thank you okay great thank you very much I just I wanted sorry to interrupt but I do want to leave a little bit of room in case our audience has any questions any yes are there any specific questions for Portia well I just wanted to say that I think you with your study of the partogram I think you've identified a very important issue that all us educators and students face you use the example of the partogram but there are so many other examples of things we teach and yet the students don't see it in practice like our previous session under late cord clamping and and all our theoretical knowledge of labor support where we see the clinical practicing midwife running from room to room with no time so I think you know this is really something that deserves a very wide discussion okay so Jane would like to know how many students you're educating a year in Lesotho am I Shanduka we have one intake per year and it's about 40 the group 40 okay and how long is the program then it's one year one year program okay so Sheila is asking about equipment for determining the fetal heart rate with the fetoscope so how do midwives pick up changes in the fetal heart rate pattern such as decelerations which is also part of the fill pot partogram partogram exactly they use the the fetoscope that is the the the basic tool that is available in all facilities the ctg is only available at the one facility that is the national referral sense that is where they get to practice or use the ctg so it means for decelerations the accelerations they can only pick it manually but on the partogram they just plot the rate and that's all they just the rate just the rate they don't identify accelerations and accelerations just to detect whether it's below 120 or is above 160 that's all right so I there's a question also from um Tara Mati Barker about the partogram she just wants to clarify if it's used both in clinical and the classroom or only in the classroom it is used the in the in the clinical area we they use the the old partogram not the the new who but we it's being introduced in the in the classroom so in the classroom they are exposed to both the new who modified one and in the old one that still has the the latin phase okay that's what I was I that was my understanding but miss Barker wanted a clarification now Sheila also points out in terms of fetal heart rate patterns that if you ascultate the fetal heart rate immediately after a contraction you will hear the deceleration so so you can identify um you know periodic changes and then she goes on to say in her setting um she required the fetal heart rate to be taken before and after attraction a contraction so that one could pick up if there was a change in the rate as the result of the contraction and this can be done with this fetoscope right I was taught to listen throughout the contraction which can be a bit challenging with you know with some of the moms yes for the manually actually you need to listen before during and after contraction right that's what I was taught but we have in the US we have lost the skill we really have lost the skill of um of ascultation in so many settings um you know because there's something that needs to be practiced yeah and and Linda agrees that sometimes it's uncomfortable for the mom during the contraction it is um so um Portia is your study ongoing or is it completed now this first patch is the one that is complete okay and then the the next phase is now to try to develop the the the framework or the guidelines for the starting with the labor documentation labor guideline because that is what the the midwife saying they don't have anything to refer to you just have to ask their colleagues for for for consult to ask to consult a colleague but they are also not sure okay well that yes that sounds good please keep us up to date on your work we really appreciate it hearing hearing from you thank you