TRAINING COURSE ON THE MANAGEMENT OF SEVERE MALNUTRITION

COURSE DIRECTOR GUIDE

World Health Organization

Department of Nutrition for Health and Development

The Course Director Guide is one part of a set of materials for conducting the course, Training Course on the Management of Severe Malnutrition. The user of this guide should be familiar with the course materials and teaching methods.

Training Course on the Management of Severe Malnutrition was prepared by the World Health Organization Department of Nutrition for Health and Development (NHD), Geneva, Switzerland, and Regional Office for South-East Asia (SEARO), New Delhi, India in cooperation with the Public Health Nutrition Unit of the London School of Hygiene and Tropical Medicine, London, UK through a contract with ACT International, Atlanta, Georgia, USA.

World Health Organization, 2002 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. Cover photo: UNICEF/5877/Roger Lemoyne Cover design for modules: minimum graphic Illustrations for modules: Susan Kress

Acknowledgements This field training course is the practical application of the WHO publication Management of Severe Malnutrition: a manual for physicians and other senior health workers, and WHO is grateful to all those involved in the production of this fundamental training course. WHO would particularly like to thank ACT International, USA, and especially Ms P. Whitesell Shirey for having developed the manuscript of the Training Course, together with Ms F. Johnson, who also acted as the course coordinator during the field testing. WHO acknowledges with all gratitude the substantial technical contribution and advice of Professor A. Ashworth-Hill from the London School of Hygiene and Tropical Medicine, who has also acted as one of the course facilitators. Special thanks are extended to Dr S. Khanum (former Regional Adviser for Nutrition and Food Safety, WHO Regional Office for South-East Asia in New Delhi), Department of Nutrition for Health and Development, for her technical contribution, comments and advice throughout the development of the training modules and also for organizing the field testing as a course director. WHO also expresses its appreciation for helpful contributions from course facilitators during the field testing of the training modules, notably: Dr S. Aiyer, India; Dr T. Nu Shwe, Myanmar; Dr E. Poskitt, UK, Dr T. Ahmed, Dr S. Shakur, and Dr K. Jamil, Bangladesh, and all the course participants from Indonesia, Nepal, Bhutan, and Myanmar, and Bangladesh. WHO expresses sincere gratitude to Professor J.C. Waterlow, UK, and to Professor A. Jackson, University of Southampton, UK, for their technical support and expertise during preparatory meetings held in London in November 1999 and September 2000. Also acknowledged are contributions of WHO staff in the Department of Nutrition for Health and Development; Dr G.A. Clugston, Dr M. de Onis, and support from the Department of Child and Adolescent Health. WHO would like to thank the International Centre for Diarrhoeal Disease and Research, Bangladesh (ICDDRB) for conducting the field testing of the training modules. The financial support of the Governments of the United Kingdom of Great Britain and Northern Ireland (Department of International Development) and the Kingdom of the Netherlands towards the development and publication of this Training Course is also gratefully acknowledged.

CONTENTS
PART ONE: PLANNING AND ADMINISTRATIVE ARRANGEMENTS .............................................................. 1

1. 2. 3. 4. 5.

Criteria for selecting hospital for clinical practice ............................................... 2 Equipment and supplies needed for a severe malnutrition ward....................... 3 Checklist for planning and administrative arrangements ..................................... 6 Criteria for selecting clinical instructor and facilitators...................................... 13 Checklist of instructional materials needed ....................................................... 16 List of other supplies needed .............................................................................. 17

PART TWO: PREPARING FOR CLINICAL PRACTICE ...................................

19

1. 2. 3.

Preparing the clinical instructor ........................................................................... 19 Visiting the ward to finalize arrangements .......................................................... 20 Scheduling clinical practice sessions ................................................................... 22

PART THREE: TRAINING FACILITATORS ........................................................... 23

1. 2. 3. 4.

General structure of facilitator training session .................................................. 23 Daily schedule ...................................................................................................... 24 Practice of facilitator techniques .......................................................................... 25 Using this Guide to conduct the facilitator training ............................................. 25

Facilitator Day 1 ....................................................................................................... 27 1. Opening session .............................................................................................. 27 2. Introduction to facilitator training .................................................................. 28 3. Module: Introduction ..................................................................................... 31 Facilitator Techniques: Working with a co-facilitator ................................... 32 4. Module: Principles of Care............................................................................ 33 Facilitator Techniques: Introducing a module ............................................... 33 Facilitator Techniques: Leading a discussion ................................................ 33 Facilitator Techniques: Adapting for nurses groups ..................................... 34 Facilitator Techniques: Individual feedback .................................................. 34 Facilitator Techniques: Oral drills ................................................................. 36 Facilitator Techniques: Video activity ........................................................... 37 Facilitator Techniques: Summarizing the module ......................................... 38 5. Module: Initial Management.......................................................................... 38 Facilitator Techniques: Conducting a demonstration .................................... 39 6. Assignments for the next day .......................................................................... 40

Facilitator Day 2 ........................................................................................................ 42 1. Continuation of module: Initial Management................................................ 42 Facilitator Technique: Coordinating role plays ............................................. 42 2. Module: Feeding ............................................................................................ 43 Facilitator Techniques: While participants are working ................................ 43 3. Assignments for the next day.......................................................................... 45 Facilitator Day 3 ........................................................................................................ 47 1. Module: Daily Care ....................................................................................... 47 2. Module: Monitoring and Problem Solving .................................................... 47 3. Assignments for the next day.......................................................................... 49 Facilitator Day 4 (Half Day)..................................................................................... 50 1. Module: Involving Mothers in Care .............................................................. 50 2. Practical arrangements for the course ............................................................. 51 3. Closing remarks to facilitators ........................................................................ 51 PART FOUR: RESPONSIBILITIES OF THE COURSE DIRECTOR DURING THE COURSE ................................................................................... 53 1. Suggestions for opening remarks to course participants........................................ 53 2. Supervision of facilitators ....................................................................................... 53 Observe facilitators at work .................................................................................. 53 Performance criteria for facilitators ..................................................................... 55 Conduct daily facilitator meetings ........................................................................ 57 3. Supervision of the clinical instructor ...................................................................... 58 4. Collection of data during the course ....................................................................... 59 5. End-of-course evaluation ........................................................................................ 59 Sample evaluation questionnaire ...................................................................... 60 6. Closing Session ....................................................................................................... 63 ANNEXES .................................................................................................................. 64 A: Chart for scheduling clinical sessions ................................................................... 65 Objectives for clinical practice sessions ............................................................... 66 B: Schedule for facilitator training ............................................................................ 68 C: Schedule for the course ......................................................................................... 72 D: Course Registration Form, Summary Participant List, and Course Director Summary ................................................................................... 74 E: Practice assignment grid ....................................................................................... 79 F: Slides for facilitator training ................................................................................. 81

TRAINING COURSE ON THE MANAGEMENT OF SEVERE MALNUTRITION: COURSE DIRECTOR GUIDE PART ONE:

PLANNING AND ADMINISTRATIVE ARRANGEMENTS

Careful planning and strong administrative support are essential before, during, and after the Training Course on the Management of Severe Malnutrition. This section of the Course Director Guide describes the necessary plans and arrangements. Clinical practice is an essential part of the training course. The course provides daily practice in using case management skills so that participants can apply these skills correctly when they return to their own hospitals. In addition to daily classroom work, each small group of participants visits a severe malnutrition ward each day for practice identifying clinical signs and managing patients. It is critical to select a location for the course (town or area) which has a hospital with a severe malnutrition ward that can be visited by participants during the course. This hospital should manage severe malnutrition according to the principles and procedures in the WHO manual titled Management of Severe Malnutrition: a manual for physicians and other senior health workers. It may be necessary to provide certain equipment, supplies, and consultation to this hospital, well in advance of the course, to ensure that the hospital will demonstrate good case management. Part One of this guide describes first how to select the hospital to be used during the course. It then presents a checklist of the necessary plans and arrangements for the entire course. Following the checklist are more detailed instructions for making some of the arrangements.

1. Criteria for selecting hospital for clinical practice

The selected hospital must have a separate ward or area for severely malnourished children, a sufficient case load, acceptable quality of care, and a director and staff who are interested in the course and willing and able to cooperate. The severe malnutrition ward will be visited daily by all course participants, who will come in several small groups throughout the day. It is best if the ward is close to lodging and classrooms to minimize time needed for transportation. The ward should have available the supplies and equipment listed on the following pages. If some supplies are not available, they will need to be provided before the course, in plenty of time for staff to learn to use them. Case management practices should be consistent with those in the WHO manual Management of Severe Malnutrition: a manual for physicians and other senior health workers. If procedures are not consistent, they should be made consistent to the extent possible prior to the training course. If there are significant discrepancies between current practices and the WHO guidelines, the effectiveness of the training will be seriously compromised as the participants will see practices that are different than those being taught in the course. If a facility wants to upgrade its procedures to be consistent with those in the WHO manual, this may require training of staff, changing ward procedures, and obtaining additional supplies; the facility may request technical assistance from WHO well in advance of a training course. If there are only a few discrepancies between current practices and the WHO guidelines, the clinical instructor should be prepared to support the WHO guidelines and explain the practice in the training site. Local adaptation of some procedures is reasonable; the clinical instructor or Course Director should be prepared to explain how the current practice is consistent (or not consistent) with WHO guidelines and the reasons for it.

Equipment and supplies needed for a severe malnutrition ward

Ward Equipment/Supplies

Dextrostix Running water Thermometers (preferably rectal and low-reading) Child weighing scales (must be functioning correctly) Items of known weight for checking scales Board for measuring length Pole of known length for checking accuracy Stadiometer (to measure standing height) Haemoglobinometer Supplies for IV: Scalp vein (butterfly) needles, gauge 21 or 23 Heparin solution, 10-100 units/ml Poles or means of hanging bottles of IV fluid Tubing Bottles or bags Paediatric nasogastric tubes Sticky tape Syringes (50 ml for feeds) Syringes (2 ml for drugs, 5 ml for drawing blood, 10 ml) Sterile needles Eye pads Bandages Gauze Supplies for blood transfusion: Blood packs Bottles Syringes and needles Other blood collecting materials Blankets or wraps for warming children Incandescent lamp or heater Wash basin for bathing children Safe, homemade toys Clock Calculator
For hygiene of mothers and staff

Toilet and hand washing facilities Soap for hand washing Place for washing bedding and clothes Method for trash disposal

For reference and record keeping

Copy of Management of severe malnutrition: a manual for physicians and other senior health workers and relevant tables such as: Weight for Height Reference Card F-75 Reference Card F-100 Reference Card Antibiotics Reference Card Suitable forms for record keeping, such as the CCP (Critical Care Pathway) or other forms requesting similar information (weight charts, monitoring records, etc.) 24- hour food intake charts
Kitchen Equipment/Supplies

Dietary scales able to weigh to 5 g Electric blender or manual whisks Large containers and spoons for mixing/cooking feed for the ward Method of cooking Feeding cups, saucers, spoons Measuring cylinders (or suitable utensils for measuring ingredients and leftovers) Jugs (1-litre and 2-litre) Refrigeration For making F-75 and F-100: Dried skimmed milk, whole dried milk, fresh whole milk, or long-life milk Sugar Cereal flour Vegetable oil Clean water supply Foods similar to those used in homes (for teaching/use in transition to home foods)
Pharmacy Equipment/Supplies

Pharmaceutical scales WHO ORS for use in making ReSoMal (or commercial ReSoMal) Mineral mix (prepared as in Appendix 4, page 53 of manual) or Combined Mineral Vitamin Mix (CMV) Electrolytes and minerals: Potassium chloride Tripotassium citrate Magnesium chloride Zinc acetate Copper sulphate Iron syrup (e.g., ferrous fumarate) Multivitamin without iron Folic acid Vitamin A (high potency syrup or 100 000 / 200 000 IU capsules

Glucose (or sucrose) IV fluids one of the following, listed in order of preference: Half-strength Darrows solution with 5% glucose (dextrose) Ringers lactate solution with 5% glucose* 0.45% (half-normal) saline with 5% glucose*
*If either of these is used, sterile potassium chloride (20 mmol/l) should be added if possible.

0.9% saline (for soaking eye pads) Sterile water for diluting Vaccines (BCG, OPV, DPT, and Measles)
Drugs (See formulations listed on Antibiotics Reference Card)

Amoxicillin Ampicillin Benzylpenicillin Chloramphenicol Cotrimoxazole Gentamicin Metronidazole Nalidixic acid Mebendazole, albendazole and/or other drugs for treatment of worms (as on page 32-33 of manual) Tetracycline or chloramphenicol eye drops Atropine eye drops For skin Gentian violet Potassium permanganate Zinc-boric ointment Petroleum jelly ointment Nystatin ointment or cream (for Candidiasis) Paraffin gauze (tulle gras) Laboratory resources accessible if needed TB tests (x-ray, culture of sputum, Mantoux) Urinalysis Stool culture Blood culture Cerebrospinal fluid culture

2. Checklist for planning and administrative arrangements

As the Course Director, you may not be directly responsible for all of the items on this checklist, but you can ensure that appropriate arrangements are being made, or can assign someone responsibility for making them. Arrangements may not be listed in the exact order in which they will be made. Space has been left for any additional reminders.
Initial Planning

1. ____

Location of course selected. The location must be near a hospital with a severe malnutrition ward that meets the criteria on pages 2 5 of this Guide. The location must also have adequate lodging and classroom facilities (see item 8 on this list). Time-frame for giving the course identified (during a time of year when the hospital will admit sufficient numbers of severely malnourished children for clinical practice). Consultant or other assistance provided to hospital, if necessary, to ensure case management practices are consistent with WHO guidelines. Course materials translated (if needed) and printed or obtained from WHO. Specific dates of course and facilitator training selected. As indicated on the schedules provided in Annexes B and C: a. ____ b. ____ c. ____ 3 days (plus at least 1 day off) allowed for facilitator training. 7 calendar days allowed for the course (course work requires 6 days: 3 days + day + 3 days). Course Director and clinical instructor available 1 - 2 days before facilitator training and during all of facilitator training and course.

2. ____

3. ____ 4. ____ 5. ____

6. ____

Letters sent to the appropriate district/regional/local office asking that office to identify appropriate physicians and senior nurses for training. Letter: a. ____ b. ____ announces the Training Course on the Management of Severe Malnutrition and explains the purpose of the course. clearly states the number of participants to attend the course (24 maximum), and that these should be physicians and senior nurses who are responsible for treating severely malnourished children in hospitals. states that participants should plan to attend the entire course (7 days with 6 days of course work).

c. ____

d. ____ e. ____ f. ____ g. ____ 7. ____

states that participants who complete the course will receive a certificate from the World Health Organization describes the location and dates of the course. states the date by which course participants should be nominated and the person to whom names should be sent. clearly states required language and reading skills and stresses that the course is challenging and requires hard work.

Facilitators and clinical instructor selected and invited. (See "Criteria for selecting clinical instructor and facilitators" on pages 13 - 15.) Ensure that: a. ____ b. ____ c. ____ there will be at least one facilitator for every 3 - 4 participants expected to attend the course. facilitators will attend all of facilitator training and the course. clinical instructor is qualified and is available from 1 - 2 days before facilitator training through the end of the course. (The clinical instructor must arrive early to assist with arrangements for clinical sessions. He should attend facilitator training, if he has not done so before, to become familiar with the course and learn facilitation skills. He will lead one clinical session during facilitator training.) course materials are sent to clinical instructor ahead of time so that he can prepare.

d. ____ 8. ____

Precise locations selected and reserved for classrooms and lodging. (To minimize transportation needs, classrooms should be within easy walking distance of the lodging and the hospital.) Selection based on availability of: a. ____ b. ____ c. ____ d. ____ e. ____ f. ____ adequate lodging for all facilitators and participants. accessibility to hospital. convenient meal service. large room for seating all participants, facilitators, and visitors to the course (needed only for the course, not for facilitator training). videotape player and monitor (1 or more). smaller rooms for groups of 6 - 8 people to work in, plus separate space for individual consultations (During facilitator training, only

one of these rooms will be needed. During the course, one room is needed for each small group of participants.) g. ____ h. ____ 9. ____ 10. ____ tables, chairs, adequate lighting, and blackboard or poster stand for each of these rooms. separate room for secretariat.

List compiled of physicians and senior nurses who will be invited to participate in the course. Letters of invitation sent out to selected participants. Letters: a. ____ b. ____ c. ____ briefly describe the purpose and organization of the course. state desired arrival and departure times for participants and stress the importance of attending entire course. describe arrangements for travel and payment of per diem.

11. ____

Arrangements made for a secretary to arrive at the course location 3 days before facilitator training to ensure that necessary administrative tasks are done. (See next section of this checklist for administrative tasks.) During the course the secretary will need to work with local staff to ensure that things go smoothly and that the facilitators' and participants' work is not unduly interrupted. This person may also need to stay an extra day after the course to pack up remaining materials and pay bills. Travel authorizations sent to facilitators, clinical instructor, and participants. Course completion certificate designed and adequate copies printed (to be signed and awarded to all participants and facilitators at the end of the course). Arrangements made for providing adequate numbers of copies of the course materials, necessary supplies for classroom activities, and supplies for clinical practice. (Necessary materials and supplies are listed on pages 3 5 and pages 16 - 18 of this Guide.) Arrangements made for sending/transporting necessary materials and supplies to the course location.

12. ____ 13. ____ 14. ____

15. ____

At the course location, before facilitator training begins 3 days before facilitator training: Secretary arrives at the course location early to take care of administrative arrangements described in this section of the checklist. 1 - 2 days before facilitator training: Course Director and clinical instructor visit the hospital ward and discuss/confirm arrangements. (See item 25 on this checklist.) 16. ____ 17. ____ 18. ____ Adequate lodging arrangements confirmed for all facilitators and participants. Arrangements made for welcoming facilitators and participants at the airport and/or train station, and hotel. Arrangements confirmed for rooms for conducting facilitator training: a. ____ b. ____ one room for conducting facilitator training (with characteristics listed in 19b below). one room for the secretary with space for storing modules, forms, and other supplies, available during both facilitator training and the course. one overhead projector. one video player and monitor. area that can be used for preparing ReSoMal, F-75, and F-100.

c. ____ d. ____ e. ____ 19. ____

Arrangements confirmed for adequate rooms for conducting the course: a. ____ b. ____ large room available on the first and last day of the course for seating all facilitators, participants and visitors. smaller room available during the course for each small group of participants, each room having: ____ sufficient table/desk area and chairs for up to 6 participants and 2 facilitators, plus separate consultation area with additional chairs. ____ ____ additional table area for supplies. blackboard or flipchart stand with paper.

____ ____ c. ____ d. ____ e. ____ f. ____

adequate lighting and ventilation. freedom from distractions such as traffic or construction noises or loud music.

videotape player and monitor, preferably on a cart which can be moved around. one room for a secretary and the course supplies. overhead projectors. (Ideally, there would be one per group, but if this is not possible, equipment may be shared.) area that can be used for preparing ReSoMal, F-75, and F-100. (Preferably, each class room will have an area that can be used; if this is not possible, a kitchen area may be shared.)

20. ____

Arrangements made for registering facilitators for facilitator training and participants for the course. a. ____ b. ____ Sample registration form (in Annex D of this Guide) reviewed and items added if needed. Registration Form prepared.

21. ____

Arrangements made for typing and copying of materials during the course (for example, registration forms, schedules, list of participants, end-of-course questionnaires). Arrangements made for meals and coffee/tea service. Arrangements made for reconfirming or changing airline, train, bus, car reservations for participants. Arrangements made for paying per diem to participants and facilitators. Hospital ward visited and confirmed to be suitable for clinical practice. Director and staff informed about practice sessions to be held during facilitator training and the course. (See the Clinical Instructor Guide for more information about preparing for clinical practice. In this Guide, see Part Two: Preparing for Clinical Practice.) a. ____ Clinical practice schedule discussed and agreed on with ward director. (See section of this guide titled Scheduling clinical practice sessions, page 22.) ____ during facilitator training, one group for 2 hours on Day 3.

22. ____ 23. ____ 24. ____ 25. ____

10

____ ____ b. ____ c. ____ 26. ____ 27. ____ 28. ____

during the course, ___ groups per day scheduled. dates and schedules confirmed in writing.

Drugs and supplies in the ward checked and supplemented as necessary. (See list pages 3 - 5.) Role of ward staff during practice sessions discussed with ward director.

Schedule for Facilitator Training prepared based on suggested schedule in Annex B. Arrangements made for daily transportation to and from hospital/classrooms. Sufficient copies made of registration forms, schedule for facilitator training, CCP pages, Discharge Cards, etc. for use during facilitator training.

During facilitator training 29. ____ 30. ____ 31. ____ Facilitators registered and given schedule and course materials for facilitator training. Plans for opening ceremony of course finalized with local authorities. Course schedule developed and reproduced in sufficient quantity to give a copy to each facilitator and participant. (Suggested course schedule is in Annex C.) Clinical practice schedule finalized and reproduced in sufficient quantity to give a copy to each facilitator and participant. (See Annex A.) Pairs of facilitators assigned (near the end of facilitator training) to work together during the course. To the extent possible, consideration given to the following when making assignments: * fluency in language in which the course is given and language spoken with mothers in the clinic * strengths (for example, clinical expertise, experience with case management procedures, understanding of course content, capability as a classroom trainer or clinical trainer) * motivation to be a facilitator * personal dynamics/temperament (for example, shy paired with outgoing) * for nurses group facilitators, ability to communicate well with nurses and adapt materials according to suggestions in the Facilitator Guide. 34. ____ Course materials and supplies organized and placed in the appropriate rooms. (See lists pages 16 - 18 of this guide.)

32. ____ 33. ____

11

During the course

35. ____ 36. ____ Course participants registered using registration form in Annex D. Groups of up to 6 participants assigned to pairs of facilitators. Group assignments posted following opening ceremony. (Note: It is preferable to have separate groups for doctors and nurses.) Copies of completed Registration Forms for participants in each group distributed to the facilitators for that group. Secretariat monitors or carries out administrative activities. Course Directory (including names and addresses of all participants, facilitators, clinical instructor, and the Course Director) provided to everyone. Course photograph, if desired, made in time to be developed before closing ceremony. Course Evaluation Questionnaire (pages 60 - 62 of this guide) modified as needed and reproduced in sufficient quantity to give a copy to each facilitator and participant. Arrangements made for closing session. Course completion certificate signed for presentation to each participant.

37. ____ 38. ____ 39. ____ 40. ____ 41. ____

42. ____ 43. ____

12

3. Criteria for selecting clinical instructor and facilitators

A full-time clinical instructor is critical for conducting this course. The clinical instructor will be responsible for selection of cases and all clinical practice done in the severe malnutrition ward. The clinical instructor's tasks are described in detail in the Clinical Instructor Guide. A group of motivated facilitators is also needed. The facilitators will work in pairs with small groups of participants to guide them through work on the modules and assist with clinical practice. Two facilitators are needed for each small group of up to 6 participants. The facilitators' tasks are described in detail in the Facilitator Guide.
Criteria for selecting clinical instructor

1.

The clinical instructor should be currently active in clinical care of children. If possible, he (or she) should have a current position on the severe malnutrition ward of the facility where the training is being conducted. (If the clinical instructor is not on the staff of the facility, a staff assistant will be needed to help with arrangements and perhaps with translation.) The clinical instructor should have proven clinical teaching skills. The clinical instructor should be very familiar with WHO guidelines for management of children with severe malnutrition and have experience using them. It is best if he has participated in the Training Course on the Management of Severe Malnutrition previously as a participant or facilitator. At least he should be familiar with and use the practices described in the WHO manual (Management of severe malnutrition: a manual for physicians and other senior health workers). He should be clinically confident, in order to sort through a ward of children quickly, identify clinical signs that participants need to observe, and determine the progress of different children and their care. He should understand the daily procedures in the ward and quickly see where participants may assist with care. He should understand each child's clinical diagnoses and prognosis so as to not compromise the care of critically ill children. He should be comfortable handling severely malnourished children and convey a gentle, positive, hands-on approach. He must have good organizational ability. It is necessary to be efficient to accomplish all of the tasks in each clinical session. The individual must be able to stay on the subject, avoiding any extraneous instruction or discussion. He must be able to keep a view of the ward and all the participants, and keep all participants involved and learning productively. Teaching three groups of participants requires 4 to 6 hours, and these are very active periods. He must be energetic. 13

2. 3.

4.

5.

6.

The individual must be outgoing and able to communicate with ward staff, participants, and mothers. He should be a good role model in talking with mothers. (A translator may be provided if needed.) If possible, in preparation for this role, the individual should work as an assistant to a clinical instructor at another course to see how to select cases, organize the clinical sessions and interact with participants. Or another skilled clinical instructor can join him during the first few days of the facilitator training or the course. The clinical instructor must be available 1 - 2 days prior to facilitator training, during all of facilitator training, and during all of the course. He must be willing and motivated to get up early each morning to review cases in the severe malnutrition ward and prepare for the day's clinical sessions.

7.

8.

Criteria for selecting facilitators Note: Facilitators may have different strengths and weaknesses. If a facilitator is weak in one of the following areas, it is important to pair him with another facilitator who is strong in that area. 1. Facilitators should be currently active in care of severely malnourished children. They must have the basic clinical skills and technical knowledge which will allow them to teach the case management process used in this course. (This criterion should be applied after a number of courses have been given.) They must recently have been participants in the Training Course on the Management of Severe Malnutrition. They must have good communication skills, including the ability to explain things clearly and simply to others. Facilitators in this course are not expected to give lectures, but to guide participants through written materials, role play exercises, discussions, etc. It is most important that facilitators be observant individuals who can see when participants are having difficulty, explain things clearly, and give helpful feedback. If participants speak a language other than the language in which the course is written, it is helpful for at least one facilitator per group to speak that language. They must be organized. They must be able to keep the group on schedule and ensure that they arrive for clinical practice on time and with the necessary supplies.

2.

3.

4.

5.

14

6.

If there will be a small group of nurses at the course, it is important to select at least two facilitators who can relate well to nurses and can teach clearly, patiently, and creatively. These facilitators will be expected to adapt some of the activities in the course according to suggestions in the Facilitator Guide, for example, by omitting certain parts of exercises, or by adding examples or demonstrations. Facilitators must be available during all of facilitator training and during all of the course. They must have the energy and motivation to work a long day with participants and then attend a facilitator meeting to review the day's work and prepare for the next day.

7.

Note: In any course, facilitators may identify participants who would eventually make good facilitators themselves. Ask facilitators to point out participants who: understand the modules easily perform well in the clinical sessions communicate clearly help others and work well with others in their group participate confidently in discussions and role plays.

15

4. Checklist of instructional materials needed

Instructional materials needed by each small group

Each small group will need the following instructional materials to work on modules in the classroom setting. During facilitator training, the group of facilitators will also need these materials.
ITEM NEEDED Facilitator Guide Set of 7 modules and Photographs booklet Sample Discharge Card NUMBER NEEDED 1 for each facilitator 1 set for each facilitator and 1 set for each participant 1 for each facilitator and 1 for each participant, plus a few extras for use in classroom 1 set for each facilitator and 1 set for each participant 1 packet for each facilitator and 1 packet for each participant 1 for each facilitator and one for each participant 1 for each facilitator and 1 for each participant 4 for each participant 3 for each participant 2 for each participant 1 set for each facilitator and 1 set for each participant 1 for each facilitator and 1 for each participant 1 for each facilitator and 1 for each participant 1 for each facilitator and 1 for each participant 2 sets per group

Set of 4 laminated reference cards Answer sheets Management of Severe Malnutrition: a manual for physicians and other senior health workers Extra copy of Critical Care Pathway (all 5 pages, stapled) Extra copies of Initial Management page of CCP, loose (for use in exercises) Extra copies of Daily Care page of CCP, loose (for use in exercises) Extra copies of Monitoring page of CCP, loose (for use in exercises) Monitoring Checklists (4 pages) 24-Hour Food Intake Chart Daily Ward Feed Chart Weight Gain Tally Sheet for Ward Set of overheads of CCP and other forms (if overhead projector is available) Alternative: Enlarged photocopies of forms Videotape Schedule for the course*

1 per group 1 for each facilitator and participant

Schedule for clinical sessions* 1 for each facilitator and participant *Based on schedules in Annexes A and C of this guide but including specific times

16

5.

List of other supplies needed

Supplies needed for each person * * * * * * * name tag and holder 2 pens 2 pencils with erasers paper highlighter folder or large envelope to collect answer sheets calculator

Supplies needed for each small group * * * * * * * * paper clips pencil sharpener stapler and staples scissors 1 roll masking tape extra pencils and erasers flipchart pad and markers OR blackboard and chalk overhead projector (if possible), and erasable markers for writing on transparencies

In addition, certain exercises require special supplies. Supplies for demonstrations, role plays and group activities for each small group include: * Ingredients and supplies for preparing ReSoMal Ingredients: ReSoMal packet Cooled, boiled water (at least 2 litres) Supplies: Mixing spoon Container to hold 1 or 2 litres Measuring cup or medicine cup with ml markings, or 50 ml syringe Small cups or spoons for tasting Same as above, plus: Container to hold > 2 litres Dietary scale that weighs to 5g*
*Scale could be shared by groups

If using: Commercial ReSoMal

ReSoMal made from standard ORS

1-litre standard ORS packet Sugar (at least 50g) Mineral mix solution (at least 40ml) or tin of CMV Cooled, boiled water (at least 2 litres)

17

* *

Copies of recipes for F-75 and F-100 used in the hospital. (If these are not suitable, you will use generic recipes given in the Feeding module.) All ingredients, containers, utensils, and other supplies needed to prepare recipes for F-75 and F-100. (Equipment such as a blender or hot plate for cooking may be needed. If necessary, some of the supplies may be shared by all of the groups in a specified kitchen area.) Props for role plays: a baby doll with clothes, a basin for bathing, a towel, a cup and saucer for feeding. (Creative substitutions are allowed.)

Supplies to be shared by groups Near the classrooms, all groups need access to the following equipment and supplies, to be shared by the groups: * * * * photocopy machine video player and monitor, preferably on a rolling cart or in a separate room that groups can easily go to (if sharing these items) hot plate, blender, dietary scale as needed for recipes electrical outlets, extension cords if needed

Additional supplies needed for clinical practice Participants will bring their laminated reference cards to clinical practice sessions. The following additional instructional supplies will be needed. Enough supplies are listed here for a course with 15 20 participants. In addition, the facilitators will need these supplies for clinical practice during facilitator training. * CCPs (100 copies of the Initial Management page plus 60 complete CCPs for a course with 15 - 20 participants.)

* 24-Hour Intake Charts (100 copies for a course with 15 - 20 participants) Copy from Annex B of the Feeding module. * Pens and pencils * 6 - 8 clipboards and string or tape to fasten clipboards to foot or head of bed * Thermometers * A few watches (or participants may all have their own) * * Dextrostix, blood samples, gloves for every participant Scales and length board, stadiometer for measuring infants and children

* Soap for handwashing, and a supply of clean cloth towels that can be washed or a supply of paper towels. (Participants must wash hands before and after clinical practice and between patients.) * If lab coats must be worn in the hospital, there should be one for each participant and facilitator, and these should be laundered as needed. To limit risk of transmitting infections, lab coats should not be shared. 18

PART TWO:

PREPARING FOR CLINICAL PRACTICE

1. Preparing the clinical instructor
A clinical instructor who meets the criteria specified in Part One of this Guide (see Criteria for selecting clinical instructor and facilitators) will not require extensive training. However, he must learn the content of the course and adapt to the methods presented in the Clinical Instructor Guide. For some clinical instructors, this is a major change in how they normally teach or conduct rounds. As the Course Director, you supervise the clinical instructor. Preparation of the clinical instructor should include the following steps: * * Send all of the course materials to the clinical instructor well in advance of the course. The clinical instructor should study all of the course materials, focusing especially on the Clinical Instructor Guide. (Note: Explain to the clinical instructor that selected activities will be conducted during the third day of facilitator training. Suggested activities are proposed on page 7 of the Clinical Instructor Guide. All clinical sessions will be conducted during the actual course.) The clinical instructor should discuss his responsibilities and any questions with you, so that you both understand and agree what he will do. Prior to facilitator training, the clinical instructor should visit the ward with the Course Director, as described in the next section. The clinical instructor should attend as much of facilitator training as possible to learn the content of the course and how the course is structured. On the third day of facilitator training, he should go early to work with the clinical assistant and translator, if needed, to prepare for selected activities. He will then practise these activities with the facilitators as participants. Refer to the Clinical Instructor Guide for details on how the instructor should prepare himself and the ward. Help the instructor to be sure that everything is ready and make arrangements for any remaining items.

* * * *

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2.

Visiting the ward to finalize arrangements

Prior to facilitator training, visit the hospital where clinical sessions will be conducted to meet the ward directors and staff, discuss, and confirm final arrangements. The clinical instructor should be present at this visit. 1. Briefly describe to the ward director the objectives of the course, the importance of clinical practice in the course, and the kinds of clinical signs and case management practices that participants will need to observe. Tour the areas where severely malnourished children may be seen in the hospital (this may include more than one ward): - Observe where children arrive, when they typically arrive, and where they are directed. (During one clinical session, participants will observe children in the admissions area or in the ward in order to identify those with severe malnutrition.) - Observe the emergency treatment area. - See the kitchen area and observe as F-75 and F-100 are prepared, if possible. - Observe how children are fed and how drugs are administered. - In all areas see what supplies and equipment are available. (Circle items not available on the list on pages 3 5 of this guide. Obtain items before the course begins.) 3. Discuss the schedule for clinical practice during facilitator training and the course. (Scheduling is described on page 22 of this guide and on pages 7 9 in the Clinical Instructor Guide.) During facilitator training, there will be a 2-hour clinical practice session on the third day. (Also, if desired and if there is time on the first day of facilitator training, there may be a brief tour of the ward.) During the course, several small groups will visit the ward at different times each day. Determine if there are certain times that are best for clinical practice or certain times that are not appropriate. Ask whether teaching sessions are conducted with parents on the ward and, if so, when they are conducted. Ask about play sessions as well. Explain that you would like participants to observe these sessions if possible. Agree on the schedule with the ward director. As soon as possible after the visit, confirm the schedule in writing. 4. Plan with the ward director what role the ward staff will play during the participants' clinical practice sessions. If possible, arrange for a clinical assistant (a regular staff member such as a nurse) to assist with clinical practice sessions. This staff member would help to identify suitable children. If necessary, arrange for a translator as well.

2.

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5.

Determine what participants will be allowed to do in the ward. It is expected that they will be allowed to feed children, monitor childrens respirations, pulse and temperature, and assist with activities such as weighing, measuring, and bathing (all with supervision). Brief ward staff so they understand what to expect during the clinical sessions (e.g., how many people will come, what they will be doing and learning). During some sessions, participants will observe and assist staff as they feed and give daily care to children in the ward. Get ideas from staff on the best ways to do this. Encourage their cooperation and thank them for their help.

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3. Scheduling clinical practice sessions

One clinical practice session must be scheduled during facilitator training, preferably for about 2 hours on the third day. This session will allow the clinical instructor to practise some of the activities planned for the course. It will allow the facilitators to become familiar with what will happen during clinical practice. During the course each small group will visit the ward once each day. Visits will be from 1 to 2 hours in length. Scheduling is discussed in detail in the Clinical Instructor Guide, pages 7 - 9. In Annex A is a blank form to use in figuring out the schedule for clinical training during the course. Plan the schedule with the clinical instructor and ward director. Make a copy for each participant. Example Here is an example of a schedule for clinical sessions in a course in which there are three small groups (groups A, B, C). Notice that groups visit the ward at different times each day to ensure that they observe different parts of the daily routine. Remember that your schedule may be very different, depending on the number of groups, the ward schedule, etc. Clinical Session
Day 1 Tour of Ward 1 hour Day 2 Clinical Signs 1.5 hours Day 3 Initial Mgmt 1.5 hours Day 4 Flexible half day, optional clinical practice Day 5 Initial Mgmt and Feeding 2 hours Day 6 Feeding 1.5 hours Day 7 Daily Care 1.5 hours Observe teaching session for mothers (occurs 14:00 4:30 daily) Observe play session (occurs 10:0011:00 daily)

Group A 11:00 12:00 9:00 10:30 13:30 15:00

Group B 13:00 14:00 10:45 12:15 9:00 - 10:30

Group C 14:15 15:15 13:30 15:00 10:45 12:15

All groups will observe play session at 10:00 10:45 12:45 (11:00 feed) 8:30 10:00 (9:00 feed) 13:00 14:30 Day 7 at 14:00 13:30 15:30 (15:00 feed) 10:15 11:45 (11:00 feed) 9:00 10:30 Day 5 at 14:00 8:30 10:30 (9:00 feed) 12:45 14:15 (13:00 feed) 10:45 12:15 Day 6 at 14:00

Day 4 at 10:00

Day 4 at 10:00

Day 4 at 10:00

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