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Authors: Carli Rogosin, MIA; Virginia Allread, MPH; and Mary Jo Hoyt, MSN, FNP, FrançoisXavier Bagnoud Center at the School of Nursing, University of Medicine and Dentistry of New Jersey Acknowledgements: The development of this clinical standard operating procedure (SOP) template was led by Nicole Buono, Project HEART Director and Elizabeth Flanagan, Senior Technical Officer as an activity of the Elizabeth Glaser Pediatric AIDS Foundation’s (EGPAF’s) Project HEART (Cooperative Agreement U62/CCU123541) in cooperation with EGPAF’s Technical Advisory Group (TAG) focused on supporting countries in the adaptation and implementation of the World Health Organization’s revised 2010 guidelines for HIV prevention, care and treatment. The clinical SOP template provided in this document was conceptualized based on feedback and review by technical directors, field-based clinical staff, and other senior staff. During the process, members of a technical review team proposed, agreed upon, and worked with the author to develop the template for SOPs for HIV prevention, care and treatment to meet the needs of country teams. The efforts of numerous individuals should be recognized. We would like to thank the following individuals for their contributions and assistance in the review and finalization of this SOP template: EGPAF Senior Technical Reviewer: RJ Simonds, Vice President of Program Innovation and Policy Technical Review Team: Denis Tindyebwa, Martha Mukaminega, Patricia Fassinou, and reviewers from Côte d’Ivoire: Ministry of Health’s National HIV Care and Treatment Program (PNPEC); implementing partners from ACONDA VS, ICAP, and HAI; health care workers from St. Thérèse de l’enfant Jésus, CIRBA, CHU Cocody and Treichville; and the Ivorian Pediatric Society. François-Xavier Bagnoud Center at the School of Nursing, University of Medicine and Dentistry of New Jersey for support: Deborah Hunte EGPAF Cover Design: Katherine Warminsky This publication was supported by the Centers for Disease Control and Prevention (CDC) through Cooperative Agreement U62/CCU123541. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. We also acknowledge the efforts of the author, technical review team, and editorial staff to ensure the quality of the publication. Finally, we would like to acknowledge the tireless efforts of our partners and staff around the world to eliminate pediatric AIDS, and the women, children and families in the countries where we work. Abbreviations and acronyms ARV ART BMI CTX DBS DOT DNA PCR HCW HIV IRIS MOH NVP SOP TB WHO Antiretroviral Antiretroviral treatment Body mass index Cotrimoxazole Dried blood spot Directly observed therapy Deoxyribonucleic acid-polymerase chain reaction Healthcare worker Human immunodeficiency virus Immune reconstitution inflammatory disease Ministry of Health Nevirapine Standard operating procedure; also, companion document FamilyCentered Care of HIV-Exposed and HIV-Infected Children in LowResource Settings: Standard Operating Procedures Tuberculosis World Health Organization Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Page 3 of 222 Clinical Mentoring Toolkit Section 1: Purpose of a mentorship program ....................................................... 6 1.1 Toolkit introduction............................................................................................ 6 1.2 Definition of clinical mentoring .......................................................................... 8 1.3 Role of the mentoring program ....................................................................... 11 Section 2: Planning the mentorship ..................................................................... 12 2.1 Roles and responsibilities ............................................................................... 12 2.2 Mentoring: getting started ............................................................................... 14 2.3 Needs assessment ......................................................................................... 18 2.4 Developing a monitoring & evaluation plan ..................................................... 20 Tool 2-A: Facility baseline needs assessment ...................................................... 21 Tool 2-B: Mentee learning needs assessment ...................................................... 25 Tool 2-C: Resource list ........................................................................................ 28 Section 3: Communication skills for mentors ..................................................... 29 3.1 Overview of essential mentor skills ................................................................. 29 3.2 Learning principles and styles ........................................................................ 30 3.3 Teaching styles ............................................................................................... 33 3.4 Communication skills ...................................................................................... 35 3.5 Teaching techniques....................................................................................... 44 Tool 3-A: VAK learning style self-assessment ...................................................... 49 Tool 3-B: Modified Honey-Mumford learning style questionnaire ......................... 52 Tool 3-C: Teaching style self-assessment ............................................................ 54 Tool 3-D: Checklist—ten steps for giving feedback .............................................. 58 Tool 3-E: Six steps for writing a case study ......................................................... 59 Tool 3-F: Case studies for pediatric HIV care and treatment ............................... 60 Tool 3-G: WHO suggestions for clinical case conferences ................................ 138 Section 4: Implementation .................................................................................. 141 4.1 Schedules and agendas ............................................................................... 141 4.2 Mentoring program models ........................................................................... 142 4.3 Defining and assessing competence ............................................................ 144 4.4 Reporting progress ....................................................................................... 146 Tool 4-A: Model mentoring schedule .................................................................. 148 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 4 of 222 Tool 4-B: Competency checklists ....................................................................... 150 Section 5:Monitoring and evaluation.................................................................. 194 5.1 The need for monitoring and evaluation ....................................................... 194 5.2 Developing indicators ................................................................................... 197 5.3 Timing and Responsible Parties ................................................................... 200 5.4 Methodologies for M&E ................................................................................ 202 Tool 5-A: Sample logframe for clinical mentoring project.................................... 205 Tool 5-B: Sample daily mentoring documentation form ...................................... 209 Tool 5-C: Sample quarterly report ...................................................................... 210 Tool 5-D: Pre- and post-mentoring questionnaire (for mentee) .......................... 213 Tool 5-E: Mentoring evaluation (for mentor) ....................................................... 215 Tool 5-F: Mentoring evaluation (for mentee)....................................................... 217 References and resources ............................................................................... 219 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 5 of 222 Section 1: Purpose of a mentorship program 1.1 Toolkit introduction Goal and objectives This clinical mentoring toolkit was developed to support mentors as they initiate their work as teachers and trainers. The underlying assumption is that the mentors to whom this toolkit is targeted are part of a larger mentoring effort lead by a district, regional or national health authority. The purpose of this package is to orient and support mentors as they embark on their efforts to train other healthcare workers (HCWs) in the provision of HIV-related care, treatment and support to children who are HIV-exposed or HIV-infected. The objectives of this toolkit are to: Provide mentors with an introduction to mentoring. Outline roles and responsibilities of mentors, mentees, and other staff involved in the mentoring program. Summarize some of the key learning, teaching and other communication skills that will support mentors in their work. Discuss the steps to initiate a clinical mentorship program, including the assessment of needs. Discuss competency standards. Outline mentorship follow-up activities. Provide an overview of how to monitor and evaluate mentorship activities. History and background Most clinicians currently providing HIV-related care and treatment, including ARV treatment, in primary and secondary health facilities are not pediatric specialists. Many clinicians providing care to children lack confidence in the care of those with HIV. Because HIV-exposed and HIV-infected children make up a significant part of their client population, it is critical that these clinicians are prepared to address the needs of this important and vulnerable group. Mentoring can be used to train HCWs experienced in the provision of care to children or in HIV-related care, treatment, and support of adults to provide similar support to infants, children, and adolescents who are HIV-exposed and HIV-infected. Mentoring is an important tool to train qualified HCWs to provide HIV-related care and treatment. In this way mentoring supports the decentralization of HIV-related care from the referral hospital to primary and secondary care facilities. This toolkit is designed to complement the document, Family-Centered Care of HIV- Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 6 of 222 Exposed and HIV-Infected Children in Low-Resource Settings: Standard Operating Procedures (SOPs). While the SOPs outline the steps in providing clinical care to infants, children and young adolescents who are HIV-exposed or HIV-infected, this toolkit provides guidance on training HCWs to provide that care. The competencies outlined in Section 4 of this toolkit are based on the SOPs. The competencies outline the skills which the mentor will help the mentee acquire. Adapting this toolkit While most of the tools in this document are intended to be used in their presented form, some, including the needs assessments and competency checklists, are better adapted for the specific mentoring program and local context. The program implementers as well as the mentors are responsible for identifying which tools require adaptation and making the necessary revisions. Mentors should feel free to further adapt the tools to meet the specific needs of their mentees. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 7 of 222 1.2 Definition of clinical mentoring What is clinical mentoring? The World Health Organization describes clinical mentoring as “a system of practical training and consultation that fosters ongoing professional development to yield sustainable high-quality clinical care outcomes.”1 The ICAP definition of clinical mentoring is more practical: “One-to-one, or one-to-small group approach to teaching clinical skills, supporting professional development and growth as well as providing collegial support to clinicians.”2 According to WHO, a clinical mentor in the pediatric HIV care and treatment context is a clinician with substantial expertise in pediatric HIV care and treatment who can “provide ongoing mentoring to less-experienced HIV clinical providers by responding to questions, reviewing clinical cases, providing feedback and assisting in case management.”3 One of the defining features of clinical mentoring is that it always takes place within the context of an ongoing relationship between mentor and mentee. This relationship is based on trust, communication, and support. The mentoring relationship takes place over time; it is not a one-off event. Mentoring focuses on real-world application. Since it occurs in a clinical setting— often the mentee’s workplace, but mentoring can also take place in the mentor’s workplace or in another clinical setting, such as a national center of excellence—the mentor and mentee focus on the specific challenges and issues facing the mentee every day, using the resources available. Mentors help the clinicians in their charge increase their clinical knowledge and skills, and also learn to take advantage of the resources at hand and access other resources that may have previously been inaccessible. Objectives of clinical mentoring While the specific objectives of a particular clinical mentoring program may vary in accordance with the health care system’s needs, WHO identifies the following general objectives: Supports the application of classroom learning to clinical care; Maintains and progressively improves the quality of clinical care; Builds the capacity of first- and second-level providers to manage unfamiliar or complicated pediatric cases or refer them when appropriate; Improves the motivation of health care workers by providing effective technical support.4 Clinical mentoring versus supportive supervision Clinical mentoring is a one-on-one or one-on-small group method of teaching clinical skills. It is carried out by an experienced clinician who has also been trained in teaching methodology. Supportive supervision “focuses on the conditions required for proper functioning of Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 8 of 222 the clinic and clinical team.” Those who carry out supportive supervision are not necessarily expert clinicians but they have the skills to assess conditions, identify gaps and needs, use problem-solving to address those needs, and establish next steps for the mid-to-long term5. See Figure 1.1 below. Figure 1.1: Overlap between clinical mentoring and supportive supervision Supportive supervision Space, equipment and forms Supply chain management Training, staffing, other human resource issues Entry points Patient satisfaction Patient flow and triage Clinic organization Patient monitoring and record-keeping Case management observation Team meetings Review of referral decisions Clinical mentoring Clinical case review Bedside teaching Journal club Morbidity and mortality rounds Assist with care and referral of complicated cases Available via distance communication From: WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings, 2006, p. 9. Audience for clinical mentoring The objectives and structure of a clinical mentoring program vary depending on the needs identified by the implementers and by the facility. This is why a needs assessment is a critical early step in setting up a clinical mentoring program. Mentoring programs should focus not only on building the individual capacity of HCWs, but also go beyond the needs of individual clinicians to address site- and system-specific capacity issues. So, for example, instead of simply teaching the physician to identify treatment failure and switch patients to second-line regimens, the mentor may also work with nurses and social workers on how to prevent treatment failure, with pharmacy and logistics personnel to ensure adequate and consistent drug supply, and with all staff on how to keep the client in care. High-quality pediatric HIV care and treatment in resource-limited settings requires the staff in a health facility to work together. This refers to a team approach in which physicians, nurses, counselors, outreach workers, pharmacists and laboratory technicians, as well as hospital administration and support staff, all work together to ensure that children and their families get the services they need to obtain and sustain good health. In smaller facilities, the healthcare team may extend beyond the facility’s own staff. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 9 of 222 Clinical mentoring can be conducted by individual mentors or by a team of multidisciplinary clinicians and auxiliary healthcare workers, each working with their respective counterpart at the facility, and all working together to establish effective skills, routines, and systems for holistic, family-centered health care. Clinical mentoring timing and phases “Mentoring should be seen as part of the continuum of education required to create competent health care providers.” Standardized pre-service and in-service training provide the foundation, both theoretical and practical, for education and clinical practice. Typically, mentoring picks up where pre-service and in-service training end and provides additional hands-on, individualized capacity development.6 Sometimes mentoring is provided as a component of pre-service or in-service training. In either case, mentor and mentee are both professionals and the mentoring experience occurs in the actual workplace. There are five phases of the clinical mentoring process:7 1. Relationship building; 2. Identifying areas for improvement; 3. Responsive coaching and modeling of best practices; 4. Advocating for environments conducive to good patient care and provider development; and 5. Data collection and reporting. All five phases are crucial to the mentoring process. Phases 1–3 highlight and rely on the mentor-mentee relationship that is central to mentoring. Phase 4 is a major focus of clinical systems mentoring. Phase 5 is critical to evaluating the success of the mentoring program. All five phases will be explored in this manual. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 10 of 222 1.3 Role of the mentoring program Cascade approach WHO states that clinical mentoring supports decentralized delivery of pediatric HIV care and treatment with high-quality care at all levels; it builds the capacity of firstand second-level providers to manage unfamiliar or complicated pediatric cases and to refer them when appropriate. Building the capacity of first- and second-level providers reduces the burden on tertiary healthcare facilities and makes pediatric HIV care and treatment services more available and accessible to geographically spread-out populations.8 Clinical mentoring prepares mentees to demonstrate and transmit best practices. Though they themselves have not been fully trained in mentoring, after completing a mentorship program the mentees will have learned skills and teaching techniques that enhance their ability to train others. Reducing burnout and turnover Successful clinical mentoring improves the motivation of healthcare workers by providing effective technical support. HCWs are better-equipped to manage the specific circumstances of their workplaces and roles, which helps reduce turnover and loss of workers from the healthcare system, either to burnout or emigration (“brain-drain”). Using this toolkit It is recommended that the mentor review this toolkit before initiating his or her first mentoring placement. The sections are designed to provide a general background in mentoring. The tools, particularly those in the appendices, are meant to be photocopied and used to support the implementation and monitoring of mentoring activities. Some tools require adaptation to the local context. This toolkit should be used in tandem with the SOPs. Where the SOPs indicate the steps required to provide quality care, the mentor will provide support around how to implement the steps, decision-making, and client-HCW communication. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 1: Purpose of a Mentorship Program Page 11 of 222 Section 2: Planning the mentorship 2.1 Roles and responsibilities Program supervisor The central organizing agency’s program supervisor: Oversees and facilitates mentor selection and orientation. Assists with regional and facility needs assessments. Oversees scheduling of mentorships. Helps select, obtain and distribute mentoring materials. Ensures that expectations are shared and understood. Acts as liaison between national health service, mentors, and facilities. Communicates regularly with mentors. Completes, compiles and analyzes mentoring reports and other data collection. Evaluates the mentors and mentees. Shares lessons learned with higher-level implementers and with mentors and facility supervisors. Mentor The mentor agrees to: Commit to the relationship for the full duration of the mentorship term. Establish ground rules. Ensure that expectations are shared and understood. Give constructive feedback to the mentee. Assess the mentee’s progress in clinical practice. Encourage self-reflection, decisions, and action. Assist with developing the capacity of the facility (or system) team. Complete reporting, as required. Evaluate the mentor program. Share lessons learned with program supervisor and higher-level implementers. Mentee The mentee is the primary beneficiary of the mentorship program. The mentee’s full participation during, and thorough evaluation and debriefing after, the mentorship are Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 12 of 222 critical pieces of a program’s success. As a participant in the mentorship program, the mentee agrees to: Assume responsibility for his or her own career development. Actively develop a constructive relationship with the mentor. Actively participate in the learning and mentoring process. Consult the mentor as needed. Evaluate the mentor program. Share lessons learned with colleagues. Facility supervisor As outlined in Section 1.2: Clinical mentoring versus supportive supervision, the facility supervisor’s role complements that of the clinical mentor. The specific role may vary from program to program and even from facility to facility. The facility supervisor may contribute to the mentorship program by: Assisting with mentorship needs assessments. Identifying need and requesting mentorship for her facility’s employees. Preparing space and materials for the mentorship activities. Welcoming the mentor into the facility and supporting the mentor while he or she is working with the facility staff. Collaborating with mentor and mentee to address facility-based or system based challenges. Reporting to the program supervisor, as requested. Evaluating the mentor’s performance, as requested. Evaluating the mentee’s progress, as requested. Administrative staff Facility administrators and other support staff may contribute to the mentorship program by: Conducting correspondence and other communication with the mentorship program leaders and the mentors themselves. Preparing space and materials for the mentorship activities. Assisting with logistics, including possible accommodation and transportation for the mentor. Assisting with reporting procedures. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 13 of 222 2.2 Mentoring: getting started Overview of mentorship process A pediatric clinical mentorship program is typically organized centrally, i.e., by a district, regional or national authority. The central organizing agency provides the program structure, acts as a coordinating body, recruits and sustains collaboration between stakeholders and uses its credibility to promote buy-in. Figure 2.2 provides an overview of the mentoring process starting from the point when a mentor (or team of mentors) is assigned to a particular health facility, with a focus on the role of the mentor(s). The role of the central organizing agency is outside the focus of this document. Figure 2.2: Steps in the initiation of a clinical mentorship program Step 1: Identify core team of mentors Mentor (or the team of mentors) is identified by central organizing agency. The mentor is responsible for contacting the site explaining his/her/team’s role, setting date of initial meeting. Step 2: Engage stakeholders and partners Meet with district health managers, facility administrators and other stakeholders. Introduce the mentoring program, its goals and objectives, and the objectives of working at the local site. Ask about their perception of needs, with a focus on pediatric care, treatment, and support, as well as their concerns and priorities. Ensure their suggestions are integrated into the overall mentoring plan. Commit to keeping this group of stakeholders informed. Meet with staff looking after children (MCH, OPD, IPD), and staff providing HIV services. Explain the mentoring program and introduce the objective of the visit (general). Invite staff to share what the health facility is doing in terms of HIV service delivery, with a focus on care for children who are HIV-exposed and infected. Receive staff feedback and suggestions on need and modalities of implementation. Introduce the need for a rapid participatory baseline assessment to inform a facility-specific action plan (including provider training needs). Get a named facility representative to work with you—preferably one of the staff you will be mentoring. Ensure assessment is informed by facility’s work plan. Step 3: Initiate implementation—conduct rapid assessment Conduct the baseline facility assessment: find out which HIV and pediatric services are provided at the facility, by whom, and where (i.e., points of service). See Section 2.2: Needs Assessment and Tool 2-A: Facility baseline needs assessment . Assess mentee learning needs. See Section 2.2: Needs Assessment and Tool 2-B: Mentee learning needs assessment. Assess access for children—entry points, mechanisms and volume of referrals, registration process, actual services provided, numbers of children in care, etc. Step 4: Analyze information and set plan Based on the findings of the rapid assessments, consider what can be done to expand and/or improve pediatric HIV care, treatment, and support services. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 14 of 222 Once these improvements have been determined: Revise goal (if necessary), set objectives and targets. Finalize plan to monitor and evaluate mentoring activities. Define a clinical mentoring schedule to support the achievement of these targets. Step 5: Initiate mentoring activities Brief stakeholders on the findings of the needs assessment: Discuss proposed plan, modify plan as per suggestions from stakeholders. Introduce mentorship tools. Institute monitoring and evaluation activities. Initiate mentoring activities with focus one one-to-one support. Initiate quality-improvement mechanisms. Share best practices. Step 6: Evaluate mentoring activities Collate and analyze monitoring data. Conduct interviews with mentees and stakeholder to assess changes is care that may be due to mentoring activities. Develop short report. Present outcomes to stakeholders. 9 Preparing mentees for pediatric care and treatment services Clinical mentoring for pediatric HIV care and treatment must address the lack of experience and, more importantly, lack of confidence that non-pediatric specialists have in regard to treating children. Appropriately assessing the mentee clinician’s level of skill and self-assurance is the first step. Clinical mentors should be familiar with the standard pre-service preparation that various cadres receive for pediatrics. The needs assessment (see Section 2.3) includes an assessment of mentee skills in pediatric HIV care and treatment. Mentees should be guided through the differences in practice and attitudes in providing care to children versus adults. Many tools are available in the companion document to this toolkit: Family-Centered Care of HIV-Exposed and HIV-Infected Children in Low-Resource Settings: Standard Operating Procedures (SOPs). Resource materials for mentorships The resources and materials for the mentorship should be decided based on the objectives of the program. If not made available centrally, the mentors, and when needed, the facility supervisors, should review, select, and make available the necessary resources. A partial list of needed resources is included as Tool 2-C: Resource list. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 15 of 222 Computers enabled for internet use are valuable for mentors and mentees who may need to access additional materials or clinical updates. Training the mentors Orientation Clinicians who are new to mentoring will benefit from an organized orientation. The orientation should introduce the clinicians to the concept of mentoring, strategies for building rapport and relationships, mentoring and teaching techniques, and assessment methods. Other topics to be covered include monitoring and evaluation of the mentorship program, program logistics, and roles and expectations. The orientation should also introduce the mentors to all available resources. The materials in this toolkit can be used as a basis for the training. Although those conducting the orientation should be experienced mentors, they do not necessarily need to be experts in pediatric HIV care and treatment, as the mentors being trained are considered experienced clinicians in that field. Where formal orientation is not provided to mentors, they may find it helpful to review the following before beginning their first mentoring assignment: This toolkit National policies, guidelines and SOPs for family-centered pediatric HIV care and treatment services Mentoring techniques and approaches Basic knowledge on quality improvement, in line with the established mentoring program goals and national policies Reporting responsibilities for the mentoring assignment Responsibilities regarding evaluation of mentees and the mentorship program10 Ongoing support for mentors Mentoring is an intense process for both mentor and mentee. Mentors can benefit from meeting with one another on a regular basis to discuss their mentorships. While difficult clinical cases can be discussed, the primary emphasis should be on the mentoring process and any challenges or lessons learned from it. Mentors should have access to each other, if not in person, via telephone or email; they also need inperson access to supervisors or master mentors who can assist with challenging situations. Academic institutions can act as valuable means of support for mentors in terms of in-house expertise in both pediatric HIV and mentoring, resources, and networking opportunities. Partnering institutions can assist with the training and preparation of mentors, as well as host the meetings and conferences that serve for on-going development and support. Mentor performance should be evaluated as a part of the mentorship program. This Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 16 of 222 is discussed in more detail in Section 5: Monitoring and Evaluation. Related tools Tool 2-A: Facility baseline needs assessment Tool 2-B: Mentee learning needs assessment Tool 2-C: Resource list I-TECH Mentoring Case Study Bank (part of Clinical Mentoring Toolkit Training Curriculum) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 17 of 222 2.3 Needs assessment Conducting needs assessments Conducting needs assessments takes time, planning, and resources. However, they are of critical importance. They establish need, ascertain baselines, and begin the process of relationship building between the facility staff and the mentoring program. This toolkit describes two types of needs assessments: facility-based baseline needs assessment and staff-based learning needs assessment. Conduct a facility-based baseline needs assessment to find out more about the pediatric HIV care, treatment, and support services provided at the facility as well as any barriers to offering these services. The baseline needs assessment also inquires about staffing, procurement supply management, and monitoring of services. It would typically be administered to a district health manager, facility administrators or clinic manager. The assessment should be administered in a conversational, informal manner to encourage interviewees to relax and discuss issues and successes openly. If there is sufficient time, the mentor should administer the baseline needs assessment to at least 2 or 3 people either on a one-to-one basis or in a small group. Feedback from more than one person gives the opportunity to validate responses. An example of a baseline assessment tool can be found in Tool 2-A: Facility baseline needs assessment . Note that this tool must be adapted for the circumstances in the specific facility being assessed. Staff-based learning needs assessment is a questionnaire administered, on a one-to-one basis, with the HCWs who will be mentored. This structured conversation provides an opportunity to find out the mentee’s learning needs and gives the mentor an opportunity to get to know his or her future trainee. The conversation should be confidential to encourage honest discussion about needs without fear of reprisal. An example of a staff-based needs assessment questionnaire can be found in Tool 2-B: Mentee learning needs assessment. Like the facility assessment tool, it must be adapted to the specific mentoring program. The needs assessment should also include: A review of actual practice in comparison to the standards of procedure (See Family-Centered Care of HIV-Exposed and HIV-Infected Children in LowResource Settings: Standard Operating Procedures (SOPs)). It should explore causes (e.g., lack of resources, need for further mentoring and training, etc.) where actual practice does not meet standards. A discussion of the mentee’s goals and objectives for the mentoring relationship. While the mentor may already have a sense of the general training goals, including the clinical skills that need to be acquired, it is important that the mentee take an active role in determining his or her learning needs and objectives. Clinical learning objectives are related to three areas: Knowledge Attitudes Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Psychomotor Skills Page 18 of 222 Once the needs assessments have been completed, the mentor should synthesize the facility and mentee needs, keeping in mind the following: Access to care for children—entry points, mechanisms and volume of referrals, registration process, actual services provided, numbers of children in care Timely diagnosis of HIV among children coming for other services Expansion of HIV services (including referrals) to meet local need Capacity development for specific staff Information about staff development and morale The needs assessments should also include a summary of mentoring priorities, a proposed mentoring schedule, and a plan to ensure that the facility can eventually provide sustainable pediatric HIV care, treatment, and support services without mentoring support. Final recommendations will need to take into account the resource constraints faced by the health facility. Related tools Tool 2-A: Facility baseline needs assessment Tool 2-B: Mentee learning needs assessment Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 19 of 222 2.4 Developing a monitoring & evaluation plan Section 5: Monitoring and Evaluation goes into depth about monitoring, reporting, developing indicators, and evaluation. Developing a monitoring and evaluation (M&E) plan is an integral part of the mentorship program development process. Determining the objectives of the program, the scope of the interventions, and the timing of evaluation must take place at the beginning of the process. If the program is implemented before there is a clear M&E plan, key data is liable to be lost. A solid M&E plan can also guide the methods used in implementation. As described in Section 5.2, targets and indicators for program activities should be determined early in the development phase. Other parts of the M&E plan include: Timeframe for monitoring reports Timeframe for mid-term and final evaluation Anticipated data collection tools Schedule and procedure for developing data collection tools Job/role description for those involved in data collection and evaluation Scope of the evaluation Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 20 of 222 Tool 2-A: Facility baseline needs assessment Name of facility: Address: Date: Introduction: Hello. My name is____________________. I am here to support the development of your facility’s pediatric care services. I will be working with staff in your clinic for the next [time period]. Before I start, I’d like to ask you a few questions about the pediatric services offered here. This is not a test; there are no right or wrong answers. I greatly appreciate your taking the time to speak with me. May I go ahead and start? Do you have any questions for me before we begin?11 Question Pediatric HIV care and treatment services overview What are the clinic’s hours of operation? Response Comment How many days per week do you offer any type of infant or child health service including EPI clinic? On a normal clinic day, how many children are seen? Describe any variation in the volume of visits, e.g., does the number of visits vary by day? Are there any seasonal variations? What services do these children typically need? What are the most common health issues you see in this area? How many HCWs are usually assigned to your child health clinics? How many nurses? How many physicians? How many other HCWs? What are their job titles (e.g., pharmacist, outreach worker, counselor, etc)? How are pediatric HIV care, treatment, and support services managed and supervised (e.g., does the clinic have an on-site manager or physician responsible for ensuring the quality of services; if so, who is this person and how do they manage and supervise pediatric services)? How are the staff that provide pediatric HIV care and treatment services managed and supervised (e.g., by the clinic manager, clinic medical officer, district medical officer or someone else)? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 21 of 222 How many examination rooms are there for pediatric examinations? On average, how much times does a pediatric patient spend at the clinic? What percentage of your pediatric population is either HIV-exposed or HIVinfected? Question Specific services What services are offered to your pediatric patients: Response Yes/No* Comment Physical examination? Growth monitoring? ARV prophylaxis (for infants)? Cotrimoxazole prophylaxis? Support for infant feeding? Immunizations and vitamin A supplementation? HIV virological testing? HIV antibody testing? Presumptive diagnosis of HIV if virological testing is not (yet) available? Counseling and support for breastfeeding? Counseling and support for formula feeding? Counseling and support for complementary feeding? Nutritional assessment and support for those with special needs? HIV related assessment and routine care? Clinical and immunological staging? Adherence assessment and support? What occurs at the pre-ART/readiness assessment visits? On average, how Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 22 of 222 long does the pre-ART /readiness process take? How is adherence to medications assessed? Prescribing ART? Monitoring of children on ART? What is the ART follow-up schedule? How is lost to follow-up defined? How is it documented? Assessment and management of ART drug toxicities? Identification of ART failure? Assessment and management of anemia? Assessment and management of common symptoms in children with HIV, e.g., cough and difficulty breathing, dermatological problems, diarrhea and other gastrointestinal problems, fever, and pain? Screening for TB exposure and TB disease? Screening and management of other OIs, such as candidiasis, otitis media, pneumonia and UTI? Psychosocial assessment? What is the process for assessing needs for referrals, making referrals and following up on referrals? Disclosure counseling? Question Facility infrastructure Does the clinic have a work plan or written strategy? May I see it? Response Comment Please comment on your commodity management system and any difficulties you face. Where is blood drawn for pediatric testing and monitoring? Are the following available for blood draw? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 23 of 222 Disposable needles & syringes Gloves Sharps box Running water Hand washing items (i.e. hand soap) Do your patients have to pay for services? If so, how much? Is there a waiver/exemption policy for women who cannot pay? Question M&E May I see the facility patient registers? (Interviewer: describe the range of registers—TB, ANC or PMTCT, VCT, ART, HIV-exposed infant, etc—as well as information inside and any strengths and/or weaknesses noted.) Response Comment How are other patient records kept? May I see the clinic SOPs (if they exist) and any other guidelines (such as IYCF, TB, IMCI) that HCWs are expected to follow? May I see the most recent monthly, quarterly or annual performance report submitted to the Ministry of Health? * If the response is “no”, ask “Where clients are referred for this service?” Adapted from: Family Health International Institute for HIV/AIDS. Baseline assessment tools for preventing mother-to-child transmission (PMTCT) of HIV. Prenatal Care Assessment Tool. EGPAF, 2003. http://www.fhi.org/NR/rdonlyres/ejkelmgqgkbumgmsmuzbeaiys3rjpgbnzed5jtygb26iny2vhlk4naexoprc woy6u6e5vnsfcd4yga/PMTCTreportcorrectedFINAL.pdf Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 24 of 222 Tool 2-B: Mentee learning needs assessment Name of staff: Name of facility: Address: Date: Introduction: Hello. My name is____________________. I am here to support the development of your facility’s pediatric care services. I will be working with you and other staff in your clinic for the next [time period]. Before I start, I’d like to ask you a few questions about your background in HIV and pediatrics as well as the topic areas about which you would like to know more. This is not a test; there are no right or wrong answers. I greatly appreciate your taking the time to speak with me. May I go ahead and start? Do you have any questions for me before we begin? Part 1: Question Response Comment What questions do you have about the mentoring process we are about to embark on? How many years or months have you been working here? Have you always worked in the same capacity? How many years of experience do you have working in HIV? How many years of experience do you have working with children? What academic preparation did you have for your position? What other relevant courses have you taken? What are your goals for this mentoring relationship? What topic/skills areas would you specifically like for me to cover? Did you request additional training or do you feel like this was imposed on you? What are your feelings about it now? What, if any, fears do you have about this mentoring process? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 25 of 222 Part 2: What services do you feel comfortable providing? (Ask only the questions relevant to the cadre of HCW interviewed.) Cadre P N C Question Comment O Physical examination? Growth monitoring? Selfassessment ARV prophylaxis (for infants)? Cotrimoxazole prophylaxis? Support for infant feeding? Immunizations? Vitamin A supplementation? Routine de-worming? HIV virological testing? HIV antibody testing? Presumptive diagnosis of HIV if virological testing is not (yet) available? Counseling and support for breastfeeding? Counseling and support for formula feeding? Counseling and support for complementary feeding? Nutritional assessment and support for those with special needs? HIV related assessment and routine care? Clinical and immunological staging? Adherence assessment and support? Prescribing ART? Monitoring of children on ART? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 26 of 222 Assessment and management of ART drug toxicities? Identification of ART failure? Assessment and management of anemia? Assessment and management of common symptoms in children with HIV, e.g., cough and difficulty breathing, dermatological problems, diarrhea and other gastrointestinal problems, fever, and pain? Screening for TB exposure and TB disease? Screening and management of other OIs, such as candidiasis, otitis media, pneumonia and UTI? Psychosocial assessment? Disclosure counseling? Cadre codes P = physician N = nurse C = counselor O = other (please specify) Self-assessment codes 1 I don’t know how to do this, or can do this but I feel I need further training 2 I can do this to standard 3 I am an expert in this area and feel comfortable teaching others NA Not applicable Additional detail for all of the above service areas can be found in Family-Centered Care of HIV-Exposed and HIV-Infected Children in Low-Resource Settings: Standard Operating Procedures (SOPs). Part 3: Question Response Comment What other services in the area of HIV pediatric care and treatment do you offer? What services not mentioned above should be offered at this facility? Adapted from: Family Health International Institute for HIV/AIDS. Baseline assessment tools for preventing mother-to-child transmission (PMTCT) of HIV. “Prenatal Care Assessment Tool”. EGPAF, 2003. Available at: http://www.fhi.org/NR/rdonlyres/ejkelmgqgkbumgmsmuzbeaiys3rjpgbnzed5jtygb26iny2vhlk4naexoprc woy6u6e5vnsfcd4yga/PMTCTreportcorrectedFINAL.pdf Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 27 of 222 Tool 2-C: Resource list Category and items General and pediatric HIV policies and guidelines National Pediatric HIV Care and Treatment Policies and Guidelines Applicable facility guidelines Supportive supervision policies, procedures, or manual Clinician support tools Pediatric HIV Care and Treatment Standard Operating Procedures Algorithms, posters, counseling cards, ARV cards, etc. Mentoring materials (teaching resources and program forms) Guidance for clinical mentors (orientation guide, manual, this toolkit, etc.) Copies of all mentoring program reporting forms List of mentoring program indicators Previous facility and mentoring reports Supplies Notebooks, pens Telephones and/or SIM cards Laptop computers (if needed) Other materials for mentor List of mentoring program, facility, and emergency contacts with name, title, facility, facility address, email address, and telephone number Expense tracking sheet/log Health and safety guidelines (if indicated) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 2: Planning the Mentorship Page 28 of 222 Section 3: Communication skills for mentors 3.1 Overview of essential mentor skills Skills and attributes of clinical mentors Clinical expertise alone is not enough. The mentor must have attributes that help create an enabling environment for learners, as well as technical competence in teaching and mentoring. Expertise/clinical skills and attributes: Knowledgeable, skilled and experienced in pediatric HIV care and treatment Currently provides pediatric HIV care and treatment services Familiar with the country’s health system; common illnesses; the context of HIV; cultural factors relating to health, sickness and HIV, including likely patient reactions and outcomes Mentoring and coaching skills: Uses effective mentoring techniques and coaching and communication skills to transfer knowledge/skills to the mentee Establishes an effective learning environment as part of a mentoring visit Helps the mentee and the client to feel comfortable with each other Gives focused, constructive feedback Ensures that communication flows appropriately in three directions between mentee-client, mentor-mentee, client-mentor Uses a variety of mentoring techniques such as bedside teaching, demonstration, clinical case review, and other methods Related Tools Tool 2-A: Facility baseline needs assessment Tool 2-B: Mentee learning needs assessment Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 29 of 222 3.2 Learning principles and styles Adult learning principles Adults learn differently than children. They bring their abilities and their life experiences to learning and, as a result, they desire more involvement in the learning process. The key to successful training and mentoring is the active participation of the mentee in establishing the goals and methods of learning. Equally important is that the mentor shares from his or her own personal experience, an integral part of building the mentoring relationship. Since most mentees are already involved in clinical practice, mentors show respect for mentees’ experience by asking them to share ideas, opinions, and knowledge, and by recognizing that they are a good resource of information themselves. The four main principles of adult learning are: 6. Adults need to feel comfortable and may be reluctant to take risks. 1. Create a comfortable and safe learning environment so that mentees feel confident that their contributions will be received respectfully. 2. Respect mentees’ different learning styles. Adapt to their needs and encourage them to explore new methods. 3. Build a relationship by sharing your experiences and commitment. 4. Be accountable for stating how you know what you know. Acknowledge when you do not know something, but be willing to find the answer. 7. Adults need to actively participate in their learning. 1. Give mentees opportunities to identify learning objectives and to participate in planning the learning. Ask them what they hope to learn and take away from the mentorship. 2. Check in at intervals to see if progress is made and whether the objectives have changed. 8. Adults have a wealth of life and work experiences. 1. Provide opportunities for mentees to share their knowledge and experiences. 2. Encourage mentees to think critically and problem-solve. 9. Adults value practical information that they can use. 1. Focus mentoring on providing knowledge and skills that mentees can make use of right away. 2. Provide a lot of opportunities for mentees to practice what they are learning and to address feelings as well as ideas and actions. 12 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 30 of 222 Learning styles There are numerous theories about how people learn. Although there is little evidence that teaching to an individual’s preferred learning style is effective, it can be assumed that using a variety of teaching methods is not only in line with adult teaching principles, but provides learners with variation that can motivate and inspire learning. Below is a discussion of two popular theories, the VAK and the Honey-Mumford models. Mentors should take some time to review these models, identify their own learning style, and consider how to teach to all of the preferences outlined in each model. Visual, auditory, kinesthetic (VAK) model The visual, auditory, kinesthetic (movement) model of learning suggests that learners use all three ways to receive and learn new information and experiences. However, according to the VAK theory one or two of these receiving styles is normally dominant. The dominant style defines the best way for a person to learn new information. This style may not always be the same for all tasks. The learner may prefer one style of learning for one task and a combination of other styles for a different task. A dynamic mentoring approach draws upon all three, which has two effects: all learners are reached regardless of their dominant style, and the variety keeps learners engaged. Suggestions for implementing the three VAK styles follow. Auditory learners often talk to themselves. They also may move their lips and read out loud. They may have difficulty with reading and writing tasks. They often do better talking to a colleague and hearing what was said. To integrate this style into the learning environment: Begin new material with a brief explanation of what is coming. Conclude with a summary of what has been covered. When teaching, use questions to draw as much information from mentees as possible and then fill in the gaps with your own expertise. Include auditory activities, such as brainstorming, and leave plenty of time to debrief activities. This allows mentees to recognize learning points from what they learned. Visual learners have two sub-categories—linguistic and spatial. Learners who are visual-linguistic like to learn through written language, such as reading and writing tasks. They remember what has been written down, even if they do not read it more than once. They like to write down directions and pay better attention to lectures if they watch them. Learners who are visualspatial usually have difficulty with the written language and do better with charts, demonstrations, videos, and other visual materials. They easily visualize faces and places by using their imagination and seldom get lost in new surroundings. To integrate this style into the learning environment: Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 31 of 222 Use graphs, charts, illustrations, or other visual aids. Include outlines, concept maps, agendas, handouts for reading and taking notes. Provide handouts for mentees to read after the learning session. Leave white space in handouts for note-taking. Invite questions to help them stay alert in auditory environments. Emphasize key points to facilitate note-takers. Have the mentees envision the topic or have them role-play the subject matter. Kinesthetic learners do best while touching and moving. This modality also has two sub-categories: kinesthetic (movement) and tactile (touch). They tend to lose concentration if there is little or no external stimulation or movement. When listening to lectures they may want to take notes for the sake of moving their hands. When reading, they like to skim the material first and then focus in on the details. They typically use colors if they can and take notes by drawing pictures or diagrams. To integrate this style into the learning environment: Use activities that get the learners up and moving. Use colored markers to emphasize key points on flipcharts or white boards. Guide mentees through a visualization of complex tasks. Have mentees transfer information from the text to another medium such as a laptop computer. 13 See Tool 3-A: VAK learning style self-assessment. The Honey-Mumford Model The Honey-Mumford model identifies four learning styles: activist, pragmatist, theorist, and reflector. As with the VAK learning styles, all learners use all of the styles to varying degrees. Mentors may want to have their mentees complete the questionnaire in Tool 3-B: Modified Honey-Mumford learning style questionnaire, to identify their learning styles. Mentors can use the model to read about the other learning styles and consider how to ensure they teach to all four styles of learning. Mentors and mentees who complete the self-assessment may recognize areas of strength, identify learning methods that best correspond to their dominant styles, and be alerted to weaknesses that can be addressed using different mentoring methods or guidance. Related tools Tool 3-A: VAK learning style self-assessment Tool 3-B: Modified Honey-Mumford learning style questionnaire Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 32 of 222 3.3 Teaching styles Pedagogy versus andragogy One way to look at teaching and learning styles is to consider differences in adult and child learning—andragogy and pedagogy. The pedagogical style is teacher-centered; the teacher decides what is taught and how it is taught. As a result the learner is dependent on the teacher for direction as well as the content itself. The focus of learning is to build a foundation of knowledge that may be useful later. Andragogy, which follows adult learning principles, is learner-centered. Learners take a much more active role in directing what they need. The focus of the learning is more on application of knowledge and the development of competency in skills needed at that moment. The role of the teacher is more as a facilitator of learning and a resource to the learner. The adult learner takes responsibility for his or her education. Each style of teaching is effective in some situations. In a mentoring situation, andragogy is more often appropriate. Ideally, the mentor will be able to develop and use a wide variety of styles based on the situation, the content being conveyed, and mentees’ learning styles (see Section 3.2). At times, the mentor should take control of the learning situation and work to ensure that the learner has a solid base of knowledge for future use. At other times learners must be encouraged and allowed to assess their needs and direct their learning. Teacher- versus learner-centered For best results, the adult learner should fully participate in his or her own learning process, working collaboratively with the teacher to determine learning objectives, methods, and then evaluate success. This is not to say that it is inappropriate to sometimes use teacher-focused methods. For some kinds of learning, this is necessary. As always, matching the method to the learning objective and the resources available for the learning activity is a necessary part of the planning process. Table 3.1: Teaching styles Teacher-centered ―――――――――――――――― Learnercentered Assertive Lectures Asks direct questions Gives factual information Suggestive Asks leading questions Offers opinions Facilitates clinical thinking Collaborative Elicits/accepts learner ideas Explores learner ideas Facilitates clinical thinking Facilitative Elicits/accepts learner feelings Offers feelings Promotes learner reflection From University of Virginia Preceptor Development Program Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 33 of 222 The assertive style is led entirely by the teacher. In the suggestive style the teacher still structures the interaction but instead of simply providing information, he or she leads the learner down a certain path through the line of questioning. The collaborative style shifts further toward the learnercentered end of the spectrum by exploring and accepting the learner’s ideas. In this case, the learner is the person organizing information. The facilitative style is the most learner-centered because it goes beyond exploring the learner’s ideas of the facts to also exploring the feelings of both learner and teacher. Providing family-centered HIV care, especially to children, can be both technically challenging and emotional, even for the most experienced clinicians. Collaborative and facilitative styles promote critical and creative thinking from a holistic perspective, better preparing mentees to address the wide-ranging interventions involved in pediatric HIV care and treatment. Tool 3-C: Teaching style self-assessment provides mentors with an opportunity to assess the styles with which he or she is most comfortable. Mentors most comfortable with a pedagogical and assertive style of teaching may need support to develop a more a more andragogical and facilitative style, which is more compatible with adult learning. Related tools Tool 3-C: Teaching style self-assessment Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 34 of 222 3.4 Communication skills Communication The centrality of the relationship between the experienced clinician and the mentee is what sets mentoring apart from supportive supervision and pre-service instruction. A strong relationship maximizes learning and sustainability. It fosters a sense of community and boosts individual and team morale. Strong relationships in the mentoring context require effective communication and trust. Effective communication Communication is the means by which we share information with others. It can take many forms: written (e.g., newspapers, memos, emails, books, notes, etc.), oral (e.g., conversation, speeches, radio programs, etc.), or non-verbal (e.g., body language, tone of voice, facial expressions, etc.). Interpersonal communication is the process by which we establish, develop, and maintain relationships. We also often use it to accomplish tasks. Successful communication requires mastery of some basic elements: clear expression of message, excellent listening skills, appropriate feedback and questioning, and positive non-verbal communication. The skills of effective communication are explained in detail below. Note that these are the same listening and learning skills taught to HCWs as the basis of client counseling—whether it is HIV pre- or post-test counseling or infant feeding counseling. By using the listening and learning skills mentors are not only using skills needed to communicate well but they are also modeling the communication skills that should be used with clients. Listening and learning skills Listening and learning skills Good mentors use verbal and non-verbal listening and learning skills to help mentees through the learning process. Mentors should: Use helpful non-verbal communication. Ask open-ended questions. Use responses and gestures that show interest. Reflect back what the individual says. Empathize—show an understanding of how she or he feels. Avoid words that sound judgmental. Skill 1: Use helpful non-verbal communication Non-verbal communication refers to all aspects of a message that are not conveyed Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 35 of 222 by the literal meaning of words. It includes the impact of gestures, gaze, posture and expressions capable of substituting for words and conveying information. Non-verbal communication reflects attitude. Helpful non-verbal communication encourages the mentee to feel that the mentor is engaged in the discussion. The acronym ROLES, as shown in Table 3.2 can be used to help remind mentors of behaviors that communicate that the mentor is actively listening. Table 3.2: Non-verbal behavior that conveys caring Explanation R A relaxed and natural attitude with mentees is important. Do not move around quickly or chat nervously. O Open posture should be adopted. Crossing one’s legs or arms can signal that you are critical of what the mentee is saying or are not listening. Using an open posture shows that you are open to the mentee and to what the mentee is saying. L Leaning forward toward the mentee at times is a natural sign of involvement. E Culturally appropriate eye contact should be maintained to communicate interest; never stare or glare at the mentee. S Sitting squarely facing another person shows involvement. If for any reason this may be threatening, then sitting to the side is an option. These physical behaviors convey respect and genuine caring. However, these are guidelines and should be adapted based on cultural and social expectations. Skill 2: Ask open-ended questions Asking questions helps identify, clarify and break down problems into smaller, more manageable parts. Open-ended questions begin with “how”, “what”, “when”, “where” or “why”. Open-ended questions encourage responses that lead to further discussion, whereas closed-ended questions tell a mentee the answer that the mentor expects; responses are usually one-word answers such as, “Yes” or “No”. Closed-ended questions usually start with words like “are you?” “did he?” “has she?” “does she?” Mentors should try to avoid questions that have a yes or no answer. For example, instead of asking, “Would you like to know more about 2nd line therapy?” the mentor may ask, “What questions do you have about 2nd line therapy?” Or, instead of “Do you understand this topic?” the mentor may ask, “What else shall I tell you about this topic?” or “Tell me, how do you think you’d apply this principle if your next patient was……?” Skill 3: Use gestures and responses that show interest Another way to show that the mentor is interested and wants to encourage a mentee to talk is to use gestures, such as nodding and smiling, and certain skills, such as clarifying and summarizing. These skills, also referred to as attending skills, Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 36 of 222 demonstrate that the mentor is actively listening to the mentee. These behaviors invite the mentee to relax and talk about herself or himself. Clarifying: Clarifying prevents misunderstanding and helps sort out what has been said. For example, if a mentee says, “We can’t diagnose HIV in 6-week-old infants because we ran out of DBS kits weeks ago and a new shipment isn’t expected till August” the mentor may respond by saying “It sounds like you haven’t been able to conduct early infant testing for weeks.” Summarizing: Summarizing pulls together themes of the discussion so that the mentee can see the whole picture. It also helps to ensure that the mentee and the mentor understand each other. Mentors should review the important points of the discussion and highlight any decisions made. Mentors can summarize key points at any time during the teaching session, not only at the end. Summarizing can offer support and encouragement to mentees and help to clarify complex topics. Skill 4: Reflect back what the mentee says "Reflecting back", also referred to as paraphrasing, means repeating back what a mentee has said to encourage her or him to say more. The person reflecting should try to say it in a slightly different way. For example, if a mentee says, “My patients have to wait outside all morning before I’m able to see them”, the mentor may reflect by saying, “It sounds like the clinic is short staffed and that is frustrating to you.” After the mentee confirms that this is an accurate reflection of what she or he said, the mentor can then say, “Let’s talk about that some more.” Reflecting back shows that the mentor is actively listening, encourages dialogue, and gives the mentor an opportunity to understand the mentee’s feelings in greater detail. Skill 5: Empathize—show an understanding of how she or he feels Empathy develops when one person is able to comprehend (or understand) what another person is feeling. One may feel compassionate toward the person. Empathy, however, is not the same as sympathy; sympathy implies that one feels sorry for (pity) the other person. Empathy is needed to understand how the mentee feels and helps to encourage the mentee to discuss issues further. For example if a mentee says, “I just can’t take the workload, I haven’t been able to take a holiday in nearly a year!” the mentor could respond by saying “It sounds like you’re burning out and really need a break as well as additional support.” Another example is if a visibly upset mentee says: “I just don’t have the medicines needed to treat this mother, as a result I think one more baby is going to be orphaned,” the mentor could respond by saying: “It sounds like the lack of resources really upsets you as it limits your ability to do a good job.” If the mentor responds with a factual question, for example, “Which medicine is it that you don’t have?” the mentee may not feel that the mentor understands what he or she is experiencing. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 37 of 222 Empathy is used to respond to a statement that is emotional. When empathizing, the mentor identifies and articulates the emotion behind a mentee’s statement. Skill 6: Avoid Judging words Judging words are words like: right, wrong, well, badly, good, enough and properly. If a mentor uses these words when asking questions, the mentee may feel that she or he is wrong, or that there is something wrong with the child. Examples of what NOT to say: “Did you give the correct dose of medicine?” “Did you follow my recommendation to discuss disclosure with the parents of that 8year-old? “Didn’t you understand what I told you yesterday about discussing family planning with every post-natal mother?” Instead ask: “What dose of medicine did you give? How did you calculate it?” “What else did you discuss with the child’s parents?” “Were you able to discuss disclosure?” “Typically, here’s what I say to broach the topic of disclosure…. ” “I notice you didn’t bring up the topic of family planning. Can you tell me more about that decision?” However, sometimes a mentor needs to use “good” judging words to build a mentee's confidence, and to recognize and praise the mentee when she or he is doing the right thing. For example: “I liked the creative way you worked the topic of family planning into the consultation.” Or “You are doing a great job here; your clients and co-workers are clearly very fond of you.”14 Building trust Trust is built by establishing credibility, accessibility and accountability. Credibility: The mentor should: Share her qualifications as an expert clinician and as a clinical mentor. Say when she doesn’t know something and follow-up with finding the answer. Give the reasoning behind her guidance and individual feedback. Be sensitive to local conditions and cultural issues. Accessibility: The mentor should: Be available for mentees to share their questions, concerns, and comments. Encourage all questions: “There is no such thing as a bad question.” Schedule mentoring visits with appropriate frequency. Acknowledge mentee strengths and accomplishments from the outset. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 38 of 222 Accountability: The mentor should: Be answerable to the program goals and objectives. Be answerable for standards of practice and instruction. Be answerable to professional and moral codes of conduct. Be answerable for his professional judgments of mentee performance. Maintain confidentiality and respect privacy.15 Barriers to communication Barriers to effective communication include: Not listening actively to the mentee. A mentor isn’t listening when he or she formulates a response before the mentee finishes asking a question, telling a story, or completing a procedure. Judging—as shown by statements that indicate that the mentee does not meet the mentor’s standards. Unwarranted reassuring—trying to induce undue optimism by making light of the mentee’s own version of a problem or challenge. Advising before the mentee has had enough information or time to arrive at a personal solution. Interrupting the mentee unnecessarily. Asking long and complex questions. Using language that is too technical or complex. Asking questions in a manner suggesting the desired answer. Asking questions in an interrogatory manner. Ignoring the mentee’s verbal or non-verbal cues. Making sudden, inappropriate changes in topics. Indicating patronizing or judgmental attitudes by verbal or non-verbal cues. Controlling the discussion rather than encouraging the mentee to state what he or she knows or how he or she would handle a particular situation. Preaching to the mentee. Encouraging dependence—increasing the mentee’s need for the mentor’s presence and guidance. Key mentoring approaches Key approaches for the mentor Think aloud: A mentor should make his/her own clinical reasoning transparent: Explaining the thought process that leads to a diagnosis Verbalizing the treatment options for a challenging case Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 39 of 222 Explaining why a particular course of action is chosen Activate the mentee: Mentors must encourage mentees to be motivated to connect their needs with patients’ needs. Use an adaptable, collaborative approach to clinical teaching—mentor must know when to stand back or jump in, while still giving enough freedom to the mentee to grow without hurting themselves or patients. Listen smart: It is important for the mentor to efficiently assess the mentee’s acquisition, synthesis, and presentation of clinical data, even if the mentor does not have previous knowledge about the patient.16 Effective questioning There are many different ways to ask questions and some are better than others for engaging the person being questioned and eliciting complex information, both of which are important for effective clinical mentoring. The manner of questioning will vary depending on the level of cognitive learning the mentor wishes to stimulate. The higher levels (application, analysis, synthesis, and evaluation) require more critical thinking than that needed for knowledge and comprehension. See Figure 3.3 on next page. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 40 of 222 Figure 3.3: Questioning and the six levels of cognitive learning Knowledge Remembering information Elicit facts What is the right dosage and route of administration of nevirapine for this patient? Comprehension Grasping the meaning What are the key physical findings of tuberculosis in a child? Application Using material in new situations Elicit reasons, strategies, and problemsolving Analysis Breaking material down into its parts Synthesis Putting material together in new ways What are some of the contributors to Kofi’s recent pneumonia? What is your proposed management plan for this patient? At the present time, what is the most appropriate approach to treat this child's poor growth? Evaluation Judging the value of material From: Bengamin S. Bloom, Bertram B. Mesia, and David R. Krathwohl (1964). Taxonomy of Educational Objectives (two vols: The Affective Domain & The Cognitive Domain). New York. David McKay. Helpful hints for effective questioning: Whenever possible, ask rather than tell. Ask one question at a time, as concisely as possible. Adjust the difficulty of your questions to the mentee's abilities, working towards increasingly higher levels of thinking. Include questions that help mentees explore their attitudes and feelings. Ask questions about process as well as outcome. Model the kinds of questions you want mentees to ask themselves. Avoid playing "Guess what I'm thinking". If you question the mentee in the presence of clients, be sensitive to the client's needs. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 41 of 222 Feedback Feedback is a critical part of the mentoring and learning process. Feedback is part of formative evaluation, which guides learning. Summative evaluation judges performance. Refer to Table 3.3 for the differences between the two. Mentors are the main providers of feedback and giving feedback is one of their primary duties. Mentors may or may not be involved in the summative evaluation of their mentees. Table 3.3: Feedback Compared to Evaluation Feedback Timing Timely (close to event) Setting Informal Basis Observation Content Objective Scope Specific Action Purpose Improvement Evaluation Scheduled (set intervals) Formal Observation Objective Global Performance “Grading” From: Bringing Education and Service Together (BEST) Curriculum, USC Importance of the mentoring relationship Learners accept feedback better when they feel the mentor has first taken time to understand their concerns and perspectives. Once the mentor has established trust and their credibility as part of the mentoring relationship, feedback will be better received and therefore more productive. However, it has been noted that, often, learners do not even realize that they are receiving feedback from a supervisor or teacher. Mentors should clearly identify their feedback: “Let’s talk about that patient encounter. Here is some initial feedback…”17 Elements of good feedback Good feedback: Is given soon after the learning event. Is given in a private setting. Relates to the learning objectives. Is specific. Focuses on the behavior, not the person. Allows the learner to self-assess. Includes comment on what was done well. Articulates the mentor’s reasoning behind his or her comments. Is constructive—negative comments are framed as learning points. Includes a clear plan for improvement—determined either by the mentor alone or through discussion between the mentor and mentee. See Tool 3-D: Checklist—ten steps for giving feedback. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 42 of 222 Other issues Stress and burnout Many healthcare workers have stressful jobs and mentees are no different. Some may feel isolated; others may be affected by HIV in their personal as well as professional lives. Problems with work or home life can have a major effect on one’s ability to learn and perform in the work setting. As mentors develop relationships with their mentees, they may come to recognize signs of stress or burnout, including attitudinal issues, drug/alcohol misuse, and high absenteeism. Sometimes mentors find themselves in the role of counselor as well as mentor, as they support their mentee’s personal as well as professional development. Related tools Tool 3-D: Checklist—ten steps for giving feedback Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 43 of 222 3.5 Teaching techniques Inspiring critical thinking Critical thinking includes reasoning, judgment, and decision-making. “A critical thinker can anticipate medical treatments and … interventions and often plans and coordinates care in advance.” Mentors and supervisors can encourage and develop critical thinking skills in their mentees by using a range of teaching methods, including demonstration, bed-side teaching, case studies, role play, case conferences, and email support. Mentors should actively plan and select their methods and tailor them to the needs of their mentees to best promote the critical thinking skills that are necessary for quality health care provision. 18 Mentor observation Observation The mentor should observe the mentee and the entire clinical team as they go about their duties. An initial observation period allows the mentor to get a sense of the daily routine, the processes and systems in place, the kinds of patients and cases that present at the health facility, and the individual characteristics of the mentee. This technique is especially useful for: Establishing the mentee’s performance baseline Observing attitudes towards clients and colleagues Observation is a useful technique to use throughout the mentoring process. It is important that the clients know why you are there observing the encounter. It is best not to give feedback until after the client has left. The exception to this is if the client’s well-being is at risk. The mentor can use checklists, SOPs, or simple note-taking to record information and track the mentee’s performance. Teaching techniques Demonstration The mentor has the mentee observe as he or she conducts a client encounter or other clinical task. The mentee may be assigned to follow along with a checklist or SOP. Demonstration should be followed by discussion and opportunities for the mentee to practice the demonstrated skills. The general process is as follows: Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 44 of 222 1. Mentor demonstrates the skill, providing an opportunity for the mentee to observe. 2. Mentor supervises the mentee who now is given the opportunity to practice the skill while the mentor observes. 3. Mentor monitors the mentee, giving her the opportunity to conduct the skill with as little interference as possible, taking into account the need to do no harm to the patient. 4. Mentor assists the mentee, giving her the opportunity to conduct the skill without the mentor. The mentor might want to discuss the procedure in advance, debrief afterwards, and be available but not necessarily present during the procedure. 19 Advancement from one step to another is not contingent on how many times the mentee has conducted the task but on her demonstration of competence and skill at the current level. This technique is especially useful for: Showing proper technique with a psychomotor skill (e. g. blood draw) Procedures unfamiliar to the mentee Bedside teaching Bedside teaching, whether ad hoc, specific, or done in ward rounds, is teaching that occurs during actual clinical care. It isn’t always at the bedside— it can also take place in the outpatient setting. Bedside teaching can also take place at the mentee’s clinic or another healthcare facility such as the national or regional/district center of excellence. The mentor can model skills, attitudes, and listening and learning skills during bedside teaching. The mentee gets the opportunity to apply what he or she has learned during classroom and practice learning activities. It differs from observation in that the teaching takes place during the encounter. It is similar to demonstration but offers more discussion and opportunity for the mentee to practice. The mentor should brief the mentee prior to joining the client. The mentor should also explain to the client the roles of the mentor and mentee. Feedback to the mentee should be given once the mentor and mentee have left the client’s side, unless the client’s well-being is in danger. This technique is especially useful for: Promoting good routines Real-life application On-the-spot thinking Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 45 of 222 Case study Case studies draw on hypothetical or historical scenarios. The mentee discusses a detailed case and explains his or her suggested course of action. The information for a given case can be given all at once or in stages, with discussion at each stage of clinical decision-making. This technique is especially useful for: Facilities that do not receive a wide variety or high number of cases, because it allows mentees to explore scenarios they might not see often in their facility Mentees with less experience, because the mentor can control all aspects of the case and the level of information See Tool 3-F: Case studies for pediatric HIV care and treatment for a collection of case studies related to this topic. The case studies can be used as they are, or adapted to the local cultural and clinical context. Role play Role play is similar to case studies in that they are not necessarily cases from the direct experience of the participants. However, in addition to prompting discussion about how to deal with a case, role play provides an opportunity to actually practice elements of the client encounter, including tasks and what to say to the client. Role plays can be emotionally intense because the players take on the identity of the client. It is therefore important to fully debrief once the role play has been completed. The debriefing can include discussion of the emotions experienced during the role play as well as the clinical aspects. Observers can follow along with checklists and SOPs to track mentee performance. This technique is especially useful for: Modeling interaction with clients Emotional topics such as disclosure Modeling attitudes Group learning Case conference The case conference is a periodic meeting, ideally every week, during which the clinical team meets to discuss the multi-disciplinary approach to treatment for individual clients. If the client volume is small, all the cases may be discussed each week. If the client volume is large, the team leader or mentor may select only particularly challenging, complex, or interesting cases to discuss. The case conference provides an opportunity to coordinate and harmonize interdisciplinary care and helps build the cohesiveness of the clinical team. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 46 of 222 Case conferences can also be held at longer intervals and using distancelearning methods such as conference calls or video-conferencing once the mentors are no longer providing on-site support or are between visits. This technique is especially useful for: Complex cases that call on the multidisciplinary team Team building See Tool 3-G: WHO suggestions for clinical case conferences. Lectures/Grand Rounds Lecture is a traditional teaching technique that is generally less interactive than other methods. The mentor gives a presentation on a specific topic to mentees and other clinical staff. Interactive lecture involves question and answer in the course of the presentation. If available, audio, video, demonstration, and other techniques can be incorporated into the lecture. This technique is especially useful for: Disseminating information to a large group at once Teaching technical material Introducing new material (that is later developed using more interactive techniques) Email support As more facilities and clinicians have access to computers and internet, email support is becoming more and more crucial to ongoing capacity-building efforts. Confidentiality regarding patient information must be protected in email correspondence. If the facility has the capacity to encrypt sensitive information, those tools should be used. If not, the facility should have a clear and enforceable policy regarding how patient information can and cannot be divulged in email correspondence. Often, patient names and identifying information can be disguised, allowing clinical questions to be discussed without impediment. This technique is especially useful for: Providing support when the mentor is not on-site Maintaining the mentorship relationship over time Answering questions that require resources or information not available onsite Related tools Tool 3-E: Six steps for writing a case study Tool 3-F: Case studies for pediatric HIV care and treatment Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 47 of 222 Tool 3-G: WHO suggestions for clinical case conferences See I-TECH Mentoring Case Study Bank, Basics of Clinical Mentoring, available at: http://www. go2itech. org/HTML/CM08/toolkit/training/index. html Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 48 of 222 Tool 3-A: VAK learning style self-assessment Instructions: Circle the answer that best represents how you generally behave. VAK learning style self-assessment 1. When I operate new equipment I generally: 1. read the instructions first 2. listen to an explanation from someone who has used it before 3. go ahead and have a go, I can figure it out as I use it 2. When I need directions for traveling I usually: 1. look at a map or ask for written directions 2. ask for spoken directions 3. follow my nose and maybe use a compass 3. When I cook a new dish I like to: 1. follow a written recipe 2. call a friend for an explanation 3. follow my instincts, testing as I cook 4. If I am teaching someone something new, I tend to: 1. write instructions down for them 2. give them a verbal explanation 3. demonstrate first and then let them try 5. I tend to say: 1. watch how I do it 2. listen to me explain 3. you have a try 6. During my free time I most enjoy: 1. reading or going to museums 2. listening to music and talking to my friends 3. playing sports or doing a hands-on project Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 49 of 222 7. When I am learning a new skill I am most comfortable: 1. watching what the teacher is doing 2. talking through with the teacher exactly what I am supposed to do 3. giving it a try myself and working it out as I go 8. When I concentrate I most often: 1. focus on the words or the pictures in front of me 2. discuss the problem and the possible solutions in my head 3. move around a lot, fiddle with pens and touch things 9. I choose household items, like furnishings, because I like: 1. their colors and how they look 2. the descriptions the sales staff gives me 3. their textures and what it feels like to touch them 10. My first memory is of: 1. looking at something 2. being spoken or sung to 3. doing something 11. When I am anxious I: 1. visualize the worst-case scenarios 2. talk over in my head what worries me most 3. cannot sit still, fiddle and move around constantly 12. I feel especially connected to other people because of: 1. how they look 2. what they say to me 3. how they make me feel 13. When I have to study for an exam I generally: 1. write lots of notes and diagrams 2. talk over my notes alone or with others 3. imagine making the movement or creating the formula Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 50 of 222 14. If I am explaining something to someone I tend to: 1. show them what I mean 2. explain to them in different ways until they understand 3. encourage them to try and talk them through my idea as they do it 15. I find it easiest to remember: 1. faces 2. names 3. things I have done 16. I remember things best by: 1. writing notes or keeping printed details 2. saying them aloud or repeating words and key points in my head 3. doing and practicing the activity or imagining it being done 17. I tend to say: 1. I see what you mean 2. I hear what you are saying 3. I know how you feel Count up your A, B and C responses. A’s = B’s = C’s = If you chose mostly A’s you have a VISUAL learning style. If you chose mostly B’s you have an AUDITORY learning style. If you chose mostly C’s you have a KINESTHETIC learning style. VAK Self-Assessment ©V Chislett MSc & A Chapman 2005 From: www. businessballs. com Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 51 of 222 Tool 3-B: Modified Honey-Mumford learning style questionnaire Instructions: Tick the white box at right if you agree with the statement at the left. After completing the questionnaire, you will add up the ticks in each column. QUESTION A P T Activist style Pragmatist Theorist style style R I find it easy to meet new people and make new friends. I am cautious and thoughtful. I get bored easily. I am a practical, “hands on” kind of person. I like to try things out for myself. My friends consider me to be a good listener. I have clear ideas about the best way to do things. I enjoy being the center of attention. I am a bit of a daydreamer. I keep a list of things to do. I like to experiment to find the best way to do things. I prefer to think things out logically. I like to concentrate on one thing at a time. People sometimes think of me as shy and quiet. I am a bit of a perfectionist. I am enthusiastic about life. I would rather “get on with the job” thank keep talking about it. I often notice things that other people miss. I act first, then think about the consequences later. I like to have everything in its proper place. I ask lots of questions. I like to think things through before getting involved. I enjoy trying out new things. I like the challenge of having a problem to solve. Reflector style TOTAL ticks Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 52 of 222 The higher numbers of total ticks for each column suggest areas that best match your learning styles. All of us use all the styles to a greater or lesser extent. Activists (Do) Immerse themselves fully in new experiences Enjoy here and now Open-minded, enthusiastic, flexible Act first, consider consequences later Seek to center activity around themselves Reflectors (Review) Stand back and observe Cautious, take a back seat Collect and analyze data about experiences and events, slow to reach conclusions Use information from past, present and immediate observations to maintain a big picture perspective Theorists (Conclude) Think through problems in a logical manner, value rationality and objectivity Assimilate disparate facts into coherent theories Disciplined, aiming to fit things into rational order Keen on basic assumptions, principles, theories, models and systems thinking Pragmatists (Plan) Keen to put ideas, theories and techniques into practice Search new ideas and experiment Act quickly and confidently on ideas, get straight to the point Are impatient with endless discussion * Note, this is an unscientific adaptation of Honey and Mumford’s LSQ instrument by Rapid BI based on the Honey and Mumford Model© of learning styles. The full LSQ can be found under copyright at www. peterhoney. com and Rapid Business Improvement, http://rapidbi. com/created/learningstyles Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 53 of 222 Tool 3-C: Teaching style self-assessment Instructions: For questions 1-18, each item is a statement from a mentor to a mentee. As you read it, focus less on the content and more on the manner in which the question or statement is given. Indicate on the scale on the righthand side your level of comfort in using this style of question or statement. There are no right or wrong answers―only preferences. 1 = very uncomfortable 2 = somewhat uncomfortable 3= neutral 1. “We’ve got a few minutes now… I’ll give you my 10-minute talk on ______________. ” 2. “What are the seven causes of _____________?” 3. “______________ is an important and common problem. Read this chapter so that you will know more about it. ” 4. “We’ve got a few minutes now… What would you like to discuss?” 5. “We saw two patients with ____________ today. What useful things did you learn and what questions do you still have?” 6. “Look carefully at your knowledge base and your clinical skills and let me know tomorrow what needs improvement and how we can work on that over our remaining time together.” 7. “What is the drug of choice for _________________?” 8. “Amoxicillin is an option for that purpose, but what other options might be better due to increases in resistance patterns?” 9. “How did you arrive at that diagnosis 4= somewhat comfortable 5= very comfortable Very uncomfortable 1 2 3 5 Very comfortable 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 5 5 5 5 5 5 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 54 of 222 and why?” 10. “O. K. So your working diagnosis for this patient is _______________. What would you recommend for treatment and why?” 11. “What if the lab test were normal? Would that change your diagnosis?” 12. “Agnes shared some difficult information about her illness with you. How did that make you feel?” 13. “There is a wide variety of opinion on how to approach that ethical situation. What do you think you would do?” 14. “You seem to be having difficulty in dealing with this patient. What issues do you think this situation might be bringing up for you?” Very uncomfortable 5 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 5 5 5 5 16. “Watch my technique with this patient and I’ll supervise you for the next.” 5 18. “Have you done this before? O. K. I’ll watch you do it.” 1 5 15. “I’m going to watch you interview this next patient.” 17. “I know you’ve not done this before but I’ll be right there to help you.” Very comfortable 5 5 Assessment Response Guide Questions 1-6 reflect variations on a pedagogic or andragogic learning style: Question 1: "We've got a few minutes now. I’ll give you my 10 minute talk on ___." This statement indicates a teacher centered approach to using available teaching time. In this case, the teacher selects the topic and mode of teaching. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 55 of 222 Question 2: "What are the seven causes of _________?" This style asks for a listing of seven specific causes of a medical problem. The implication is that the student will recite these from memory, a type of inquiry used in a pedagogic style. Both of these approaches may be useful with a student who has a poor knowledge base. Question 3: "______ is an important and common problem. Read this chapter so that you will know more about it." In this example, the teacher determines the subject matter and the material and mode of learning. Question 4: "We've got a few minutes now. What would you like to discuss?" The preceptor allows the student to determine the content of some teaching time and implies discussion rather than a more formal talk or lecture. This is in keeping with a more andragogical style of teaching. Question 5: "We saw two patients with _______ today. What useful things did you learn and what questions remain?" Here, the preceptor asks the student to assess what they already knew about a clinical problem and to determine what additional learning was needed. Question 6: "Look carefully at your knowledge base and your clinical skills and let me know tomorrow what needs improvement and how we can work on that over the remaining three weeks." An even more in-depth self-assessment is asked of the student and significant responsibility for self-directed learning is offered. Both of the pedagogical and andragogical styles are useful, depending upon the student's skills and abilities. You may have tendencies to be more or less comfortable using certain styles. There is no right or wrong teaching (or learning) style. If you are comfortable with the components of both of these styles, it is likely that you are innately comfortable dealing with students at a variety of skill levels. If you tend towards a certain approach, you probably are most comfortable dealing with students for whom this approach is most appropriate. However, expanding your repertoire may be useful in order to maximize your educational encounters with students of a variety of levels. Questions 7-12 from the “Teaching style self-assessment” tool explore your comfort with the Assertive-Suggestive-Collaborative-Facilitative teaching styles. Look at each of the questions below and identify which teaching style is represented. Question 7: "What is the drug of choice for ___________?" This question addresses the assertive style, asking for very specific information. Question 8: "Amoxicillin is an option for that purpose, but what other options might be better due to increases in resistance patterns?" Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 56 of 222 This is a suggestive statement; the student is being led down the clinical thought process through the line of questioning. Question 9: "How did you arrive at that diagnosis and why?" Question 10: "O. K. So your working diagnosis for this patient is ______. What plan would you recommend and why?" Both of these questions explore the student's ideas for their decision. This is a very useful assessment technique, as it allows the teacher to assess not only if the answer itself is right or wrong, but the process by which that answer was arrived. Question 11: "What if the x-ray was normal? Would that change your diagnosis?" This questioning technique varies a clinical situation in order to assess other aspects of the student's knowledge. It still falls under the collaborative style. Question 12: "Agnes shared some difficult information about his illness with you. How did that make you feel?" This question falls under the facilitative style, discussing the feelings elicited in a patient encounter. In this case, the student's experiences are what are most important and they drive the interaction. Make a note of the teaching style(s) you prefer. Are there any styles that you would like to experiment more with to expand your teaching repertoire? Questions 12-13 of the “Teaching style self-assessment” tool assess student attitudes. Students' attitudes are most accurately reflected by their behavior, but discussion of these ideas and opinions can be fostered through questioning. Exploration of feelings is a part of the facilitative teaching style. Question 13: "There is a wide variety of opinion on how to approach that ethical situation. What do you think you would do?" Ethical issues may arise from time to time in practice. Although you and your mentees may vary in your comfort in discussing them, they are good opportunities to explore the attitudes of your mentees. Question 14: "You seem to be having difficulty in dealing with this patient. What issues do you think this situation might be bringing up for you?" It is a high-level skill for the clinician to be able to comfortably self-assess an unexpected emotional reaction to a patient. As a preceptor, you can help your mentees develop this skill through the kinds of questions you ask. Questions 16, 17, and 18 refer to teaching technical skills. Adapted from “Teaching Style Self-Assessment,” University of Virginia Health System Preceptor Development Program curriculum, Module 2: Teaching and Learning Styles. http://www. med-ed. virginia. edu/courses/fm/precept/module2 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 57 of 222 Tool 3-D: Checklist—ten steps for giving feedback Solicit mentee thoughts, concerns and questions about the mentoring activity. Listen to the mentee, using attentive body language, and without interrupting. Ask the mentee to identify their needs with regard to this mentoring session. Provide specific positive feedback that shows what the mentee was doing right. Provide specific corrective feedback that shows what the mentee needs to change. Offer specific suggestions for improvement. Prioritize goals (if necessary). Offer other resources for improvement, as needed. Arrange for a follow-up mentoring activity or discussion. Have the mentee summarize the feedback and the improvement plan. Adapted from USC BEST Curriculum Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 58 of 222 Tool 3-E: Six steps for writing a case study 19. Establish the learning objective(s) for the case study—what do you want your audience to learn? 20. Describe the patient and give case detail. 1. Provide baseline information (e. g., sex, age, HIV status, WHO clinical stage, symptoms, recent medical history, relevant social history). 2. Move the story and learner toward the first clinical decision point. 3. Keep the information brief but include all detail necessary for decision-making. 21. Focus the mentee’s attention on discrete clinical decision-making opportunities. 1. Relate the opportunities to the learning objective(s). 22. (Optional) Present several decision options. 1. Options should be relevant. 2. Only one option at a time can be plausibly chosen. 3. Each option should be about the same length, demonstrate the same importance, be equally plausible, and give the same level of detail so the learner is not prejudiced toward any one option. 23. Identify the correct (preferred) response. 1. Discuss the correct (preferred) response. 2. Give the clinical evidence and reasoning to support it. 24. (Optional) Give new, additional information to lead learners to another clinical decision-making point. Adapted from I-TECH Clinical Mentoring Toolkit, Developing Clinical Case Studies Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 59 of 222 Tool 3-F: Case studies for pediatric HIV care and treatment Topic 1: Family-centered care ................................................................... 62 Case study 1: Paulvie and Lucien .................................................................. 62 Case study 2: Limpho and Thandie ............................................................... 62 Topic 2: Developmental monitoring .......................................................... 63 Case study 1: Nomble.................................................................................... 63 Case study 2: Sulaiman ................................................................................. 64 Case study 3: Ernesto.................................................................................... 64 Topic 3: Infant feeding in the context of HIV ............................................ 66 Case study 1: Mwenzi .................................................................................... 66 Case study 2: Selina ...................................................................................... 67 Topic 4: HIV testing of infants and young children ................................. 68 Case study 1: Maria ....................................................................................... 70 Case study 2: Boubacar ................................................................................. 70 Case study 3: Dwe ......................................................................................... 70 Topic 5: HIV counseling for pediatric HIV testing .................................... 71 Topic 6: Routine care of the child with HIV infection .............................. 73 Case study 1: Joshua .................................................................................... 74 Case study 2: Tiro .......................................................................................... 74 Case study 3: George .................................................................................... 74 Topic 7: Initiating ART ................................................................................ 76 Case study 1: Francine .................................................................................. 77 Case study 2: José ........................................................................................ 77 Case study 3: Tigist ....................................................................................... 77 Topic 8: Growth monitoring ........................................................................ 79 Case study 1 .................................................................................................. 81 Case study 2 .................................................................................................. 81 Case study 3 .................................................................................................. 82 Case study 4 .................................................................................................. 82 Case study 5: Lerato ...................................................................................... 83 Case study 6: Nomble.................................................................................... 85 Case study 7: Tebogo .................................................................................... 86 Case study 8: James ..................................................................................... 88 Case study 9: Tumelo .................................................................................... 89 Case study 10: Nelson ................................................................................... 91 Case study 11: Neelum .................................................................................. 93 Case study 12: Lesedi ................................................................................... 94 Sub-topic 8.1: Breastfeeding, malnutrition, and HIV disease .................. 94 Case study 1: Josiah...................................................................................... 94 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 60 of 222 Case study 2: Mamello .................................................................................. 96 Sub-topic 8.2: Abnormalities in head circumference ............................. 101 Case study 1: Kagiso ................................................................................... 101 Case study 2: Hendrick ................................................................................ 103 Sub-topic 8.3: Growth pattern of the HIV-infected child ........................ 107 Case study 1: Siphiwe ................................................................................. 107 Case study 2: Kefilwe .................................................................................. 110 Case study 3: Abraham ............................................................................... 113 Sub-topic 8.4: Recording and interpreting BMI ....................................... 116 Case study 1: Agnes .................................................................................... 116 Case study 2: Sipho ..................................................................................... 117 Sub-topic 8.5: Using weight for length/height chart ............................... 121 Case study 1: Precious ................................................................................ 121 Case study 2: Thabo .................................................................................... 123 Case study 3: Kopano.................................................................................. 125 Case study 4: Joseph .................................................................................. 127 Case study 5: Palesa ................................................................................... 129 Case study 6: Ruth ...................................................................................... 131 Case study 7: Emily ..................................................................................... 133 Case study 8: Vusi ....................................................................................... 135 Key points on growth monitoring............................................................. 137 These case studies should be adapted to the local context but, in many cases, can be used as they are. They may be used for individual or group mentoring or teaching. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 61 of 222 Topic 1: Family-centered care These case studies emphasize that caring for a child in the context of family is critical to the health of the child. Healthcare workers should identify concrete actions and strategies to better implement a family-centered approach to care. The family-centered approach to care acknowledges that the best health outcomes occur when clinicians recognize that the family is central to supporting the health of the child. A healthy, engaged and involved family is the best environment for the child. In this approach, the clinician engages the child and caregivers in the clinical assessment and decision-making. The approach also provides support and reduces barriers to health care for the entire family. Case Studies Case study 1: Paulvie and Lucien Paulvie, a mother of four, has spent two hours in a crowded waiting room with all of her children. She has come to the clinic today because her three-yearold child, Lucien, has had a fever for two days. She is finally ushered into the exam room by a pleasant but uninterested nurse, who takes Lucien’s temperature and weight, tells him to take off his shirt, and leaves the room. A few minutes later the healthcare worker enters the room and asks, “Why are you here today?” Paulvie describes the fever and other symptoms; the healthcare worker does not comment. He examines the child without speaking to him, and then says “It’s just a virus. He will be OK,” and leaves. Case study 2: Limpho and Thandie Limpho brought her daughter, Thandie, to the hospital at 19h. Thandie is fouryears-old and has had a fever for two days. Limpho was working all day and so wasn’t able to bring Thandie to the clinic during the day. She left her other three children in the care of her husband, but she is worried because he has to leave for work at 22h; it is 21h when she and Thandie are called to the exam room. The healthcare worker greets Limpho and Thandie, introduces herself and sits down. She acknowledges the long wait for attention before asking Limpho a number of questions about Thandie’s health and current symptoms. She also asks Limpho about her own health and asks how things are at home. Before examining Thandie, she also asks Limpho “Is there anything else you would like to tell me or ask me?” The healthcare worker then examines Thandie closely, explaining some of her findings along the way, such as “It does not look like her ears are infected” and notes “It looks like you’ve been taking good care of her.” When she is finished, she sits again and explains that she thinks Thandie is suffering from a common virus that has been making a lot of children in the area sick. She explains why she thinks this, and describes what she expects (“This virus generally lasts around three days”). She describes how to manage Thandie’s symptoms with fluids and a fever-reducer, and shows her how to measure and administer the medicine. Before leaving, she asks Limpho if she has any questions or anything she’d like to discuss. She provides a follow-up appointment for Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 62 of 222 Thandie and tells Limpho about a clinic where she can receive treatment for her own health. Discussion questions Did the case illustrate the concept of family-centered care? Did the healthcare worker address the caregiver’s health? How did the healthcare worker engage the child? What would have improved the approach taken in the case? How are family-centered concepts of care commonly used in the setting where you work? Sample responses These are contrasting cases: There is almost no effort made to communicate or reach understanding with Paulvie and Lucien. The healthcare worker did not address Paulvie’s health. A family-centered approach, in which the healthcare worker discussed the mother’s health, used a more interactive communication technique, and assessed outside factors that might affect the child’s health, would have improved this visit. In contrast, the healthcare worker uses many good communication techniques with Limpho and Thandie, including acknowledging the difficulties of waiting a long time for care, asking open ended questions, sitting rather than standing, and repeatedly checking Limpho’s understanding and asking Limpho if she wants to add or ask anything else. She also acknowledges Limpho and the family by asking about their health and welfare, and referring her to a clinic. She teaches Limpho how to take care of Thandie and tells her what to expect from the illness. The healthcare worker did not engage the child, but since the child is only four-years-old, this may not be necessary at this point. Topic 2: Developmental monitoring These case studies provide mentees with an opportunity to practice developmental assessment through the use of case studies. They raise awareness of the importance of assessing child development and introduce the use of child development assessment tools to assist in this process. The general approach to pediatric care is both developmental (child’s development influences your approach to the child and family and informs your guidance to both) and family-centered (as discussed in the previous section). Case studies Case study 1: Nomble Nomble is a 10-week-old infant who is feeding and growing normally, is responsive to sound, seems to focus on her mother’s face, and is vocal. But her mother expresses concern because Nomble is still not able to support her head well and has to be positioned and supported carefully. She turns her Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 63 of 222 head when lying prone, but is unable to lift her head when placed on her belly. Case study 2: Sulaiman Sulaiman is a six-month-old baby who you are seeing for the first time today. He has been cared for by his maternal aunt since birth because his mother died shortly after he was born. There are five other children in the home, along with two other adults. Because Sulaiman’s aunt works during the day, he is cared for by the neighbor in the morning and by the older children once they return from school. The aunt reports that Sulaiman has not received vaccinations yet because she has not had time to bring him to clinic. She does not express any particular worries about Sulaiman’s growth or development, but her neighbor insisted that she bring Sulaiman to the clinic because she thinks something is wrong and that Sulaiman seems “slow”. Case study 3: Ernesto Ernesto is a three-year-old boy you are seeing for the first time because he recently moved to the area. He is accompanied by his mother and an infant sibling. His mother expresses concerns about his speech. He is very verbal but it is extremely difficult for people to understand him. Because she spends most of her time with him, his mother has learned to “read” his expressions and non-verbal cues and can generally understand what he is trying to say but others have great difficulty. Moreover, he often does not grasp what others are saying to him. Discussion questions What questions would you ask the caregiver in each case? What would you look for on the physical examination? Do you think there is a cause for concern? If so, what might be some of your next steps? What information would you give the caregiver? Sample responses Case study 1: Nomble When you hold Nomble to your shoulder, does she try to lift her head? When she’s on her back or on her stomach, does she try to lift her head? Does Nomble turn her head in response to sound or movement? Does she seem startled or frightened if there is a loud noise? Have you noticed any problem with her eyes? Is there anything else you’re worried about or have noticed seems different than you expected? Assess general tone and musculature, symmetry, ability to support the head and turn the head. Check vision and hearing. Since the physical examination and review of systems is otherwise normal, and because she is still less than three months of age, it may be that Nomble needs a little more time to develop the neck musculature to support the head. There is a range of normal development and Nomble Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 64 of 222 falls within a normal range. At this visit, provide reassurance to the caregiver and emphasize the importance of follow-up. Reassess at 14 weeks. Case study 2: Sulaiman Since this is an initial visit, a complete history should be obtained, including prenatal, birth and family history, and nutrition evaluation. Information should be sought on the mother’s health problems and cause of death. Additional focus should be placed on the social history, given that there are some indications that Sulaiman has a mixed group of caregivers and because Sulaiman has not had the expected health visits. See if she can provide a more specific description of the concerns raised by the neighbor. What does she think the neighbor meant? Sulaiman needs a complete physical examination, including measurement of weight, length, and head circumference and developmental assessment. Pay close attention to any signs or symptoms of HIV. At this age, he would be expected to have head control and to be able to sit with minimal support. He should be vocal and babbling, turning his head to sound, focusing on objects and faces and able to follow moving objects. He should attempt to grasp objects. He should be emotionally expressive. It would be important at this point to determine the specific cause of the delay; therefore the healthcare worker should establish a differential diagnosis, which may include HIV, nutritional inadequacy or lack of environmental stimulation. To rule these out, first discuss HIV testing, nutritional intake and Sulaiman’s home environment to determine the most effective means of intervention. Based on the results of testing and investigation, intervention may include ART, food supplementation, referrals for physiotherapy and occupational therapy, and education to the caregiver on how to increase the level of home stimulation for Sulaiman. Stress the importance of regular health visits for all infants; describe the purpose of the visits in terms of monitoring, immunization, etc. Discuss barriers to attending health visitswithout placing blameand discuss ways to remove barriers, including engagement with community services, if available. Case study 3: Ernesto Was there ever a time when Ernesto’s speech and ability to understand seemed better than it is now? Have you noticed any problem with Ernesto’s ability to hear? If Ernesto is busy playing and is not looking at you, does he respond if you speak to him in a normal tone of voice? Does Ernesto have a history of ear infections or head trauma? Is there anything else you are worried about or have noticed seems different than you expected? A general examination of developmental and growth progress should be conducted, giving special attention to determining whether the issue with Ernesto’s speech is a single, isolated problem or part of a group of Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 65 of 222 symptoms that indicate generalized developmental delay. Are there other signs of delay, for example in motor skills? Then conduct basic vision and hearing screening with Ernesto. Also do ear exam to make certain there is no evidence of acute (pus behind the eardrum) or chronic (perforated and scarred eardrum) infection. There may be a cause for concern with Ernesto. Next steps should include a determination of whether Ernesto’s difficulties are due to problems with hearing, which would explain his difficulties with speech and understanding, or whether there are other signs of developmental delay or physical abnormalities. Ernesto should be referred for speech and hearing evaluations. But if Ernesto’s overall growth is delayed, nutritional inadequacy and HIV should be investigated. If available and appropriate, referral for a developmental assessment should be made. Topic 3: Infant feeding in the context of HIV All mothers, and especially those living with HIV, need counseling and support for safer infant feeding practices to prevent these problems and to reduce the risk of MTCT. Counseling is ongoing; it is important to continue counseling and support beyond the first year of life, especially in the weeks and months after a breastfeeding child is weaned or after a formula-fed child is no longer receiving formula. Breast milk is the perfect food for babies and protects them from many diseases, especially diarrhea and respiratory illnesses, and the risk of dying of these diseases. HIV can be transmitted from mother-to-child through breastfeeding. But the risk of MTCT through breastfeeding can be reduced by ensuring that: Support is provided to women to breastfeed exclusively in the first six months of life—in other words avoid all foods or liquids other than breast milk Women with HIV who are eligible are on ART HIV-exposed infants receive ARV prophylaxis Children need milk in some form until at least two years of age. Children weaned before two years of age—which includes HIV-exposed children weaned at about 12 months of age—will require animal milk (such as cow, sheep or goat milk) as part of a diet providing adequate micronutrient intake. Unpasteurized milk needs to be boiled before it is served to a child or an adult. Case studies Case study 1: Mwenzi Mwenzi is living with HIV and is not eligible for ART. She is breastfeeding her six-month-old infant, who is receiving ARV prophylaxis. She does not have a Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 66 of 222 regular source of clean water. In addition, she has not disclosed her status to her mother-in-law, who lives in the home. She asks you if she should stop breastfeeding. Case study 2: Selina Selina is living with HIV and is receiving ART. She has been breastfeeding her 5-month-old baby boy. She reports that he is frequently experiencing diarrhea, and when you talk with Selina, you learn that her mother-in-law gives the baby porridge and water while Selina is at work. Discussion questions What questions would you ask the caregiver? What would you recommend to each of these mothers? What other issues need to be addressed at this visit? Sample responses Case study 1: Mwenzi Because there is no regular source of clean water and because she has not disclosed her HIV status to others in the home, formula feeding is not recommended in this case; instead, recommend continued breastfeeding to 12 months of age with the introduction of complementary foods now (at 6 months of age). Water should be boiled before it is used for drinking. Infant ARV prophylaxis should continue while the baby continues to breastfeed. Explore the mother’s willingness to follow these recommendations. Ask about adherence to ARV prophylaxis and CTX prophylaxis. Check dosing and schedule. Provide support and encouragement; seek community support if needed. Check the immunization and vitamin A records and schedule; administer as needed. Check growth and development. Explore with the mother the possibility of disclosing her HIV status to her mother-in-law. Ask about disclosure to her partner and/or other friends or relatives. Ask about the mother’s care and ensure she is following up for HIV care and for family planning or other services as needed. Case study 2: Selina Does the infant seem ill or dehydrated? If so, follow procedures for assessment and management of a child with diarrhea. Provide counseling to support exclusive breastfeeding. Discuss with the mother what she could say to her mother-in-law to teach her about the importance of exclusive breastfeeding; focus on the fact that exclusive breastfeeding for the first six months is recommended for everyone, not just women with HIV. Suggest that the mother-in-law come to the clinic for Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 67 of 222 counseling on the importance of breastfeeding exclusively for the first six months of life. If there is no way to stop the mother-in-law from giving the baby water and porridge, counsel the mother to teach the mother-in-law to boil the water before giving it to the baby. Explore the possibility of disclosing her HIV status to her mother-in-law (if this has not been done). Ask about disclosure to her partner and/or other friends or relatives. Is her partner aware of her HIV status? Does he support her infant feeding approach? Has she spoken to her mother-in-law about the recommendation that the baby receive breast milk only? Would a home visit help? Would bringing the mother-in-law to the clinic to discuss feeding issues be helpful? Assess growth and development. Is the baby growing well? Are there any signs of malnutrition or growth failure? Are there signs of dehydration? Assess for signs and symptoms of HIV disease. Is HIV testing warranted because of the baby’s symptoms? Ask about adherence to ARV and CTX prophylaxis. Ask about growth and development and about any other problems she or the baby are having. Topic 4: HIV testing of infants and young children Diagnosing HIV infection in children is somewhat different than diagnosing HIV infection in adults. While many of the same tests and procedures for HIV testing and counseling in children are used in adults, such as pre- and post-test counseling and rapid HIV antibody tests, there are a number of differences in how these tests and procedures are used and interpreted. The same antibody tests that are used in adults can be used in children. But, the result of the HIV antibody test is interpreted differently in children under the age of 18 months than in children and adults older than 18 months. Interpretation of results also depends on whether or not the child is breastfeeding. HIV testing in children less than 18 months of age or in those who are still breastfeeding is not a one-time event. Instead, HIV testing and counseling in children less 18 months is an ongoing process that may require the child to be tested multiple times. HIV infection cannot be excluded in breastfeeding children (of any age) because they continue to be at risk of acquiring HIV infection through breast milk if the mother is herself living with HIV. Key points when using antibody tests in children less than 18 months of age: Maternal HIV antibody is transferred across the placenta during pregnancy. ALL children born to mothers living with HIV will test HIV antibody positive in the first months of life. Maternal antibodies may remain detectable in the child’s blood for as long Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 68 of 222 as 18 months. The HIV antibody test can only definitively indicate HIV-infection after the age of 18 months, when maternal antibodies are no longer present. HIV-infected babies will also develop their own HIV antibodies, but an antibody test cannot distinguish between the mother’s and the baby’s antibodies. A positive HIV antibody test will NOT distinguish whether or not a child less than 18 months of age is HIV-infected. Rather, it shows that: The mother is living with HIV, and The child is HIV-exposed and is at risk of HIV-infection. If the child is not HIV-infected, the HIV antibodies from the mother will fade away during the first 6–18 months of life. Most uninfected children test HIV-antibody negative by 12 months of age. By 18 months of age, all uninfected children will test HIV-antibody negative. If the child is HIV-infected, the maternal HIV antibodies will fade during the first 6–18 months of life, but the child will continue to produce his or her own HIV antibodies. If HIV antibodies are present at or after the age of 18 months, this indicates the child is HIV-infected. Since most HIV-uninfected children lose maternal antibodies by the age of 12 months, a high index of suspicion of HIV infection is warranted in children who are still antibody-positive after 12 months of age. A negative HIV antibody test before the age of 18 months indicates the child does not have HIV infection, unless the baby is currently breastfeeding or has breastfed within the previous six weeks. Because an HIV antibody test cannot definitively diagnose infection in children less than 18 months, laboratory testing for evidence of the virus or virus particles is needed to determine HIV status. The test most often used for detection of virus is the DNA PCR test. Dried blood spot (DBS) specimens can be used to conduct DNA PCR tests. If DNA PCR testing is not available, HIV-exposed children less than 18 months of age must be closely monitored for signs and symptoms of HIV disease. Signs and symptoms warrant further evaluation to diagnose HIV infection by clinical and immunological criteria so that the child can be appropriately treated. A positive virological test in a child of any age indicates HIV infection. All children with appositive virological test who are less than 24 months of age should initiate ART urgently while repeat testing is performed for confirmation. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 69 of 222 Case Studies Case study 1: Maria Maria comes to the clinic with her eight-week-old baby girl. Maria’s HIV status is unknown and the baby has never been tested. The baby is breastfeeding and according to her weight and length, seems healthy. Do you offer HIV testing for the baby? For Maria? Why? If testing were to be conducted on the baby, which test would you use? Maria’s test result is positive. What does the HIV test result mean for the child? What testing is required for the child? When? What else should you do for this child at this visit? Case study 2: Boubacar A mother comes to the clinic because her six-month-old son, Boubacar, is very sick. He is admitted to hospital. The mother agrees to participate in a group pre-test session for caregivers of admitted children. The mother has never breastfed. Do you offer HIV testing for Boubacar? Using the HIV testing algorithm, which test would you conduct if the child is tested? Boubacar’s test result is positive What does the HIV test result mean? Does the child require further HIV testing? If so, which test? When? Case study 3: Dwe A grandmother is staying with her two-year-old grandchild, Dwe, who has been admitted to hospital for malnutrition, diarrhea and high fever. You learn from the grandmother that the child’s mother died last year. She doesn’t know whether or not the mother had an HIV test. Do you offer HIV testing for Dwe? Using the HIV testing algorithm, which test would you conduct? The test result is positive. What does the HIV test result mean? Does the child require further HIV testing? If so, which tests? When? Sample responses In all 3 of the case studies, conduct pre- and post-test counseling and ensure the mother or grandmother gives informed consent before conducting testing. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 70 of 222 Provide the children with the standard components of care (immunizations, vitamin A, growth monitoring, etc). Children who are HIV exposed should receive CTX prophylaxis according to guidelines and a plan for determination of HIV status should be made. In these case studies, it is too late to offer infant ARV prophylaxis. If the mother is HIV infected, she should be linked to care and evaluated for ART eligibility. Case study 1: Maria Ideally, HIV testing would be conducted for the mother rather than the infant at this visit. If Maria does not consent to HIV testing for herself, but will allow the baby to be tested, the appropriate test to conduct would be an HIV-antibody test. A positive HIV antibody test in this scenario would indicate that the child is HIV-exposed (that the mother is HIV-infected); the baby will need DNAPCR testing to determine if she is infected. A negative test indicates that the child is unlikely to be HIV-exposed because she is too young to have lost maternal antibody. If the mother acquires HIV while breastfeeding, the child will, in turn, be at risk of HIV through breastfeeding. Case study 2: Boubacar Ideally, HIV testing would first be conducted for the mother rather than the infant. If the mother does not consent to HIV testing for herself, but will allow the baby to be tested, the appropriate test to conduct would be an HIV-antibody test. A positive HIV antibody test in the infant would indicate that the child is HIV-exposed (that the mother is HIV-infected). If the mother’s test is positive, the infant is very likely HIV-exposed unless the mother was infected within the past 6 months (since the baby was born). In either case, the baby should receive a virological test to determine his status. If virological testing is not available and the child is HIV-exposed and is sick, then clinical criteria for HIV infection should be considered and the infant should have an HIV antibody test at the age of 18 months. Case study 3: Dwe An HIV antibody test is recommended for this child. The mother may or may not have died of complications related to HIV. If the mother was HIV infected, then HIV infection would be suspected in the child, given her symptoms. Because the child is 2 years old, a positive antibody test indicates that Dwe is infected with HIV. Confirmatory testing should be conducted, but the child should be immediately evaluated for ART and should start CTX prophylaxis. A negative antibody test would indicate that the child is not infected. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 71 of 222 Topic 5: HIV counseling for pediatric HIV testing The goal of pediatric HIV testing and counseling is to identify HIV-exposed and HIV-infected children as soon as possible so that they may be engaged in life-saving care and treatment. Without early HIV care and treatment, including anti-retroviral therapy (ART), 30% of HIV-infected children will die before their 1st birthday and 50% before their 2nd birthday. Early access to HIV care and treatment can delay disease progression, improve health and prevent death in children. It is important to provide pre-test information clearly and sequentially, in a way that will make the most sense to caregivers. Always allow time for questions. HIV testing allows children exposed or infected with HIV to receive treatment that can save their life. While emphasizing that testing is an important part of the child's care, ensure that the caregiver understands the right to decline testing. If testing is declined, the child will continue to receive care. However, undiagnosed and untreated HIV may endanger the child’s health and future. Post-test counseling always includes: Delivery of results, discussion and explanation of the meaning of the results Attention to the caregiver’s ability to process and cope with the information provided Assessment of sources of caregiver support system, identifying potential sources of social support, referring and providing support Consideration of CTX prophylaxis (depending on the child’s status, age, and other factors) Infant and young child feeding (IYCF) counseling, when appropriate Discussion of post-test follow-up, which will vary according to the results of the test, the age of the child, infant feeding counseling needs and the specific needs of the child and family. If there are other caregivers for the child, discuss their counseling needs and ask who will be responsible for bringing the child to clinic visits. Discussion of the care and treatment needs of the mother and other family members Case Studies Use the case studies describe in Topic 4: HIV testing of infants and young children. This time, ask mentees to conduct pre- and post-test counseling, as time allows. Work in pairs so that one person (a mentee) is the counselor and one is the caregiver. Cue cards for the pre- and post-test sessions can be found in Family-Centered Care of HIV-Exposed and HIVInfected Children in Low-Resource Settings: Standard Operating Procedures (SOPs). Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 72 of 222 Case study 1: Maria Case study 2: Boubacar Case study 3: Dwe Discussion questions How did it feel to conduct the counseling? Was it difficult to give positive results? Was it difficult to remember all of the components of counseling? What counseling skills did you use? How would you respond if the caregiver refused testing for the child and/or for herself? Sample responses Caregivers are entitled to decline HIV testing for themselves or for their child. Although HIV testing is strongly recommended, the caregivers’ decision should be respected. If the HIV test is declined, the counselor should provide additional, individual counseling to: Further explore concerns about testing Clarify the importance of knowing the child’s status to provide the best healthcare. Encourage the caregiver to reconsider testing. If HIV testing is still declined: Let the caregiver know your door is open, and that she or he can decide to have the child tested anytime. If available, provide the caregiver with a take home flyer. Arrange for further pre-test counseling at the next visit. This decision not to test should be noted on the child health card and in the medical record so that healthcare workers can follow up during subsequent clinic visits. Topic 6: Routine care of the child with HIV infection HIV infection is a chronic illness with diverse clinical manifestations and psychosocial challenges. The routine care of HIV-infected children demands a dedicated multidisciplinary approach from a variety of healthcare professionals. The HIV primary care provider, while ensuring health maintenance and preventing disease, must serve as the coordination of services crucial to the management of children in the context of the family. Since children live with and are raised within a family (i.e., they do not live in isolation), the health and well-being of the family has a direct impact on the child. A healthy family fosters the growth and development of a healthy child. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 73 of 222 Routine health maintenance—including assessment of growth, nutrition, development and mental health; immunizations; evaluation and management of intercurrent illnesses; anticipatory guidance for the prevention of injury and disease; dental referrals; and screening for hearing and vision—should be provided for all children. In addition to the routine care that all children should receive for health maintenance, infants and children with HIV require additional assessments, evaluations and treatment. HIV is a chronic disease that requires regular and careful monitoring. HIV treatment is a life-long commitment; families affected by HIV need ongoing counseling, support and referrals for health and community services to meet ever-changing needs. Case Studies Case study 1: Joshua Joshua was diagnosed with HIV-infection eight months ago, at the age of 2.5 years, when he was admitted to the hospital with tuberculosis and malnutrition. He was in the hospital for eight weeks. He was first started on a 3-drug regimen for TB and was given extra feedings and a high-calorie diet. Two weeks before discharge, he started ART with AZT, 3TC and NVP. He completed his TB treatment one month ago. Today, his mother reports he is doing well but she worries that he will never catch up on growth. She says he is much smaller than other children his age. Case study 2: Tiro Tiro is an 8-month-old child who was just diagnosed with HIV infection. Her mother was HIV-negative during pregnancy, so it is believed she was infected during the post-partum period. This is Tiro’s first visit to the HIV clinic. She is breastfeeding and eating complementary foods. She was started on CTX immediately but is not on ART. Her growth is faltering but she has no other symptoms of HIV. Case study 3: George George is 6 years old and has been on ART for a year. He was tested for HIV at the age of 5 because his mother became ill and died of AIDS. His two siblings, a sister who is 8 and a brother who is 10, are not HIV-infected. The children are cared for by their maternal grandmother. Their father is in the hospital and is very ill. George says he feels well and goes to school every day. The grandmother also says George is healthy, but that she is exhausted and doesn’t know how she will be able to continue to care for the children. Since their father became ill, there is very little income for the household. Discussion questions What will you do at this visit? How will you assess the child’s health? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 74 of 222 Do any investigations need to be conducted (e.g. blood tests, x-rays)? Do any specific interventions need to be considered? What psychosocial issues should be considered today? What counseling will you provide? Should any referrals or linkages to additional care or support be considered? Sample responses For all cases: Conduct history and physical (full history and physical on the first visit and symptom-directed history and physical for follow-up visits). Determine WHO clinical and immunological staging. Examine eligibility for ART (if not on treatment). Assess adherence. Assess growth and development at every visit. Offer routine care, including immunizations and Vitamin A. Assess for exposure to TB and for signs or symptoms of TB. Assess CTX prophylaxis. Conduct psychosocial assessment for the family. Assess linkages to care and treatment for other family members. Provide counseling and support, especially in the areas of adherence, follow-up, disclosure and nutrition. Discuss all findings with the caregiver (and child, if appropriate) and make a plan. Case study 1: Joshua Pay special attention to Joshua’s adjustment to ART, side effects, adherence and understanding of the treatment. Review the schedule and dosing; check dosage for growth. Assess growth. If growth is appropriate, reassure the caregiver. If growth is still slow, conduct a thorough nutritional assessment and provide nutritional counseling. Check if Joshua should continue INH prophylaxis. Review CTX. Conduct a full psychosocial assessment and assessment of maternal care and treatment. The family has been through a lot and the diagnosis is relatively new. Consider community supports, including peer support and counseling. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 75 of 222 Case study 2: Tiro This is a first visit for Tiro, so conduct a full history and physical. Conduct a full nutritional assessment, with particular attention to the quality and quantity of the diet. If adequate, the first step is treatment for HIV infection (unless there are signs or symptoms of acute illness or OI). Prepare the family to start Tiro on ART. Ideally, Tiro would start ART immediately, but be sure there has been adequate counseling and that home visits or quick follow-up can be done. Maternal care is of critical importance—the child’s health depends on the mother. Ensure the mother is in care and undertake a psychosocial assessment and provide or refer for psychosocial support and counseling. Case study 3: George The most important issue at this visit is to consider the psychosocial issues for the family and to provide as much support as is available to the grandmother and children. Are social grants available? Food and nutrition programs? Practical support? Support from community agencies? Also assess the child’s awareness of his diagnosis and treatment; discuss first steps toward disclosure if child is not aware of HIV. Disclosure to siblings is also important. Consider the impact of the loss of their mother and the apparent impending loss of their father on the children. Are their support groups or counselors available to help the children? Topic 7: Initiating ART Currently, highly active combination ARV regimens including at least three drugs are recommended for treatment of HIV in infants, children, adolescents and adults eligible for treatment. Current research demonstrates that the initiation of ARV therapy (ART) early in infancy and childhood dramatically reduces the risk of death and disease progression.20 Without effective treatment, an estimated one third of infected infants will have died by one year of age and about half will have died by two years of age.21,22 Although use of ART in HIV-infected children is associated with increased survival, this increased survival is associated with challenges in selecting successive new ARV regimens. Additionally, therapy is sometimes associated with short- and long-term toxicities. ARV drug resistant virus can develop in children who receive regimens containing one or two drugs and incompletely suppress viral replication. Additionally, drug resistance may be seen in ARV-naïve children who have become infected with HIV despite maternal/infant ARV prophylaxis. To guide decision-making regarding eligibility criteria for ART; choice of ARVs for first- and second-line treatment; monitoring and management of Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 76 of 222 patients on ART; management of ART toxicity; and management of ART failure, international guidelines have been developed that consolidate the available clinical and operational evidence and help clinicians in the field to make informed decisions. Under current guidelines ART is initiated in all children less than 24 months of age and in children more than two years of age who meet clinical or immunological staging criteria. It is important to stage children with HIV infection because staging: Clarifies the prognosis of individual patients. May strengthen the clinical diagnosis of HIV infection when laboratory testing is unavailable. Affects the type of treatment interventions, including indications for starting and/or changing ART. At every healthcare visit, children living with HIV should have their WHO clinical stage assessed. If the child is not yet on ART, eligibility should be assessed at every visit. If the child is on ART, the effectiveness of the treatment should be assessed. New clinical events may have an impact on staging. Case studies Case study 1: Francine Francine is 12 months of age and was just diagnosed with HIV infection based on the results of virological testing. Virological testing was negative at six weeks. Testing was conducted again one month ago because Francine was symptomatic (growth faltering and developmental delay). Francine received ARV prophylaxis for six weeks; her mother is on ART. Case study 2: José José is 3 years old and is not on ART. His last visit was 3 months ago. At that time, he was assessed as WHO Clinical Stage 2 and CD4 of 29%. Today, his grandmother reports that José was hospitalized for more than one month with severe pneumonia and oral candidiasis. Case study 3: Tigist Tigist is 8 weeks old. Virological testing conducted 3 weeks ago was positive and Tigist has been referred for treatment. She was started on CTX 3 weeks ago. She did not receive ARV prophylaxis because she was born at home and was not seen until the age of 5 weeks. She is breastfeeding. Her mother is not on ART and has not been to clinic for HIV care for several months. Discussion questions What questions will you ask the caregiver today? How will you assess the child? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 77 of 222 What are the next steps in the child’s care? Suggested responses Case study 1: Francine Assess the caregiver’s knowledge and understanding of HIV treatment and her willingness to initiate treatment. Conduct a full history, including social and family history and review of symptoms. Specifically ask about other symptoms that may be indicative of acute illness or OI. Explore the issues related to growth failure and developmental delay. Ask about the mother’s treatment; explore adherence. Ask about exposure to TB. A complete physical examination is indicated, including assessment of growth and development. If baseline laboratory testing has not been done, specimens should be obtained at this visit. A DBS specimen for confirmatory virological testing should be obtained if one has not already been sent. Assess WHO clinical stage and immunological stage (if CD4 test results are available). Discuss findings with the caregiver and formulate a plan of care. Francine needs to start ART urgently. Intensive counseling and readiness assessment must be performed; ideally, the family should be linked to community services and/or home care in order to provide ongoing support and counseling from the start of treatment. Francine should be started on a 3-drug regimen; consider the maternal drug regimen, the child’s age, and the current guidelines. Case study 2: José Conduct the interval history. If possible, obtain the hospital records to ascertain the specific diagnoses and treatments. Ask if treatment for ART was discussed while the child was hospitalized. Assess the caregiver’s knowledge and understanding of HIV treatment and her willingness to initiate treatment for José. Conduct a full review of symptoms and discuss current medications and dosages. Ask about adherence to the medicines that have been prescribed. Conduct a full physical examination to carefully assess baseline status in a child who is now eligible for ART. Obtain baseline laboratory tests, as needed, including CD4 testing and viral load (if available). Discuss findings with the caregiver and formulate a plan of care. Begin to prepare the family for ART, using a step-wise approach appropriate to the specific needs for the family and their understanding of HIV and HIV treatment. Although the child needs ART, the family should be fully prepared before initiating therapy—ideally over the course of at least 2 or 3 visits. Consider counseling in the community or in the home if it is difficult for the family to return to the clinic frequently. Case study 3: Tigist Assess the caregiver’s knowledge and understanding of HIV treatment and her willingness to initiate treatment. Explore the lack of antenatal and Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 78 of 222 postnatal care without judging the mother. Conduct a full history, including social and family history and review of symptoms. Specifically ask about symptoms that may be indicative of acute illness or OI. Explore the mother’s feelings about getting treatment for her own disease. Ask about exposure to TB in the home. A complete physical examination is indicated, including assessment of growth and development. If baseline laboratory testing has not been done, specimens should be obtained at this visit. A DBS specimen for confirmatory virological testing should be obtained if one has not already been sent. Assess WHO clinical stage and immunological stage (if CD4 test results are available). A psychosocial assessment of the family should be performed. Discuss findings with the caregiver and formulate a plan of care. Tigist needs to start ART urgently, but there are serious issues to address in order to ensure the family is able and willing to assume responsibility for the child’s care and treatment. Intensive counseling and readiness assessment must be performed; ideally, a home visit should be performed to better assess capacity for adherence to care. The family should be linked to community services and home care in order to provide ongoing support and counseling. It is critical to support the mother and link her to care for her own health. Topic 8: Growth monitoring An adequate rate of growth is the hallmark of good nutritional status in children; growth problems may be indicative of acute and/or chronic health problems. Given the serious nature of inadequate weight gain, particularly among children with HIV, caregivers should be encouraged to request health care promptly when they think their child is losing weight or not gaining weight sufficiently, even if it is not yet time for their child’s routine growth monitoring visit. Growth monitoring provides an opportunity for the healthcare worker to intervene to prevent serious growth problems. Nutritional interventions should be an integral part of the care of an HIVexposed or infected child. Improved diet may enhance antiretroviral treatment (ART) acceptability, adherence and effectiveness. The provision of nutritional intervention and support is labor intensive, so it makes sense to provide this level of education, counseling and referral to those for whom it is needed. The way to screen for need is to review growth monitoring information for each and every infant and child at each and every health facility visit. Children whose growth is faltering are then targeted for nutritional assessment and appropriate interventions based on the growth monitoring information. Growth monitoring is a part of each clinic visit for every child. Growth monitoring, which includes measures of height, weight and head circumference, is critical for the prevention and early identification of growth faltering. Since growth problems often precede a medical Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Growth faltering (failure to thrive) involves failure to meet expected potential in growth and other aspects of well-being. Page 79 of 222 diagnosis, growth issues may be indicative of medical problems or HIV disease progression. Growth problems may indicate a need to start or change ART. Early weight loss or inadequate rate of growth can be identified by observing the child’s weight, length/height and HC at a single point in time and over time. If any single measurement falls below the – 1 z-score line (whether weight-forage or weight-for-length/height) should be further assessed and an intervention developed based on a nutrition assessment. Children who fall below the – 3 line require hospitalization. Interpreting points on growth charts z-score Growth indicators Weight-for-age Above 3 Above 2 See note 1 Above 1 Weight-for length/height BMI-for age Head circumference Obese Obese Macrocephaly Overweight Overweight Possible macrocephaly Possible risk of overweight (see note 2) Possible risk of overweight (see note 2) 0 (median) Below – 1 Below – 2 Underweight Wasted Wasted Possible microcephaly Below – 3 Severely underweight (See note 3) Severely wasted Severely wasted Microcephaly Notes: 1. A child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-for-length/height or BMI-for-age. 2. A plotted point above 1 shows possible risk. A trend towards the 2 z-score line shows definite risk. 3. This is referred to as very low weight in IMCI training modules. (Integrated Management of Childhood Illness, In-service training. WHO, Geneva, 1997). Measurements in the shaded boxes are in the normal range. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 80 of 222 Case Studies Case study 1 Case study 2 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 81 of 222 Case study 3 Case study 4 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 82 of 222 Discussion questions Ask mentees to interpret the child’s growth curve for each of the growth charts shown above. Then ask how they would assess the child and advise the caregiver. What actions should be taken? What referrals should be made, if any? Sample responses Case study 1 This child’s weight gain is adequate. Compliment the caregiver, noting that this is exactly what we like to see. No nutrition intervention is necessary unless there are other issues. Case study 2 The growth pattern represents early growth faltering. It is important to determine if the child is ill. If this child has no obvious reason to explain growth faltering—e.g. acute illness—undertake a nutrition assessment to identify the underlying issues before growth faltering affects development. If neither nutritional intake nor acute illness explain the growth faltering, consider eligibility for ART (or, consider ART failure or inadequate adherence if the child is already on ART). Case study 3 This growth pattern reflects prolonged growth faltering. Undertake a nutrition assessment to identify underlying causes for growth faltering. It is important to act quickly and refer for medical care and social services; hospitalization may be required. If neither nutritional intake nor acute illness explain the growth faltering, consider eligibility for ART (or, consider ART failure or inadequate adherence if the child is already on ART). Case study 4 This growth curve represents severe growth failure. The response to this case depends on the clinical presentation of the particular case, but there is a good chance that this child might require hospitalization to address the underlying case of the malnutrition and to treat the undernutrition. If neither nutritional intake nor acute illness explains the growth faltering, consider eligibility for ART (or, consider ART failure or inadequate adherence if the child is already on ART). Case study 5: Lerato Lerato is an HIV-uninfected girl who comes to your clinic for vaccines and regular check-ups. This is her nine-month check-up, and she is here for her first measles vaccine. Her mother says she is doing well; she has no concerns. Lerato’s weight at this visit is 8kg. Using the girl’s weight-for-age chart, plot this value. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 83 of 222 How does her weight compare to other girls her age? Her weight is just below median (50th percentile), meaning she is about average weight for her age. It would seem that the transition at six months of age to include complementary foods is going well. (Teaching point: an infant’s growth can falter at this time due to lack of complementary foods and calories.) Lerato returns to the clinic at 12 months of age for her first dose of vitamin A. Her weight is 9kg. How would you describe her growth? She is making steady weight gain (i.e. following curve). At 18 months of age she returns for her fourth doses of DTaP, IPV, and Hib and her second dose of measles vaccine. Her weight is 9kg. How would you describe her growth? No growth, flat curve What are some possible causes for this lack of growth? Acute illness (e.g. diarrhea, pneumonia), lack of food (e.g. perhaps the family has been short of money for food), HIV infection (ask mother if she has recently had an HIV test and if so, what were the results? If mother is now HIV-positive, ask her if she has been breastfeeding Lerato). Ask mother if she gave birth to another infant. What would you recommend at this point? Explain dietary needs of toddlers using information on the child health card, refer to social services if family needs help accessing sufficient quantity of food, have the mother return to clinic in 1 month to recheck weight. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 84 of 222 Case study 6: Nomble Nomble is a six-week-old infant born to a healthy, asymptomatic HIV-positive mother who said she has been advised not to breastfeed. She says Nomble has a mild cough and slight diarrhea, but is otherwise well. You review his child health card and find the following weights: birth weight 3.6kg and today’s weight 4.5kg. Using the boy’s weight-for-age chart, plot these values. How would you At birth, his weight was above the median (50th describe his weight and percentile). He has gained weight since birth, but he growth? has dropped below the median. Between which z-score lines is his weight-forage? Is he heavier or lighter than “average” for his age? Between median and -2 z-score. He is lighter than average. What would you do at this point? Explore infant feeding practices with the mother; encourage exclusive formula feeding and review criteria for safe formula feeding. Perform HIV virological test (DNA PCR test), start CTX, and have mother return in one month for HIV test result and weight check. At 10 weeks of age Nomble’s weight is still 4.5 kg. His mother reports that she didn’t have access to clean water to prepare his formula, so she has been Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 85 of 222 supplementing with tea and juice. He has had more diarrhea. Please describe his growth. No weight gain, at -2 line, possible explanations include poor caloric intake (tea and juice), acute diarrheal illness secondary to lack of potable water and HIV disease. What would you do at this point? Follow IMCI guidelines for management of diarrhea. Check results of infant’s HIV test. If the test is positive, ARV therapy should be initiated urgently; CTX should be continued. Irrespective of HIV test results, refer urgently for social services to help the mother obtain the necessary supplies to safely formula feed; review safe and exclusive formula feeding. Case study 7: Tebogo Tebogo is a 10-week-old infant born to a woman who had no prenatal care and was diagnosed with HIV during labor and delivery. She received single dose NVP plus AZT and 3TC during labor and for 7 days post-partum. She is following instructions to exclusively breastfeed, even though Tebogo doesn’t seem that interested in eating and cries a lot. He also doesn’t seem to notice the people around him, does not have a social smile, and seems floppy. He is taking CTX and nevirapine. He had an HIV test done at six weeks of age, but the sample was lost. He had a repeat sample sent at his last visit at nine Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 86 of 222 weeks of age. His mother was told to come back today for the results. You review his child health card and find the following: Birth: Weight = 2.5 kg at -2 z-score 2 weeks: Weight = 2.9 kg 6 weeks: Weight = 3.5 kg still at -2 zscore 9 weeks: Weight = 3.5 kg between -2 and -3 z-score no weight gain, critical, less than -3 z-score Use the boy’s weight-for age chart and plot these values. Describe the growth trend shown on his weight-for-age chart. He was born much smaller than average and did not gain weight in the last month. Does his weight-for-age chart show a current growth problem or risk of a problem, and if so, what is it? He is severely underweight. How would you assess him? Check him for signs and symptoms of marasmus and kwashiorkor. Also check for signs of HIV disease (oral thrush, lymphadenopathy, hepatospleenomegaly) check temperature and signs and symptoms of sepsis (he is at high risk because of his very poor nutritional status). Get results of HIV test. The test results come back and Tebogo is HIV-positive. What would you do at this point? Hospitalize him for treatment of severe malnutrition Discontinue nevirapine prophylaxis and start ARV therapy urgently. Send blood for CD4 (but do not delay start of ARV therapy while waiting for results). Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 87 of 222 Case study 8: James James was born to an HIV-positive woman who took AZT during her pregnancy and single dose NVP plus AZT and 3TC during labor and postpartum. She never returned for follow-up visits and she is not on ARVs. James is not on CTX or nevirapine and has not had an HIV test. She brings him in today because a friend encouraged her to get him tested and said if he was HIV-positive that there are medications he can take. His growth parameters are the following: Birth: Weight = 4.3 kg at +2 z-score 4 weeks: Weight = 4.6 kg 7 weeks: Weight = 5.0 kg at median (50th percentile) 12 weeks: Weight = 5.4 kg 16 weeks: Weight = 5.5 kg slightly less than median (50th) between median and -2 z-score at -2 z-score Plot these on his weight-for-age chart and describe the growth trend. His birth weight was greater than average, but since then his growth has faltered and he has crossed two lines. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 88 of 222 Does his weight-for-age chart show a current growth problem or risk of a problem, and if so, what is it? He is underweight. What are some of the causes/explanations for his weight loss? Possible explanations: HIV infection, mixed feeding or formula feeding with non-potable water, acute illnesses/infections (e.g. diarrhea, respiratory) What else would you like to know to better assess his situation? HIV status, infant feeding status, economic and social situation at home, maternal health, care and treatment status Case study 9: Tumelo Tumelo is a three-year-old child whose aunt brings him to clinic today because he has had a fever and cough for two weeks and enlarged lymph nodes. You review his child health card and find the following information. Use the boy’s weight-for-age chart and plot all values. Birth: Weight = 3.5 kg 6 months: Weight = 7.5 kg around median for age around median Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 89 of 222 12 months: Weight = 9.3 kg for age 18 months: Weight = 10.0 kg 24 months: Weight = 11.0 kg around median for age 30 months: Weight = 11.0 kg 36 months: Weight = 10.0 kg around median for age between median (50th percentile) and 2 z-score close to -2 z-score -3 z-score Judging from the plotted points, does he seem to have any growth problem or risk of a growth problem? If so, what problem? Growth relatively normal until two years of age at which time he made no weight gain followed by weight loss in the past six months. How would you assess him? Check HIV status (his rapid HIV test is negative). Ask about exposure to TB; perform TST if available. Assess eating habits and intake. Evaluate social/economic situation. How would you treat him today? Following IMCI guidelines, treat him with antibiotics for presumptive bacterial pneumonia. Educate the aunt about healthy foods and food frequency. Refer for social services as needed, for social and economic support. Refer him to nutritionist, if available. Have them return in two weeks for follow-up. They return as scheduled. His cough and other symptoms are no better. What do you do now? Today, you learn that his uncle has had a cough for a long time and has lost weight. He started treatment for TB last month. Follow guidelines for evaluation and treatment of TB. Re-evaluate nutritional intake and provide appropriate counseling and referral. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 90 of 222 Case study 10: Nelson Nelson is a nine-month-old infant you are seeing for an acute visit because he has had a few days of cough, congestion, and fever. His father says today he started crying and it seems that something hurts him. On physical exam you see some yellow discharge in his right ear canal. Using the boy’s weight-forage chart plot the following information: Birth: Weight = 3.6 kg 6 weeks: Weight = 5.0 kg 12 weeks: Weight = 6.4 kg 20 weeks: Weight = 6.6 kg 6 months: Weight = 7.1 kg 9 months: Weight = 7.1 kg median (50th percentile) still at median (50th percentile), following curve still at median (50th percentile), following curve inadequate weight gain, between median and -2 weight gain, still between median and 2 z-score no weight gain, at -2 zscore Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 91 of 222 How would you describe his growth? His weight and growth were normal for age until 20 weeks of age when his growth slowed. He has not gained any weight since his six month visit. His weight is much less than the average for his age. How would you assess him? Check for signs, symptoms, and risk factors for HIV. Ask about TB exposure. Do complete physical exam. Assess economic and food situation. Findings: no obvious risk factors for HIV or TB, no food insecurity, he has acute ear infection. What would you do at this point? If father consents, obtain DNA PRC HIV test. Treat him with antibiotics for the ear infection. Provide nutritional counseling and stress the importance of complementary foods. Encourage small, but frequent feedings while he is sick. F/u visit in 1 month for weight check, follow up of ear infection and results of DNA PCR. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 92 of 222 Case study 11: Neelum Neelum is a five-year-old, HIV-negative girl who presents to clinic because, according to her mother, she doesn’t like to go outside and play with other children. Neelum prefers watching TV and playing with the computer. You examine her child health card and have the following growth information: 3.5 Weight = 19.5 kg just below +2 line years: Weight = 20.9 kg just below +2 line 4 years: Weight = 21.4 kg just below +2 line 4.5 Weight = 22 kg just below +2 line years: 5 years: Plot this on her weightShe weighs more than girls her age (risk of for-age chart and overweight), and this has been the case since she describe what you see. was three-and-a-half years old. What could explain Neelum’s borderline overweight status? What is your plan for her? Sedentary life (TV, computer, minimal time in outdoor activities), high caloric intake, medical problem (e.g. hypothyroidism). Obtain dietary history. Measure her height and calculate BMI (more accurate measure of overweight and obesity). Do a complete physical exam. Provide nutrition counseling, assess child and family’s willingness to address her borderline overweight status and refer to nutritionist, if available. Follow up in one month. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 93 of 222 Case study 12: Lesedi Lesedi is a two-year-old boy. Use the boy’s weight-for-age chart. 12 months: 15 months: 18 months: 24 months: Weight = 8.4 kg Weight = 9.6 kg Weight = 10.4 kg Weight = 10.9 kg between median and -2 between median and -2 between median and -2 between median and -2 Plot these values on his child health card and describe what you see Lesedi has maintained his weight between the median and -2. He has been following a normal growth curve. Sub-topic 8.1: Breastfeeding, malnutrition, and HIV disease Case study 1: Josiah Josiah is a one-month old born to an HIV-positive mother. He is exclusively breastfed and is taking NVP prophylaxis. His mother is concerned because Josiah seems to be fussy and always hungry. Birth: 1 month: Weight = 2.6 kg Weight = 3.4 kg just above -2 line gaining weight, still just above 2 line Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 94 of 222 How will you assess if Josiah is getting enough breast milk? What will you do for Josiah and his mother during this visit? How would you describe Josiah’s growth? What do you want to do now? Obtain complete history: prenatal, psychosocial history and intercurrent history. Mother reports that Josiah has been well since birth. Mother feels well and is taking ARV therapy. Adherence is not an issue. Obtain a feeding history – Josiah feeds on each breast for about 15 minutes, but does not empty each breast. Inspect his mother’s breasts to check for inverted nipples, cracks or evidence of mastitis. Her breasts are healthy. Observe Josiah breastfeeding and offer guidance concerning poor attachment. Plot Josiah’s growth curve. He is underweight. Do a complete physical and developmental exam. Get blood for DNA PCR. Instruct his mother on proper latching. Educate his mother about the relationship between nutrition, Josiah’s immune system and risk of infections and the need for close growth monitoring (measure and plot weight, length, and head circumference). Support her in her decision to exclusively breastfeed and remind her about the benefits of exclusive breastfeeding. Encourage adherence. Schedule follow-up visit in two weeks, when Josiah will stop NVP, commence CTX. Advise the mother to bring Josiah to clinic sooner if he is ill or she has new concerns. His mother returns with Josiah when he is three months old. She didn’t bring him sooner because he was sick with vomiting and diarrhea. She brought him to the hospital but refused to have him admitted. You review his child health card and find the following: 2 months: 3 months: Weight = 3.6 kg Weight = 3.7 kg How will you assess him? critical, below -3 line still critical, below -3 line Do complete physical exam. He is thin, pale, breathing heavily and rapidly. His growth failure is critical. Check results of his HIV test and refer for urgent hospitalization. Josiah’s HIV test results come back positive. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 95 of 222 Case study 2: Mamello Grace is an 18 year-old woman with HIV diagnosed during her first pregnancy. She was enrolled in the PMTCT program. She was not eligible for ART and took AZT during pregnancy and single dose NVP and TDF + FTC and AZT 3hrly in labor. Her baby, Mamello, received NVP at birth and has continued it daily. When Grace and Mamello return for their first post-partum check at six weeks both are doing well. Mamello is breastfeeding without difficulty and has gained weight as expected. Grace wants to know if Mamello has HIV. What do you tell Grace? You tell Grace that you will do a test to check for HIV today. What test should be used? PCR DNA HIV How will you assess Mamello’s growth? Weigh and measure Mamello’s length and head circumference, and plot them on the growth chart. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 96 of 222 Mamello’s measurements: Birth: Weight= 3.5kg 6 weeks: Weight= 4.8kg Describe Mamello’s growth Length= 50cm HC= 34 cm Length= 57cm HC= 36.5 cm His weight and length are close to median for his age, while his head circumference is close to the -1 line. What other interventions should be performed? Do complete physical exam. Do developmental exam. Prescribe CTX and provide counseling about infant feeding (exclusive breast feeding for 6 months). Mamello’s NVP should be continued for the duration of the breastfeeding period (unless the child is diagnosed as HIV-infected). Encourage Grace to go for follow-up care of her HIV disease. Eligibility for ARV therapy in breastfeeding women is the same as for women who are pregnant. The physical exam is normal. His developmental exam shows that has a social smile, normal reflexes and muscle strength for his age. There is no immediate cause for concern. When should Grace bring Mamello At 10 weeks of age, or sooner if he is back to clinic for his next ill. appointment? They return as scheduled. Mamello’s first virologic test is negative. He is still breastfeeding and is doing well, taking CTX and NVP. His exam is normal. His weight is 6.2kg, length is 60cm and head circumference is 38cm. You plot his growth curves. His development is appropriate for his age. His mother is not on ARV therapy. Describe Mamello’s growth on his Weight and length are at the median growth chart. for his age, while his head circumference is slightly less than the -1 line. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 97 of 222 What will you tell Grace about this test? What else will you do for Mamello? When should Grace and Mamello return for their next appointment? You explain to Grace that since his first test was negative you cannot find any HIV in his blood. However, since he is breastfeeding he is still exposed to HIV, so you will test him again after he stops breastfeeding completely. You explain the importance of continued exclusive breastfeeding to the age of six months and continuing NVP prophylaxis throughout the breastfeeding period. Refill his CTX and NVP prescriptions. Schedule follow-up in a month. Grace and Mamello do not return for three months. The social worker who visits the home says Grace was admitted with a severe case of shingles one month ago. She went to her mother’s village to recuperate. Her mother is helping out with Mamello. The social worker manages to convince Grace to bring Mamello for a check-up. Grace tells you Mamello had two episodes of diarrhea while they were away. Her mother fed Mamello porridge while she was in hospital. She still breastfeeds whenever she feels well and has energy. Mamello is now six months old. His weight gain has been poor and he is unable to sit unsupported. On physical exam you find he has oral thrush. What should you do to assess Measure his weight, length and head Mamello’s growth? circumference and plot them on his child health card. 6 months: Weight= 6kg Describe Mamello’s growth. Length= 68cm HC=39cm His weight velocity has dropped off and is between -2 and -3 lines, indicating he is stunted. He is maintaining his linear growth at about the median. His head circumference is less than the -3 line, indicating microcephaly. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 98 of 222 Does Mamello have HIV? What can you do to find out? What will you tell Grace? Because Mamello has symptoms that might be related to HIV infection (growth failure, oral thrush, developmental delay, and microcephaly), the team should explain to Grace that Mamello requires another PCR DNA for HIV. Given the strong evidence of HIV infection, refer to HIV specialist to consider urgent initiation of ARV therapy while awaiting PCR results. Continue CTX. Refer him for nutritional rehabilitation. Have Grace return in three weeks for the PCR DNA results. She returns in three weeks. The DNA PCR test is positive. You explain to Grace that Mamello has HIV infection. Although she is extremely upset, Grace finds hope in the fact that Mamello will continue to receive care and treatment. What do you do now? Reinforce the importance of continuing CTX and breastfeeding. If he has not started ARV therapy, he needs to start ARV therapy urgently. Blood for CD4 should be sent, but this should not delay the initiation of ARV therapy. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 99 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 100 of 222 Sub-topic 8.2: Abnormalities in head circumference Case study 1: Kagiso Kagiso is a six-month-old infant born to an HIV-positive mother on ARV therapy. Her mother has not been able to bring her for her routine vaccinations because she has been ill. According to her mother, Kagiso has been exclusively breastfeeding, but doesn’t seem to have a very strong suck. Also, she is not as strong as her cousin, who is the same age. Upon physical examination, you find a small infant with poor muscle tone globally. She babbles but doesn’t seem to fix and follow with her eyes. You have the following growth information. Birth: Weight= 2.5kg between median Length = 47cm and -2 line 6 months: Weight = 5.8kg just above -2 line Length = 61cm at -2 line HC = 38cm just above -2 line -3 line Please describe Kasigo’s She is underweight, she is stunted, and her weight, length, and head head size is much smaller than girls her age circumference in comparison to (she has microcephaly). other girls her age. What might explain her small head size? Congenital problem, intra-uterine infection, HIV encephalopathy (especially given her global developmental delays). Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 101 of 222 What other physical exam findings would you check for? Oral thrush, hepatosplenomegaly, lymphadenopathy (all associated with HIV disease). What is your plan to take care of Consent mother to obtain PCR DNA HIV Kagiso? test from Kagiso. Start CTX for prevention of OIs. Given the very strong clinical evidence of HIV infection, consider sending blood for CD4 count and refer to HIV specialist to consider urgent initiation of ARV therapy while awaiting PCR results. Provide nutritional counseling, advising the mother to continue exclusive breastfeeding while starting complementary foods. Refer to a neurologist. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 102 of 222 Case study 2: Hendrick Hendrick is a 12-month-old whose father brings him to clinic because he’s noticed some “funny” movements of the child’s arms and legs, and occasionally his eyes roll up into his head. His father brought Hendrick’s child health card, so you review his growth. Birth: 2 months: 4 months: 6 months: 9 months: 12 months: Weight = 3kg Length = 50cm Weight = 5.4kg Length = 57cm HC = 40cm Weight = 7.6kg Length = 65cm HC = 44cm Weight = 7.2kg Length = 68cm HC = 47cm Weight = 9kg Length = 72cm HC = 50cm Weight = 10kg Length = 75cm HC = 51cm Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors slightly less than median median just under median near median +1 line slightly above median near median +2 line between median and -2 line near median +3 line median near median above +3 median near median above +3 Page 103 of 222 Describe Hendrick’s growth since birth What might explain Hendrick’s rapid head growth? What will you do to address Hendrick’s abnormal head growth? Hendrick has been growing in weight and length at a normal rate (briefly lost weight at six months of age, which may have been due to acute illness), but his head circumference has been growing quite rapidly since two months of age. Meningitis, hydrocephalus Do complete physical exam with special attention to neurological exam. Check HIV status. Ask about exposure to TB. Refer immediately to hospital/neurologist (especially because of funny movements – could be sign of seizures) for admission. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 104 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 105 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 106 of 222 Sub-topic 8.3: Growth pattern of the HIV-infected child Case study 1: Siphiwe Siphiwe is a four-year-old known HIV-positive child followed in the HIV clinic. She is healthy, has generalized lymphadenopathy and history of ear infections and respiratory infections, but has not required ARVs. She lives with her mother and has a good appetite. Her child health card has the following information: 2 years: 2.5 years: 3 years: 3.5 years: 4 years: Weight = 10 kg Length = 80cm Weight = 11 kg Length = 85cm Weight = 12 kg Length = 90 cm Weight = 12 kg Length = 90cm Weight = 12 kg Length = 90cm between median and -2 line just above -2 line between median and -2 line just above -2 line between median and -2 line just above -2 line between median and -2 line just below -2 line between median and -2 line at -3 line Plot these values on No growth since three years of age. the weight for age chart and describe what you see. What are some reasons for this lack of growth? Progression of HIV, lack of access to food, TB infection. What will you do to assess the situation? Take careful, detailed psychosocial history, screen for TB exposure, ask about intercurrent infections, check CD4 count. Physical exam did not reveal acute infection, CD4 count was 380. No recent exposure to TB or symptoms of TB. You learn that Siphiwe’s father died, her mother is bedridden and Siphiwe is being cared for by her aunt. What do you do now? Educate aunt about optimal nutrition for Siphiwe. Refer to nutritionist and refer for community food resources and community social support. If available, consider a home visit. Schedule follow-up in one month. If growth failure occurs despite adequate nutrition, ARV therapy is indicated. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 107 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 108 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 109 of 222 Case study 2: Kefilwe Kefilwe is a two-year-old who was diagnosed with HIV at 15 months of age (transmitted via breast milk) and receives her care at the HIV clinic. Her CD4 % was 25% at 15 months of age. She has lymphadenopathy and a history of recurrent respiratory infections, including sinusitis and one hospitalization for pneumonia. You review her child health card and find the following information: Birth: Weight = 3kg just below median Length = 48.5cm just below median 3 months: Weight = 5.5kg between median and -2 Length = 58cm just below median 6 months: Weight = 6.5kg between median and -2 Length = 63cm between median and -2 9 months: Weight = 7.7kg below median Length = 67cm between median and -2 12 months: Weight = 8.5kg below median Length = 70cm between median and -2 15 months: Weight = 9kg below median Length = 73cm above -2 18 months: Weight = 9.3kg at -2 Length = 75cm at -2 24 months: Weight = 9kg at -2 Length = 76cm at -3 Plot the values and She has lost weight and her height velocity has describe Kefilwe’s slowed considerably. growth to date. How would you assess her? Ask her father about access to food and potable water, changes in economic status, ask about exposure to TB, do complete physical exam, check CD4%. Her father states that she was hospitalized again for pneumonia. She has had non-bloody diarrhea and intermittent fever for the past two weeks, and her appetite has decreased. She has not been exposed to anyone with active TB. Her physical exam is significant for a pale, dehydrated, ill-appearing child with oral thrush and hepatosplenomegaly. Her CD4% is 18%. What would you do Hospitalize her and start her on ARVs and CTX. now? Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 110 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 111 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 112 of 222 Case study 3: Abraham Abraham is a 12-month-old perinatally-infected toddler who has been followed in the HIV clinic since birth. He has been on ARVs since being diagnosed at six weeks of age. He also takes CTX. He does not crawl and makes minimal sounds. Birth: 3 months: 6 months: 9 months: 12 months: Weight = 2.8kg Length = 51cm Weight = 5.8kg Length = 58cm Weight = 7.6kg Length = 65cm Weight = 9kg Length = 71cm Weight = 8kg Length = 72cm [at -2] [at median] [between median and -2] [between median and -2] [closer to median] [between median and -2] [at median] [between median and -2] [at -2] [just above -2] Plot measurements on the child health card and describe Abraham’s growth. He has lost weight and his height growth has slowed down. What would explain his lack of growth? Progression of HIV, TB infection, social problems, poor/no adherence to ARVs or ARV failure for other reasons (e.g. drug resistance or inadequate dosing). How will you assess him? Take careful social and medical history and assess adherence to ARVs. Do complete physical exam including developmental assessment. You learn that his parents passed away and he is being cared for by his 16year-old brother who was afraid to give him medications because he didn’t know how. What is your plan? Teach the older brother how to give the medications. Check Abraham’s CD4% and viral load. Refer to nutritionist, community food resources and social services. If available, schedule home visit. Schedule follow-up appointment in one month. The older brother returns with Abraham as scheduled. Abraham is much more interactive, is able to crawl and is talking more. His weight is 8.5kg. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 113 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 114 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 115 of 222 Sub-topic 8.4: Recording and interpreting BMI Case study 1: Agnes Agnes is a two-year-old orphan. Her mother died during childbirth and father died of HIV when Agnes was two weeks old. She is uninfected and is being cared for by a wealthy aunt. The aunt believes that Agnes could still become infected with HIV and thinks the best way to prevent this is give her plenty to eat “to make sure she is not skinny.” She has not had any intercurrent illnesses. You have the following weights and lengths: 2 months: Weight = 4 kg 12 months: Weight = 13.2 kg Length = 50 cm Length = 82 cm 4 months: Weight = 5.5 kg 18 months: Weight = 16 kg Length = 55 cm Length = 92 cm 6 months: Weight = 7.1 kg 24 months: Weight = 17.5 kg Length = 62 cm Length = 97 cm 9 months: Weight = 10 kg Length = 70 cm Use the BMI chart in the child health card to plot the measurements. How would you describe Agnes’ growth? What would you do next? She is overweight At two months her BMI is 16 (normal). At four months her BMI is 18 (normal) At six months her BMI is 19 (approaching overweight) At nine months her BMI is 20 (overweight) At 12 months her BMI is 20 (overweight) At 18 months her BMI is 19 (overweight) At 24 months her BMI is 19 (overweight) Take complete dietary history, do a complete physical exam and developmental exam. Perform rapid HIV test. The diet history shows that Agnes’ aunt gave her extra-calorie formula as an infant and started solid foods at three months of age. Currently Agnes drinks six glasses of full cream milk each day, and her aunt puts extra sugar and oil in her food and drinks. The physical and developmental exams show she is normal other than her weight. Her rapid HIV test came back negative. What is your next step? Share the HIV test results and reassure her aunt that Agnes is not infected with HIV. Explain routes of HIV transmission in infants and toddlers. Provide nutritional counseling and refer Agnes to a nutritionist. Schedule a follow-up appointment in one month. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 116 of 222 Case study 2: Sipho Sipho is a two-and-a-half year-old orphan. His parents died when he was six months-old, and he has subsequently lived in four different households over the past two years. He was placed in an orphanage one month ago. The caseworker at the orphanage is concerned because he has had diarrhea for the past month and his appetite is poor. She wants to know if he has HIV. She hands you three different child health cards for Sipho. You organize the data in one Card and have the following information. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 117 of 222 12 months: 18 months: 24 months: 30 months: Use the BMI chart in the child health card to plot all the measurements. How would you describe Sipho’s growth based on his BMI? What is your plan for him? Weight = 7.0 kg Length = 73 cm Weight = 7.8 kg Length = 78 cm Weight = 8.5 kg Length = 83 cm Weight = 8.9 kg Length = 85 cm He has suffered from severe wasting since one year of age. At 12 months his BMI is 13 (approaching severe wasting—13.4) At 18 months his BMI is 13 (severe wasting) At 24 months his BMI is 12, (severe wasting) At 30 months his BMI is 12 (severe wasting) Take a complete history and perform a physical exam including developmental exam. Conduct a rapid HIV test. The test is likely positive. Give zinc and vitamin A, start CTX. Admit for nutritional rehabilitation and possible treatment of occult infection. He urgently needs to initiate ARV treatment. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 118 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 119 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 120 of 222 Sub-topic 8.5: Using weight for length/height chart Case study 1: Precious Plot Precious’ weight and height. Use the girl’s weight-for-length/height chart: Weight = 2.4 kg Weight = 4 kg Weight = 5.2 kg Weight = 6.4 kg Weight = 7.4 kg What do Precious’ measurements indicate about her growth? Length = 46 cm Length = 55 cm Length = 61 cm Length = 66 cm Length = 75 cm Point 1: Just above -1 line Point 2: Falls to just below -1 line Point 3: Falls to -2 line. At this age, Precious is on the verge of being wasted. Point 4: Still at the -2 line Point 5: Below the -2 line Conclusion: Precious started off below average weight for height, has been losing weight and now is wasted. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 121 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 122 of 222 Case study 2: Thabo Plot Thabo’s weight and height. Use the boy’s weight-for-length/height chart: Weight = 13 kg Weight = 14.5 kg Weight = 16 kg Weight = 16.8 kg What do Thabo’s measurements indicate about his growth? Length = 85 cm Length = 91 cm Length = 97 cm Length = 105 cm Point 1: Between +1 and +2 lines. Thabo is at risk of being overweight. Point 2: Between +1 and +2 lines. Thabo is at risk of being overweight. Point 3: Closer to +1 line Point 4: Just above the median. Conclusion: Thabo’s weight and height have become proportional and average for age. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 123 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 124 of 222 Case study 3: Kopano Plot Kopano’s weight and height. Use the boy’s weight-for-length/height chart: Weight = 2.7 kg Weight = 3.8 kg Weight = 5.4 kg Weight = 7.5 kg What do Kopano’s measurements indicate about his growth? Length = 45 cm Length = 52 cm Length = 59 cm Length = 70 cm Point 1: At +1 line Point 2: At median Point 3: At -1 line Point 4: At -1 line Conclusion: Kopano has been losing weight relative to his height (which is what usually happens when children are calorically deprived, i.e. they lose weight and after time their height velocity slows down) but he remains in the normal range, albeit at the lower end. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 125 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 126 of 222 Case study 4: Joseph Plot Joseph’s weight and height. Use the boy’s weight-for-length/height chart: Weight = 5.6 kg Weight = 7 kg Weight = 10 kg Weight = 12.5 kg What do Joseph’s measurements indicate about his growth? Length = 60 cm Length = 65 cm Length = 80 cm Length = 84 cm Point 1: Just above -1 line Point 2: At median Point 3: At median Point 4: Between median and +1 line Conclusion: Joseph is doing well. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 127 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 128 of 222 Case study 5: Palesa Plot Palesa’s weight and height. Use the girl’s weight-for-length/height chart: Weight = 4 kg Weight = 5.5 kg Weight = 7.1 kg Weight = 10 kg Weight = 13.2 kg Weight = 16 kg Weight = 17.5 kg What do Palesa’s measurements indicate about her growth? Length = 50 cm Length = 55 cm Length = 62 cm Length = 70 cm Length = 82 cm Length = 92 cm Length = 97 cm Point 1: At +2. Palesa is overweight. Point 2: At +2. Palesa is overweight. Point 3: At +1. Point 4: At +2. Point 5: Just above +2. Palesa is overweight. Point 6: Just above +2. Point 7: Remains at +2 z-score. Conclusion: Palesa is overweight. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 129 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 130 of 222 Case study 6: Ruth Plot Ruth’s weight and height. Use the girl’s weight-for-length/height chart: Birth: 1 month: 2 months: 3 months: 4 months: 6 months: What do Ruth’s measurements indicate about her growth? Weight = 4.2 kg Weight = 4.6 kg Weight = 5.0 kg Weight = 5.2 kg Weight = 5.6 kg Weight = 5.8 kg Length = 53 cm Length = 54 cm Length = 56 cm Length = 57 cm Length = 57 cm Length = 58 cm Point 1: Weight at +2 line, length at +2, weight/length between median and +1 line Point 2: Weight just above median, length at +2, weight/length at +1 Point 3: Weight at median, length at +2, weight/length between median and +1 Point 4: Weight between median and -2 line, length slightly above +2, weight/length between 0 and +1 Point 5: Weight between median and -2 line, length slightly below +2, weight/length at +1 Point 6: Weight at -2 line, length between 0 and +2, weight/length at +1 Conclusion: Ruth is not maintaining good weight gain. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 131 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication Skills for Mentors Page 132 of 222 Case study 7: Emily Plot Emily’s weight and height. Use the girl’s weight-for-length/height chart: Birth: 4 months: What do Emily’s measurements indicate about her growth? Weight = 3 kg Weight = 5 kg Length = 48 cm Length = 57 cm Point 1: Weight between median and -2 line, length just below 0, weight/length between median and -1 line Point 2: Weight at -2 line, length between -2 and -3, weight/length between median and -1 line Conclusion: Emily is underweight and stunted and her weight for length is proportional and in the normal range. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 133 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 134 of 222 Case study 8: Vusi Plot Vusi’s weight and height. Use the boy’s weight-for-length/height chart: 12 months 15 months 18 months 7.0 kg and 73 cm 7.4 kg and 75 cm 7.8 kg and 78 cm What do Vusi’s measurements indicate about his growth? 24 months 30 months 8.5 kg and 83 cm 8.9 kg and 85 cm 1. Weight just slightly above -3 line, length between 0 and -2, weight/length at -3 line 2. Weight still just slightly above -3 line, length just above -2, weight/length same 3. Weight at -3 line, length just above -2, weight/length same 4. Weight still at -3 line, height just above -2, weight/height same 5. Weight less than -3 line, height between 0 and -2, weight/height same Conclusion: Vusi is severely wasted. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 135 of 222 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 136 of 222 Key points on growth monitoring 1. When interpreting growth charts, be alert for the following situations, which may indicate a problem or suggest risk: Child’s growth line crosses a z-score line. Sharp incline or decline in child’s growth line. Child’s growth line remains flat (stagnant); i.e. no gain in weight or length/height. Whether or not the above situations actually represent a problem or risk depends on where the change in the growth trend began and where it is headed. For example, if a child has been ill and lost weight, a rapid gain (shown by a sharp incline on the graph) can be good and indicate “catch-up growth.” Similarly, for an overweight child a slightly declining or flat weight growth trend towards the median may indicate desirable “catch-down.” It is very important to consider the child’s overall health and social situation when interpreting trends on growth charts. 2. Growth failure is sign of HIV disease progression and independent risk factor for death. Disturbances in growth are detectable well before the onset of opportunistic infections or other manifestations. 3. AIDS wasting is defined as weight loss of 10% or more of body weight or deceleration in weight gain resulting in downward crossing of 2 or more of the percentile lines for age (e.g., 95th, 75th, 50th, 25th, 5th) in a child older than 1 year or in the 25th percentile of weight for height on consecutive measurements separated by more than 30 days in addition to the presence of chronic diarrhea or chronic fever. 4. Note that it is important to plot all values (i.e. use weight-for-age, length/heightfor-age and weight-for-length/height) charts to fully assess a child. These case studies can be adapted or used as they are for individual or group mentoring sessions. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 137 of 222 Tool 3-G: WHO suggestions for clinical case conferences How to organize a clinical team meeting (clinical case conference) The purpose of clinical team meetings is to communicate, to efficiently share patient information and plans of care, and to share responsibility for all aspects of care and outcomes. Choose a day of the week and a precise time and do not change so the team meeting will become a fixed appointment for the clinical team at the health facility. Designate a clinical team meeting leader who should prepare the weekly patient list and agenda. This should not usually be the medical officer! Discuss only a subset of patients each week. Develop among the team a consistent way to provide only essential information regarding each patient. When preparing for a health care team meeting: Have the right people attend. Ensure team members are prepared or have been given enough time to prepare. Ensure that the meeting room is adequate and comfortable. Do not overwhelm the agenda. Team meetings should not be longer than one hour. If there are too many cases, postpone some of them to the following week. If there are too many cases per week regularly, schedule two team meetings per week. Empower team members with communication and problem-solving skills. Remind the clinical team that, in the beginning, everybody will need to learn how to handle the meetings. Things will get faster after a few meetings. Other tips to help achieve successful meetings include the following. Discuss only a few patients each week. Start and end on time. Determine how all team members will have a chance to speak openly. Participation and respect All member of the team should have a chance to contribute. The atmosphere of the meeting should encourage active participation by everyone, regardless of cadre or clinical role. Everyone has an opportunity to contribute to the meeting’s success. It is important in any group work that individuals respect each other and each other’s viewpoint. Respect often breaks down when individuals do not listen to each other. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 138 of 222 Who does what? Clinical team leader/mentor Prepare a reasonable agenda (see example below) Ensure that there are not too many cases for the meeting Ensure that team members come prepared with relevant information about the cases to discuss If possible, photocopy the material for the team members Clinical officers and nurses Decide which are the most urgent cases to discuss Review the files of the patients to be discussed Prepare a summary with only the relevant information, allowing the team to decide the appropriateness of medical eligibility to antiretroviral therapy and whether the patient is ready to start Explain the cases to the rest of the team Use this opportunity to clarify doubts and clinical questions with the rest of the team but prepare a very concise and precise list Explain the cases to the rest of the team Use the opportunity to clarify questions with the rest of the team but prepare a very concise and precise list Respond patiently to each team member’s questions Have time available at the end of the meeting for additional questions or doubts from the rest of the team (especially if the medical officer is not posted at the facility) Other clinical staff Consult with clinical officers and nurses on the cases to discuss Prepare a summary with only the relevant information to the discussion Medical officer/supervisor/mentor Ask only relevant information about the case Review patient files only if necessary Explain the clinical background of the possible decision Involve each team member Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 139 of 222 Sample agenda Cases Reporting clinical officer or nurse Reporting antiretroviral therapy aide Decision of the team (to be completed during meeting) Comments 1600– Mary Eustace Jomo 1610 Olukoto 1610– Lydia Adimu Mary 1620 Sureti 1620– Adimu Oliver Turi Wangari 1630 1630– Adimu Mike Tituri John 1640 1640– Jomo Ann Smith Mary 1650 1650–1710 Discussion and clarification of clinical issues 1710–1730 Discussion and clarification of issues related to antiretroviral therapy aides 1730 Meeting ends Adapted from “Annex 11: Suggestions for Clinical Case Conference”, WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resourceconstrained settings. World Health Organization. 2006. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 3: Communication skills for mentors Page 140 of 222 Section 4: Implementation 4.1 Schedules and agendas Scheduling Once the mentor has undertaken the facility baseline assessment and assessed mentee learning needs (see Section 2.3), the next step is to set up a mentoring schedule. The mentoring schedule should consider: Which topics need to be covered—as determined by the learning and baseline needs assessments Approximately how much time will be needed for each topic—based on the learning needs assessment. Time estimates may need to be adjusted based on progress. Mentoring program model (see the next section)—based on the projected amount of time required and the mentor’s availability. Best learning methods for each learning need—based on teaching resources available. See Section 3.5: Teaching techniques. A sample mentoring schedule is attached in Tool 4-D: Model mentoring schedule. Related Tools Tool 4-D: Model mentoring schedule Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 141 of 222 4.2 Mentoring program models Multi-week on-site model The most familiar model is the multi-week on-site model. This model permits the mentor(s) to spend a continuous, extended amount of time with the mentee clinician or clinical team. This model works well for remote sites. In this model, the mentor becomes part of the clinical team, even if he or she is mentoring only one or two individuals. The mentor (or mentoring team) participates in clinical staff meetings. Advantages: Get to know the mentee and facility more quickly than with other models Continuity of mentoring Immediate opportunities for follow-up Disadvantages: Mentor can only be at one or two sites (e.g., mornings at one clinic, afternoons at another) at any point in time Mentors coming from a distance may require accommodation/lodging Intensive mentoring period can be mentally exhausting Could reduce amount of time mentee has to complete routine duties Periodic on-site model In this model, the mentor visits the site for specific mentoring activities on a regular basis, i.e., weekly, biweekly, monthly, etc. Frequency is determined by the needs assessment. This model works well when the mentor is responsible for working at several sites within a small geographic area. Advantages: Mentor can work at several sites during the same period of time Minimal interference of mentoring activities with routine duties Easier to make mentoring part of the professional routine in the long-term Disadvantages: May have long intervals between activity and follow-up Get to know the mentee and facility less quickly than with extended on-site model Relies more heavily on remote support (telephone, email, etc.) when mentor is not on-site Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 142 of 222 Distance support Distance support by telephone, email, video-conference, moderated web site, radio, television, or other method is a necessary complement to any long-term mentoring model. Distance support complements the in-person interaction that takes place during mentoring visits. After the on-site mentoring phase is completed, the mentee can continue the relationship with the mentor via distance support. Dedicated phones or SIM cards can be distributed to mentors and mentees. Use the SIM card feature that prevents calls to unauthorized numbers; the program participants can then use the cards only for the mentorship program’s purposes. Telephone, letter, and computer correspondence must be held to strict confidentiality standards. Protocols about the confidentiality of patient information apply to distance support. Other support Scheduled lectures (Grand Rounds), conferences, and training workshops can all be part of the mentoring continuum. Such events can be open to all staff, not just those who are being mentored. Such events can be considered mentoring activities or as complements to mentoring activities. Individual versus systems mentoring Mentees work best with mentors from the same cadre. Whether individually or as part of a team, same-cadre mentors can more easily establish relationships and be familiar with the mentee’s roles and responsibilities. They have an advantage when it comes to credibility—they themselves have already done the same job. If mentors come from a different cadre, it is important to factor in the added time for relationship-building, as well as for learning roles. Multidisciplinary team mentoring is best for addressing not only individual skill and performance, but the facility systems that are in place to support pediatric HIV care and treatment. A team approach to mentoring reinforces the relationships and systems by which the healthcare workers provide services. This, in turn, increases institutional learning and sustainability. Related tools See I-TECH’s PRIME Framework for Establishing HIV Clinical Mentoring Programs in Resource-Limited Settings (Clinical Mentoring Toolkit). Available at: http://www.go2itech.org/HTML/CM08/toolkit/programs/print/settingup/ PRIME_Framework.doc Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 143 of 222 4.3 Defining and assessing competence Defining and assessing competence As a trainer and educator, the mentor will be in a position of assessing mentee performance. The mentor should use the competency checklists in Tool 4-E: Competency checklists as well as the Family-Centered Care of HIV-Exposed and HIV-Infected Children in Low-Resource Settings: Standard Operating Procedures (SOPs), which explain the steps required in the care and treatment of infants and children who are HIV-exposed and infected. For each competency, the standard of competence should be clearly described as in the example in Table 4.1, below. In deciding whether a mentee meets the performance standard in the competency checklist, the mentor should refer back to the Family-Centered Care of HIV-Exposed and HIV-Infected Children in LowResource Settings: Standard Operating Procedures. The example in Table 4.1 refers to competency 6 from the competency checklist for SOP “Section 1: Care of the HIVexposed infant”. Table 4.1: Grading of competencies in checklist Competency Assess CTX prophylaxis and makes accurate decisions to initiate, continue or discontinue CTX. Corresponding procedure from SOP Initiate CTX prophylaxis for HIV-exposed infants at the age of 4-6 weeks or as soon as possible thereafter. Continue CTX until HIV infection is ruled out. Determine the appropriate dose of CTX and provide a prescription. Discuss with the caregiver: Rational for prescribing CTX Dosing and administration What to do if a dose is missed Potential side effects: CTX is generally well-tolerated, but encourage caregiver to report rash, fever, persistent vomiting or other potential adverse effects right away Demonstrate how to measure and administer the medication. Manage adverse reactions according to the recommendations. Use Dapsone as an alternative prophylaxis strategy if CTX is discontinued due to severe adverse reaction. Standards and grading* 1 (Needs improvement): mentee does not prescribe CTX or does not check dosing, administration or adherence at follow-up visits 2 (Satisfactory): mentee initiates CTX in timely manner and at the correct dosage, recalculates dosage at every visit, understands when CTX is discontinued, knows what to do in the event of side effects. 3 (Excellent): in addition, the mentee also does an excellent job educating caregiver, demonstrates how to measure and administer medication, screens for side effects at every visit, counsels and supports excellent adherence. NA (Not applicable) RL (Resource limitations): e.g., CTX is not available. Check dosing, administration and adherence at every visit. In the absence of nationally-set standards, the clinical mentor with input from the facility supervisor and other experienced clinicians should determine the standards and grading system. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 144 of 222 In many cases the mentor will need to use their own discretion to decide on grading, factoring in not only the competencies listed in Tool 4-E: Competency checklists but also the full range of a healthcare worker’s roles and responsibilities, including: Knowledge and technical skills Problem-solving skills Psychosocial knowledge and skills Professionalism and ethical practice System-based practices Applying quality improvement Providing patient-centered care Employing evidence-based medicine These categories overlap and are not exhaustive. Each healthcare program and, consequently, the mentorship program, should determine their core and related competencies. Timing of assessment The frequency of assessment depends on the learning needs of the mentee as well as reporting requirements. There should be at least one mid-mentorship assessment before the final one at the end. Use Tool 4-E: Competency checklists and any standards developed (see Table 4.1) to assess mid-term and final progress. Assessments during the course of the mentorship allow the mentor and mentee to keep track of progress and to revise and re-prioritize learning objectives, if needed. Related Tools Tool 4-E: Competency checklists Family-Centered Care of HIV-Exposed and HIV-Infected Children in LowResource Settings: Standard Operating Procedures (SOPs) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 145 of 222 4.4 Reporting progress Frequent documentation At the end of each day, the mentor should complete the Daily Mentoring Documentation Form (see Tool 5-A: Sample logframe for clinical mentoring project). This documentation form will be used as the basis of weekly and quarterly reports (discussed below and in Section 5). At the completion of each week, the mentor should: Debrief the week’s activities with mentees: Discuss the week’s accomplishments. Discuss next week’s priorities. Set date and time for next visit. Agree on action points for both mentor and mentee for next visit. Discuss how to keep in touch should questions come up. Complete and submit the mentoring activity report forms and any other debriefing reports as appropriate for the week’s activities and to make the case for next steps in the mentorship (see Tool 5-A: Sample logframe for clinical mentoring project and Tool 5-B: Sample daily mentoring documentation form on page 206 and page 210). Complete assessment of mentee progress, if called for. Debrief the week’s activities, either with facility supervisors, other local stakeholders, and the coordinating agency (e.g., the mentoring program supervisor), or in a written form. Key points might include the following: 23 What mentoring activities did you complete today/this visit? Overall, how did the consultation/mentoring session go? What were the biggest problems you saw in terms of quality of care? What are the factors contributing to these problems? What recommendations did you give to your mentee/clinical team? How were the recommendations received? Were there any knowledge gaps that can be addressed by training? How was the clinician-client interaction? What recommendations did you make regarding that interaction? How well does the referral system work? What recommendations did you make regarding the referral system? Do you think the mentoring session was useful to the mentee/clinical team? Why or why not? What changes would you make in how this clinical consultation/mentoring Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 146 of 222 session was arranged? Support for mentors As mentioned in Section 2.4, mentors will need support from other mentors and mentoring program supervisor, if applicable. Mentor clinicians should be encouraged to use their networks to deal with challenging clinical and mentoring issues. Periodic formal meetings with other mentors are not only helpful in providing a structure for addressing problems and preventing mentor burnout but also for learning about best practices and new techniques. Whether formal or informal, the mentor meetings can overlap with or follow a similar format as the debriefings described in the above topic, “Frequent documentation”. Related Tools Tool 5-A: Sample logframe for clinical mentoring project Tool 5-B: Sample daily mentoring documentation form Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 147 of 222 Tool 4-D: Model mentoring schedule Week 1: Facility-based DAY 8:00-13:00 Clinic observations (by Monday Lunch Lunch mentor) 14:00-17:00 Discussion of findings Interactive discussion and case studies, presented by mentor; topic: growth monitoring Tuesday Clinic observations (by Lunch mentor) Wednesday Clinic observations (by Lunch Lunch Lunch mentor) Thursday Clinic observations (by mentor) Friday Clinic observations (by Discussion of findings Interactive discussion and case studies, mentor) presented by mentor; topic: infant diagnosis and assessment and management of common symptoms in children with HIV Discussion of findings Multidisciplinary team meeting to discuss complex patient cases Discussion of findings Interactive discussion and case studies, presented by mentor; topic: DBS collection, storing, drying and packaging Discussion of findings Interactive discussion and case studies, presented by mentor; topic: Routine care of the HIV-infected child and assessment and management of common symptoms in children with HIV Week 2: Visit to pediatric center of excellence by all mentees DAY 8:00-13:00 Lunch 14:00-17:00 Lunch Mentees observe Debrief morning activities Monday pediatric clinic, center of Multidisciplinary team meeting to discuss complex excellence in capital city Tuesday Wednesday Thursday Friday Mentees start taking active role in providing care at pediatric clinic, center of excellence in capital city Mentees start taking active role in providing care at pediatric clinic, center of excellence in capital city Mentees providing care under guidance of experts at pediatric clinic, center of excellence in capital city Mentees providing care under guidance of experts at pediatric clinic, center of excellence in capital city Week 3: Facility-based DAY 8:00-13:00 Mentor demonstration Monday patient cases Lunch Debrief morning activities In-patient rounds Lunch Debrief morning activities In-patient rounds Visit to Central Laboratory to observe HIV DNAPCR testing Lunch Debrief morning activities Psychosocial assessment Attendance at conference in capital city Lunch Debrief morning activities Multidisciplinary team meeting to discuss complex patient cases Closure of residence at center of excellence Lunch Lunch 14:00-17:00 Discussion of findings Interactive discussion and case studies, Lunch presented by mentor; topic: nutrition, nutrition assessment and growth monitoring Discussion of findings Interactive discussion and case studies, presented by mentor; topic: supporting adherence and bedside teaching Tuesday Mentor support and bedside teaching Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 148 of 222 Wednesday Mentor support and Lunch Discussion of findings Multidisciplinary team meeting to discuss complex Lunch Discussion of findings Interactive discussion and case studies, bedside teaching patient cases Thursday Mentor support and bedside teaching Friday Mentor support and Lunch bedside teaching presented by mentor; topic: ART and failure of first line therapy Discussion of findings Interactive discussion and case studies, presented by mentor; topic: Complications of ART Week 4: Facility-based: weekly visits (with support by phone and e-mail) DAY 8:00-13:00 Lunch 14:00-17:00 Monday Tuesday Lunch Discussion of findings Wednesday Mentor support and bedside teaching Multidisciplinary team meeting to discuss complex patient cases Interactive discussion and case studies, presented by mentor; topic: IRIS and ARV toxicities including hepatotoxicity and management of lipodystrophy syndrome Lunch Lunch Thursday Friday Week 5: Facility-based: weekly visits (with support by phone and e-mail) DAY 8:00-13:00 Lunch 14:00-17:00 Monday Tuesday Lunch Discussion of findings Wednesday Mentor support and bedside teaching Multidisciplinary team meeting to discuss complex patient cases Interactive discussion and case studies, presented by mentor; topic: treatment failure and Lunch Lunch Thursday Friday Week 6: Facility-based: weekly visits (with support by phone and e-mail) DAY 8:00-13:00 Lunch 14:00-17:00 Monday Tuesday Lunch Discussion of findings, re-assess learning needs, Wednesday Mentor support and bedside teaching Thursday Friday set mentor schedule for upcoming weeks, set date of “graduation” Multidisciplinary team meeting to discuss complex patient cases Interactive discussion and case studies, presented by mentor; topic: disclosure counseling Lunch Lunch If facility is ready, visits should graduate to twice monthly for 2–3 months, monthly for another 2–3 months and then graduate from the mentoring program. Even after graduation, facilities should have phone or e-mail access to a clinical expert for difficult cases. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 149 of 222 Tool 4-E: Competency checklists Competency checklist—Section 1: Care of the HIV-exposed infant Cadre Physician Med. Officer Description Score* Comment 1. Correctly identifies all of the components of initial and routine follow-up visits for an HIV-exposed infant. Nurse _________ Physician Med. Officer Nurse 2. Conducts a thorough initial history of an HIV-exposed infant or young child, including medical history, concomitant medications, concomitant illness, social and family history and review of systems. _________ Physician Med. Officer 3. Performs comprehensive psychosocial assessments and works with families to develop a family plan of care. Nurse Counselor _________ Physician Med. Officer Nurse 4. Assesses ARV prophylaxis and makes accurate decisions to continue or discontinue treatment according to maternal ARV use and infant feeding status. _________ Physician 5. Assesses adherence and adjusts dosage of medications at every visit. Med. Officer Nurse Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 150 of 222 Competency checklist—Section 1: Care of the HIV-exposed infant Counselor _________ Physician Med. Officer 6. Assess CTX prophylaxis and makes accurate decisions to initiate, continue or discontinue CTX. Nurse _________ Physician 7. Correctly measures, plots, and interprets weight of young infants and children. Med. Officer Nurse _________ Physician Med. Officer 8. Correctly measures, plots, and interprets length of young infants and children less than 2 years of age. Nurse _________ Physician 9. Correctly measures, plots, and interprets height of children over 2 years of age. Med. Officer Nurse _________ Physician Med. Officer 10. Correctly measures, plots, and interprets head circumferences of infants and children less than 3 years of age. Nurse _________ Physician 11. Responds to growth problems correctly and consistently. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 151 of 222 Competency checklist—Section 1: Care of the HIV-exposed infant Med. Officer Nurse _________ Physician Med. Officer Nurse 12. Accurately and routinely assesses child development; recognizes “red flags” related to developmental milestones and makes appropriate decisions or plans to respond to problems that are identified. Counselor _________ Physician Med. Officer Nurse 13. Routinely reviews immunization status of infants and children; administers vaccinations following standard operating procedures. _________ Physician Med. Officer Nurse 14. Assesses need for vitamin A supplementation, routine worm treatment (mebendazol), and administers according to standard operating procedures. _________ Physician 15. Recognizes signs and symptoms associated with HIV disease in infants. Med. Officer Nurse _________ Physician 16. Performs comprehensive physical assessments at the initial visit. Med. Officer Nurse Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 152 of 222 Competency checklist—Section 1: Care of the HIV-exposed infant _________ Physician Med. Officer 17. Performs symptom-directed physical examination appropriately for routine follow up visits. Nurse _________ Physician Med. Officer 18. Accurately follows algorithms for infant and young child HIV testing according to age and status of infant feeding.* Nurse Counselor Lab Tech _________ Med. Officer Nurse 19. Provides counseling and support for infant feeding following standard operating procedures. Counselor _________ Physician 20. Develops a comprehensive follow-up plan for the infant. Med. Officer Nurse Counselor _________ Physician Med. Officer 21. Enquires about health and HIV status of family members; follows standard operating procedures for referral of infants, children or Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 153 of 222 Competency checklist—Section 1: Care of the HIV-exposed infant other family members for medical services. Nurse Counselor _________ Physician Med. Officer 22. Tracks referrals and makes every effort to contact the caregiver or family for missed visits. Nurse Counselor _________ Physician 23. Reviews/checks maternal (or caregiver) health and treatment status at every visit Med. Officer Nurse _________ Med. Officer Nurse Counselor 24. Provides counseling and makes recommendations for HIV testing for siblings, maternal partner or other family members. _________ Physician Med. Officer Nurse 25. Accurately and thoroughly documents visits in the medical record, on the child health card and facility registers or logs as needed. Counselor _________ Physician 26. Protects confidentiality of patients and families. Med. Officer Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 154 of 222 Competency checklist—Section 1: Care of the HIV-exposed infant Nurse Counselor Lab Tech _________ Score codes: 1 Needs improvement (Task or procedure not completed correctly, NA Not applicable (Indicator is inappropriate to context) completed in the wrong order, or step omitted) DK Don’t know (Did not or could not assess) 2 Satisfactory (Task or procedure completed correctly, in the correct order, RL Resource limitations (Skill or care limitation is clearly related to if necessary) resource limitations) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) ** Counseling and testing for determination of infant HIV status is included in Section 2. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 155 of 222 Competency checklist—Section 2: Diagnosis of HIV in infants and children Cadre Physician Med. Officer Nurse _________ Description 1. Uses medical records, history and physical examination and testing algorithms to correctly determine appropriate HIV testing procedures and schedule for asymptomatic HIV-exposed infants less than 18 months of age in a setting where no viral testing is available: Score* Comment Breastfeeding infant Non-breastfeeding infant Physician Med. Officer Nurse _________ 2. Uses medical records, history and physical examination and testing algorithms to correctly determine appropriate HIV testing procedures and schedule for asymptomatic HIV-exposed infants less than 18 months of age in a setting where viral testing is available: Breastfeeding infant Non-breastfeeding infant Physician Med. Officer Nurse 3. Accurately follows WHO guidelines to make a presumptive diagnosis of HIV infection for a sick child < 18 months of age in the setting where no viral load is available. _________ Physician Med. Officer Nurse _________ 4. Uses medical records, history and physical examination and testing algorithms to identify infants and children of unknown HIV status who should receive providerinitiated testing and counseling (e.g. infants and children < 5 years of age; infants and children with tuberculosis; infants and children with growth failure or Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 156 of 222 Competency checklist—Section 2: Diagnosis of HIV in infants and children developmental delay; or siblings of an HIVexposed or HIV-infected child. 5. Conducts accurate, comprehensive and Physician supportive pre-test counseling sessions for caregivers. Med. Officer Nurse Counselor _________ Physician Med. Officer 6. Consistently uses appropriate counseling skills and techniques to convey information to caregivers. Nurse Counselor _________ Physician 7. Always uses universal precautions. Med. Officer Nurse Counselor Lab Tech _________ Physician 6. Correctly performs rapid HIV antibody testing. Med. Officer Nurse Counselor Lab Tech _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 157 of 222 Competency checklist—Section 2: Diagnosis of HIV in infants and children 7. Correctly performs DBS specimen Physician collection procedure. Med. Officer Nurse Counselor Lab Tech _________ Physician Med. Officer Nurse Lab Tech _________ Physician Med. Officer 8. Accurately interprets HIV testing results in determining infant or child HIV status and appropriate follow-up procedures. Determines if the child is: HIV infected HIV uninfected HIV exposed, infection status unknown 9. Conducts accurate, comprehensive and supportive post-test counseling and delivery of test results. Nurse Counselor _________ Physician Med. Officer 10. In collaboration with the family, creates a plan of care for the infant and family based on test results. Nurse _________ Physician Med. Officer 11. Effectively links child and family to ongoing care, treatment and community services according to the plan of care. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 158 of 222 Competency checklist—Section 2: Diagnosis of HIV in infants and children Nurse Counselor _________ Physician Med. Officer 12. Accurately documents HIV testing and counseling procedures in the appropriate registers, patient-held and facility records. Nurse Counselor Lab Tech _________ Score codes: 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Competency checklist—Section 3: Routine care of the HIV-infected child Cadre Physician Med. Officer Nurse Description Score* Comment 1. Correctly identifies all of the components of initial and routine follow-up visits for an infant, child or adolescent with HIV infection. _________ Physician 2. Conducts thorough initial history of an infant, child or adolescent including medical Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 159 of 222 Competency checklist—Section 3: Routine care of the HIV-infected child history, concomitant medications and Med. Officer illness, social and family history, and review of systems. Nurse _________ Med. Officer Nurse 3. Performs comprehensive psychosocial assessments and works with families to develop a family plan of care. Counselor _________ Physician 4. Asks about exposure to TB and assesses for symptoms of TB at every visit. Med. Officer Nurse Counselor Lab Tech _________ Physician 5. Performs WHO clinical staging at every visit. Med. Officer Nurse _________ Physician Med. Officer 6. Performs WHO immunological staging following the defined schedule for CD4 testing. Nurse _________ Physician Med. Officer 7. Accurately assesses ART eligibility in infants and children who are not receiving ART. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 160 of 222 Competency checklist—Section 3: Routine care of the HIV-infected child Nurse _________ Physician 6. Assesses adherence and adjusts dosage of all medications at every visit. Med. Officer Nurse _________ Physician Med. Officer 7. Assess CTX prophylaxis and makes accurate decisions to initiate, continue or discontinue CTX. Nurse _________ Physician 8. Correctly monitors and interprets growth parameters. Med. Officer Nurse _________ Physician 9. Responds to growth problems correctly and consistently. Med. Officer Nurse _________ Physician Med. Officer Nurse 10. Accurately and routinely assesses child development; recognizes “red flags” related to developmental milestones and makes appropriate decisions or plans to respond to problems that are identified. Counselor _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 161 of 222 Competency checklist—Section 3: Routine care of the HIV-infected child 11. Routinely reviews immunization status Physician of infants and children; administers vaccinations following standard operating Med. Officer procedures. Nurse _________ Physician Med. Officer Nurse 12. Assesses need for vitamin A supplementation, routine worm treatment (mebendazol), and administers according to standard operating procedures. _________ Physician 13. Recognizes signs or symptoms of potential ART toxicity. Med. Officer Nurse _________ Physician 14. Performs comprehensive physical assessments at the initial visit. Med. Officer Nurse _________ Physician Med. Officer 15. Performs symptom-directed physical examination appropriately for routine follow up visits. Nurse _________ Physician Med. Officer 16. Provides counseling and support for feeding and nutrition following standard operating procedures. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 162 of 222 Competency checklist—Section 3: Routine care of the HIV-infected child Nurse Counselor _________ Physician 17. Develops a comprehensive follow-up plan for the infant. Med. Officer Nurse Counselor _________ Physician 18. Reviews/checks maternal (or caregiver) health and treatment status at every visit Med. Officer Nurse Counselor _________ Physician Med. Officer 19. Follows standard operating procedures for referral of family members for medical services. Nurse Counselor _________ Med. Officer Nurse 20. Tracks referrals and makes every effort to contact the caregiver or family for missed visits. Counselor _________ Med. Officer 21. Provides counseling and makes recommendations for HIV testing for Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 163 of 222 Competency checklist—Section 3: Routine care of the HIV-infected child siblings, maternal partner or other family Nurse members. Counselor _________ Physician Med. Officer Nurse 22. Accurately and thoroughly documents visits in the medical record, on the child health card and facility registers or logs as needed. Counselor _________ Physician 23. Protects confidentiality of patients and families. Med. Officer Nurse Counselor Lab Tech _________ Score codes: 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Page 164 of 222 Competency checklist—Section 4: Nutrition and growth Cadre Physician Description 1. Demonstrates ability to support a breastfeeding mother to: Med. Officer Correctly attach her infant Nurse Correctly position her infant Counselor Screen for breast problems Score* Comment _________ Physician 2. Demonstrates ability to teach a mother how and why to: Med. Officer Express breast milk Nurse Heat-treat breast milk Counselor _________ Physician Med. Officer Nurse Counselor 3. Demonstrates ability to teach mothers when and how to wean their infants. Provides supportive and technically accurate information to women whose infants are nearing 12 months of age _________ Correctly screens mothers to ensure they can provide a nutritionally adequate and safe diet without breast milk Physician 4. Correctly measures, plots, and interprets weight of young infants and children. Med. Officer Nurse Counselor _________ Physician 5. Correctly measures, plots, and interprets Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 165 of 222 Competency checklist—Section 4: Nutrition and growth length of young infants and children under 2 Med. Officer years of age. Nurse Counselor _________ Physician 6. Correctly measures, plots, and interprets height of children over 2 years of age. Med. Officer Nurse Counselor _________ Physician 7. Correctly calculates, plots, and interprets BMI of infants and children. Med. Officer Nurse Counselor _________ Physician Med. Officer 6. Correctly measures, plots, and interprets head circumferences of infants and children under 3 years of age. Nurse Counselor _________ Physician 7. Able to investigate and counsel on undernutrition and overweight. Med. Officer Nurse Counselor Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 166 of 222 Competency checklist—Section 4: Nutrition and growth _________ Physician Med. Officer 8. Demonstrates ability to conduct a nutrition assessment on a child whose growth is faltering/failing. Nurse Counselor _________ Physician Med. Officer 9. Demonstrates ability to educate and counsel clients on the “Five keys to safer food”. Nurse Counselor _________ Physician Med. Officer 10. Demonstrates ability to conduct an assessment of the safety of formula feeding. Nurse Counselor _________ Physician 11. Able to counsel on safe and hygienic formula preparation. Med. Officer Nurse Counselor _________ Physician Med. Officer 12. Demonstrates ability to correctly educate, counsel and support mothers to introduce complementary foods. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 167 of 222 Competency checklist—Section 4: Nutrition and growth Nurse Counselor _________ Physician 13. Able to counsel mothers on feeding children with the following special needs: Med. Officer Children with HIV Nurse Children with diarrhea Counselor Children who are vomiting _________ Children with upper respiratory infection Physician Med. Officer Nurse 14. Accurately documents infant feeding and nutrition-related procedures in the appropriate registers, patient-held and facility records. Counselor _________ Score codes: 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Page 168 of 222 Competency checklist—Section 5: Antiretroviral treatment (ART) Cadre Physician Med. Officer Description Score* Comment 1. Consistently and correctly confirms HIV infection status in infants and children prior to initiation of treatment. Nurse _________ Physician Med. Officer 2. Accurately determines eligibility for ART using age and clinical criteria (no CD4 testing available) Nurse _________ Physician Med. Officer 3. Accurately determines eligibility for ART using age, clinical and immunological criteria (CD4 testing available). Nurse _________ Physician Med. Officer 4. Effectively performs step-wise adherence preparation counseling with children and caregivers. Nurse Counselor _________ Physician Med. Officer 5. Consistently initiates HIV treatment counseling before a child is eligible for treatment (whenever possible). Nurse Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 169 of 222 Competency checklist—Section 5: Antiretroviral treatment (ART) _________ Physician 6. Carefully assesses readiness for adherence prior to initiating first-line ART. Med. Officer Nurse _________ Physician 7. Creates a final adherence to treatment plan with the child and caregiver. Med. Officer Nurse Counselor _________ Physician Med. Officer 8. Counsels caregiver and child about management of mild, self-limiting side effects. Nurse Counselor _________ Physician Med. Officer Nurse 9. Counsels caregiver and child about signs and symptoms of serious or lifethreatening toxicity that require attention at a health facility. Counselor _________ Physician Med. Officer 10. Arranges referrals for psychosocial and treatment adherence support as needed and as available. Nurse Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 170 of 222 Competency checklist—Section 5: Antiretroviral treatment (ART) Counselor _________ Physician Med. Officer 11. Enquires about medical history, social history, concomitant medications and allergies prior to selecting first-line regimen. Nurse _________ Physician 12. Accurately follows guidelines for selection of first-line ART. Med. Officer Nurse _________ Physician 13. Accurately determines appropriate dosing for ART. Med. Officer Nurse _________ Physician 14. Re-calculates dosing at each visit. Med. Officer Nurse _________ Physician 15. Addresses adherence at each follow-up visit. Med. Officer Nurse Counselor _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 171 of 222 Competency checklist—Section 5: Antiretroviral treatment (ART) 16. Assess for potential ART toxicity at Physician each follow-up visit. Med. Officer Nurse _________ Physician 17. Accurately assesses WHO clinical staging at each visit. Med. Officer Nurse _________ Physician Med. Officer 18. Conducts and reviews laboratory tests for routine monitoring according to established guidelines. Nurse Lab Tech _________ Physician Med. Officer 19. Correctly screens all children living with HIV for signs or symptoms of TB disease at every visit. Nurse _________ Physician Med. Officer 23. Comprehensively documents counseling, care and treatment in the medical record and child health card. Nurse Counselor _________ Score codes: Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 172 of 222 Competency checklist—Section 5: Antiretroviral treatment (ART) 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Competency checklist—Section 6: Complications of ART Cadre Physician Med. Officer Nurse _________ Description Score* Comment 1. Routinely teaches caregivers and children to recognize potential ART toxicity: Teaches caregivers to anticipate selflimiting, mild ART toxicities/side effects, and how to management them at home Ensures caregivers know how to contact the clinic or health worker. Teaches caregivers to recognize toxicities that require immediate medical attention Physician Med. Officer Nurse 2. Routinely performs interval history and review of systems and conducts symptomdirected physical examination at each follow-up visit. _________ Physician Med. Officer 3. Asks about changes to the psychosocial assessment of the family, including health of family or household members. Nurse Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 173 of 222 Competency checklist—Section 6: Complications of ART _________ Physician Med. Officer 4. Accurately assesses the severity of signs or symptoms. Nurse _________ Physician Med. Officer Nurse 5. Accurately develops differential diagnosis (by considering other disease processes) in response to symptoms and/or physical findings. _________ Physician 6. Determines whether signs or symptoms are related to ART. Med. Officer Nurse _________ Physician Med. Officer Nurse 7. Accurately responds to toxicity assessment: provides supportive counseling and symptom relief for mild to moderate symptoms and supports adherence to ongoing treatment. Counselor _________ Physician Med. Officer Nurse 8. . Accurately responds to toxicity assessment: recognizes severe and/or lifethreatening symptoms and responds appropriately following guidelines. _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 174 of 222 Competency checklist—Section 6: Complications of ART 9. Correctly identifies toxicity related to a Physician single drug and makes appropriate singledrug substitutions. Med. Officer Nurse _________ Physician Med. Officer 10. Assesses children (with new signs or symptoms after initiating ART) for IRIS using appropriate diagnostic methods. Nurse _________ Physician Med. Officer Nurse 11. Recognizes or describes signs and symptoms related to lactic acidosis; conducts or describes appropriate assessment and management. _________ Physician Med. Officer Nurse 12. Recognizes or describes signs and symptoms associated with abacavir hypersensitivity; conducts or describes appropriate assessment and management. _________ Physician Med. Officer 13. Recognizes or describes hepatotoxicity and/or rash related to NVP; conducts appropriate assessment and management. Nurse _________ Physician Med. Officer Nurse 14. Describes metabolic complications associated with long-term ART; describes assessment and management of signs and symptoms of metabolic complications Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 175 of 222 Competency checklist—Section 6: Complications of ART and/or lipodystrophy. Counselor _________ Physician Med. Officer Nurse 15. Conducts patient and caregiver counseling and provides ongoing support related to severe toxicity and changes to ART. Counselor _________ Physician Med. Officer Nurse 16. Ensures child and caregiver readiness prior to initiating single-drug substitution or re-starting ART after discontinuation for toxicity. Counselor _________ Physician Med. Officer Nurse 17. Ensures appropriate follow-up plan related to toxicity management or changes to ART regimen; assesses need for home visits and/or community support. Counselor _________ Physician Med. Officer 18. Comprehensively documents counseling, care and treatment in the medical record and child health card. Nurse Counselor Lab Tech _________ Score codes: Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 176 of 222 Competency checklist—Section 6: Complications of ART 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Competency checklist—Section 7: Treatment failure Cadre Physician Med. Officer Nurse Description Score* Comment 1. Routinely performs interval history and review of systems and conducts symptomdirected physical examination at each follow-up visit. _________ Physician Med. Officer Nurse _________ 2. Correctly assesses infants and children for clinical criteria of ART failure. Accurately performs WHO clinical staging at every visit Checks to ensure child has received at least 24 weeks of ART Conducts nutritional assessment Assesses adherence Considers IRIS Physician 3. Accurately assesses children for immunological failure. Med. Officer Nurse _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 177 of 222 Competency checklist—Section 7: Treatment failure 4. Where available, correctly uses viral load Physician measurement as part of the assessment of ART failure. Med. Officer Nurse _________ Physician 5. Accurately determines eligibility for second-line treatment. Med. Officer Nurse _________ Physician Med. Officer 6. Correctly identifies appropriate secondline regimen according to age, first-line regimen, concomitant medications etc. Nurse _________ Physician Med. Officer 7. Provides comprehensive counseling and adherence preparation prior to initiating second-line regimen. Nurse Counselor _________ Physician Med. Officer 8. Assess readiness for second-line regimen prior to initiation. Ensures home and community support as needed. Nurse Counselor _________ Physician 9. Provides support, counseling and community referrals as needed for families Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 178 of 222 Competency checklist—Section 7: Treatment failure of children not eligible for second-line Med. Officer treatment, especially if issues of adherence and/or inadequate nutrition are barriers to Nurse effective treatment. Counselor _________ Physician Med. Officer 10. Determines appropriate follow-up interval for children assessed for ART failure. Nurse _________ Physician Med. Officer 11. Comprehensively documents counseling, care and treatment in the medical record and child health card. Nurse Counselor _________ Score codes: 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Competency checklist—Section 8: Assessment and management of common symptoms Cadre Physician Description Score* Comment 1. When assessing for anemia: always screens for danger signs requiring Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 179 of 222 Competency checklist—Section 8: Assessment and management of common symptoms emergency care and urgent referral. Med. Officer Nurse _________ Physician 2. Correctly screens for anemia: Med. Officer Takes detailed family history Nurse Conducts full physical examination _________ Takes laboratory specimens Physician 3. Correctly grades severity of the anemia, assesses cause and provides treatment. Med. Officer Nurse _________ Med. Officer 4. Consistently provides appropriate anemia-related education and support to child and caregiver: Nurse Discusses treatment plan Counselor Provides nutrition counseling (if appropriate) Physician _________ Teaches danger signs or symptoms that require urgent return Discusses follow up care Physician Med. Officer Nurse 5. When assessing cough, difficulty breathing, and pneumonia: always screens for danger signs requiring emergency care and urgent referral. _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 180 of 222 Competency checklist—Section 8: Assessment and management of common symptoms Physician Med. Officer 6. Correctly screens clients with cough, difficulty breathing, and pneumonia: Nurse Conducts a careful history and review of systems _________ Conducts physical examination Conducts investigations (pulse oximetry and chest x-ray, collect sputum specimen) Med. Officer 7. Correctly grades severity of the pneumonia symptoms, assesses cause and provides treatment. Nurse Conducts WHO staging _________ Continues CTX Physician Administers immunizations, vitamin A supplementation, and/or routine worm treatment (mebendazol), if eligible Nurse 8. Consistently provides appropriate cough, difficulty breathing, pneumonia-related education and support to child and caregiver: Counselor Reviews medication administration _________ Updates family psychosocial assessment Physician Med. Officer Teaches danger signs or symptoms that require urgent return Discusses prevention Discuses follow up care Physician 9. When assessing for dermatological Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 181 of 222 Competency checklist—Section 8: Assessment and management of common symptoms problems: always screens for danger signs Med. Officer requiring emergency care and urgent referral. Nurse _________ Physician Med. Officer Nurse _________ Physician Med. Officer Nurse 10. Correctly screens for dermatological problems: Asks correct screening questions Conducts full physical examination Takes laboratory specimens 11. Correctly grades severity of the rash (dermatological problem) and other symptoms, assesses cause and provides treatment. _________ Med. Officer 12. Consistently provides appropriate dermatological problem-related education and support to child and caregiver: Nurse Discusses treatment plan Counselor Discusses prevention (if appropriate) _________ Teaches danger signs or symptoms that require urgent return Physician Discusses follow up care Physician Med. Officer Nurse 13. When assessing diarrhea and other gastrointestinal problems: always screens for danger signs requiring emergency care and urgent referral. _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 182 of 222 Competency checklist—Section 8: Assessment and management of common symptoms Med. Officer 14. Correctly screens patients with diarrhea and other gastrointestinal problems: Nurse Asks correct screening questions _________ Conducts full physical examination Physician Takes laboratory specimens Physician Med. Officer 15. Correctly classifies severity of the dehydration, diarrhea and/or dysentery, assesses cause and provides treatment. Nurse _________ Nurse 16. Consistently provides appropriate diarrhea and other gastrointestinal problem-related education and support to child and caregiver: Counselor Discusses treatment plan _________ Teaches danger signs or symptoms that require urgent return Physician Med. Officer Discusses prevention (hygiene) Discusses follow up care Physician Med. Officer 17. When assessing fever: always screens for danger signs requiring emergency care and urgent referral. Nurse _________ Physician 18. Correctly screens patients with fever: Med. Officer Conducts detailed history and review of Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 183 of 222 Competency checklist—Section 8: Assessment and management of common symptoms systems and search for focus of infection Nurse Conducts comprehensive physical _________ examination if focus of infection is not obvious Takes laboratory specimens Physician Med. Officer 18. Correctly classifies the child with fever 9based on focus of infection, assesses cause and provides treatment. Nurse _________ Med. Officer 20. Consistently provides appropriate feverrelated education and support to child and caregiver: Nurse Discusses treatment plan Counselor Teaches danger signs or symptoms that require urgent return Physician _________ Discusses follow up care Physician Med. Officer 21. Suspects pain when appropriate in younger children; assesses and quantifies pain in the older child. Nurse _________ Physician 22. Correctly manages patients with pain: Med. Officer Diagnoses and treats the underlying conditions causing pain. Nurse _________ Uses non-pharmacological measure to control pain. Provides pharmacological treatment as Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 184 of 222 Competency checklist—Section 8: Assessment and management of common symptoms indicated Med. Officer 23. Consistently provides appropriate painrelated education and support to child and caregiver: Nurse Discusses treatment plan Counselor Teaches danger signs or symptoms that require urgent return Physician _________ Discusses follow up care Score codes: 1 Needs improvement (Task or procedure not completed correctly, NA Not applicable (Indicator is inappropriate to context) completed in the wrong order, or step omitted) DK Don’t know (Did not or could not assess) 2 Satisfactory (Task or procedure completed correctly, in the correct order, RL Resource limitations (Skill or care limitation is clearly related to if necessary) resource limitations) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) * Counseling and testing for determination of infant HIV status is included in Section 2. Competency checklist—Section 9: Assessment and management of common infections Cadre Description Med. Officer 1. Correctly assesses every child for signs and symptoms of tuberculosis (TB) at every visit: Nurse Asks key screening questions _________ Conducts clinical examination targeting signs suppressive of extrapulmonary TB Physician Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Score* Comment Page 185 of 222 Competency checklist—Section 9: Assessment and management of common infections when suggested by screening questions 2. Follows national guidelines for IPT for infants and children with TB exposure. Physician Med. Officer Nurse _________ 3. Orders correct procedures to confirm suspicion of TB: Conducts TST if available Obtains sputum specimens where indicated Obtains chest x-ray Physician 4. Provides correct treatment for TB. Med. Officer Determines if CTX should be initiated, continued or discontinued Nurse _________ Conducts WHO staging Administers immunizations, vitamin A supplementation, and/or routine worm treatment (mebendazol), if eligible Med. Officer 5. Consistently provides appropriate TBrelated education and support to child and caregiver: Nurse Discusses treatment plan Counselor Provides adherence counseling and support Physician _________ Updates psychosocial assessment of family Considers contact tracing Advises and arranges for family to be evaluated for TB Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 186 of 222 Competency checklist—Section 9: Assessment and management of common infections Arranges DOT Teaches danger signs or symptoms that require urgent return Discusses follow up care Med. Officer 6. Correctly assesses children for signs and symptoms of candidiasis when suggested by symptoms: Nurse Asks key screening questions _________ Conducts clinical examination targeting mouth and throat Physician Conducts clinical staging Physician Med. Officer Nurse _________ 7. Provides correct treatment for candidiasis. Considers ART or ART failure Assesses CTX prophylaxis Provides correct treatment Administers immunizations, vitamin A supplementation, and/or routine worm treatment (mebendazol), if eligible Med. Officer 8. Consistently provides appropriate candidiasis-related education and support to child and caregiver: Nurse Discusses treatment plan Counselor Teaches danger signs or symptoms that require urgent return Physician _________ Discusses follow up care Physician 9. Correctly assesses children for signs and Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 187 of 222 Competency checklist—Section 9: Assessment and management of common infections symptoms of otitis media when suggested Med. Officer by symptoms: Nurse Asks key screening questions _________ Conducts clinical examination targeting ears Conducts clinical staging Physician Med. Officer 10. Provides correct treatment for otitis media. Nurse Provides urgent referral to hospital when mastoiditis is suspected. _________ Provides correct treatment Determines if CTX should be initiated, continued or discontinued Administers immunizations, vitamin A supplementation, and/or routine worm treatment (mebendazol), if eligible Med. Officer 11. Consistently provides appropriate otitis media-related education and support to child and caregiver: Nurse Discusses treatment plan Counselor Teaches danger signs or symptoms that require urgent return Physician _________ Discusses follow up care Physician Med. Officer Nurse 12. When assessing for urinary tract infection: always screens for danger signs requiring emergency care and urgent referral. _________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 188 of 222 Competency checklist—Section 9: Assessment and management of common infections Physician Med. Officer 13. Correctly screens clients with urinary tract infection: Nurse Conducts a careful history and review of systems _________ Conducts physical examination Conducts WHO staging Continues CTX Physician Med. Officer Nurse _________ 14. Correctly grades severity of the urinary tract infection symptoms, assesses cause and provides treatment. Administers immunizations, vitamin A supplementation, and/or routine worm treatment (mebendazol), if eligible Med. Officer 15. Consistently provides appropriate urinary tract infection-related education and support to child and caregiver: Nurse Reviews medication administration Counselor Updates family psychosocial assessment Physician _________ Teaches danger signs or symptoms that require urgent return Discusses prevention Discuses follow up care Score codes: 1 Needs improvement (Task or procedure not completed correctly, completed in the wrong order, or step omitted) 2 Satisfactory (Task or procedure completed correctly, in the correct order, if necessary) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation NA DK RL Not applicable (Indicator is inappropriate to context) Don’t know (Did not or could not assess) Resource limitations (Skill or care limitation is clearly related to resource limitations) Page 189 of 222 Competency checklist—Section 9: Assessment and management of common infections 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) * Counseling and testing for determination of infant HIV status is included in Section 2. Competency checklist—Section 10: Psychosocial support and family-centered care Cadre Physician Med. Officer Nurse Counselor _________ Description Score* Comment 1. Uses “listening and learning skills” with clients and their caregivers. Able to adjust counseling and communication style based on client’s age and developmental stage Always ensures consultations with clients are private and confidential Routinely takes time to explain chronic HIV care Physician 2. Conducts psychosocial assessments: Med. Officer Conducts initial psychosocial assessment with all new clients and their caregivers Nurse Counselor _________ Updates psychosocial assessment as appropriate Routinely screens older children, adolescents or caregivers for well being Physician Med. Officer Nurse 3. Provides pre-ART adherence education and counseling following the recommendations for adherence preparation visits 1, 2, and 3. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 190 of 222 Competency checklist—Section 10: Psychosocial support and family-centered care Counselor _________ Physician Med. Officer 4. Assesses caregiver and client readiness for ART and develops and ART adherence plan with clients and/or caregivers. Nurse Counselor _________ Physician Med. Officer 5. Provides ART adherence support for clients on ART. Nurse Counselor _________ Physician 6. Provides pre-disclosure counseling: Med. Officer Uses “listening and learning skills” Nurse Structures the counseling session around the 5 “A’s” Counselor _________ Explains that disclosure is a process, its importance and implications Assesses readiness for disclosure Physician 7. Provides disclosure counseling: Med. Officer Provides support to plan for disclosure Nurse Counselor Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 191 of 222 Competency checklist—Section 10: Psychosocial support and family-centered care _________ Physician 8. Provides post-disclosure counseling: Med. Officer Asks about support needs Nurse Discusses positive living Counselor Discusses disclosure to others _________ Score codes: 1 Needs improvement (Task or procedure not completed correctly, NA Not applicable (Indicator is inappropriate to context) completed in the wrong order, or step omitted) DK Don’t know (Did not or could not assess) 2 Satisfactory (Task or procedure completed correctly, in the correct order, RL Resource limitations (Skill or care limitation is clearly related to if necessary) resource limitations) 3 Excellent (Task or procedure completed with precision and efficiency, in the correct order, if necessary) * Counseling and testing for determination of infant HIV status is included in Section 2. INSTRUCTIONS FOR ADAPTING THIS CHECKLIST INTO CADRE-SPECIFIC COMPETENCY CHECKLISTS 1. For each row, check the box(es) in the first column that indicate which cadre performs this task/competency according to national or facility protocol and procedures. 2. Copy all the rows marked “Physician” into a new checklist. You will not need to copy column 1: Cadre. 3. Do the same for all the rows checked for each “Medical Officer”, “Nurse”, “Counselor”, and any other cadres listed by “Other”. 4. You should now have multiple cadre-specific competency checklists. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 192 of 222 Recommendations to improve mentee’s practice (mark recommendations agreed upon for next visit): Examples of information you shared/skills you demonstrated that were aimed at improving the mentee’s practice: Mentor’s signature: _____________________________________________ Mentee’s signature: _____________________________________________ Date: __________________________ Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 4: Implementation Page 193 of 222 Section 5: Monitoring and evaluation 5.1 The need for monitoring and evaluation What is monitoring and evaluation? Monitoring and evaluation (M&E) are essential components of successful program management and implementation. M&E help the mentor and mentee identify areas for improvement and recognize lessons learned. M&E data also give program implementers and funders valuable information regarding project progress, efficient use of resources, and success in achieving project objectives. Monitoring Monitoring is the routine tracking of key elements of project or program performance through record-keeping, reporting, and surveillance. Monitoring data can be quantitative or qualitative but is usually more of the former. Monitoring data does not, by itself, tell much about the project or program’s overall or long-term success; that is what evaluation sets out to prove. As an example, monitoring data will tell the mentor and central organizing agency how many people were mentored over the past month, quarter or year, the topics in which they were mentored, and how many of the mentees graduated from their mentorship programs. Evaluation Evaluation is assessment at planned intervals of the changes in results that can be attributed to the program or project intervention. Evaluations are often conducted at a mid-point in a project, at the project’s conclusion, and sometimes months or years after the project ends. The evaluation process uses monitoring data and a mix of quantitative and qualitative methods for gathering information about the project’s long-term outcomes and impact. Effective evaluation permits implementers and funders to know whether an intervention has been worth the time and resources. As an example, evaluation data can tell the central organizing agency if the mentoring program supported the scale up of HIV-related pediatric care, treatment and support facilities in the health facilities that hosted mentors. Evaluation data might also provide information on the confidence level of mentees who graduated from the program. Logical Framework Model A logical framework is a tool for project management, monitoring, and evaluation. The logical framework (or “logframe”) describes the process and expected results of a project and identifies the means of collecting information to assess them. The logframe helps organize the information for each level of a project: activities, outputs, outcomes, and impact. A modified logframe table appears below: Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 194 of 222 Table 5.1: Logical Framework Inputs Goal/Impact Indicators Means of Verification Timeline Responsible Party Outcomes* Outputs* Purpose/Outcome Activities* Results/Outputs Process/Activities Activities, outputs, and outcomes serve as the inputs for the next respective level. Additional inputs may also be required. The row titles in Table 5.1 list the levels of the project. Goal/Impact: The overall goal of the project or intervention, e.g., reduce the death rate in HIV-infected children under the age of 5 Purpose/Outcome: An objective or action step that the project will undertake in an effort towards achieving the goal, e.g., build healthcare capacity to provide pediatric HIV care and treatment services, increase coverage of early infant testing Expected results/Outputs: the deliverables required to achieve the purpose, e.g., trained healthcare workers, clinics built and staffed Process/Activities: what the project will do to achieve its outputs, e.g., conduct clinical skills-building training, draft clinic architectural plans The activities produce outputs, the outputs influence the outcomes, and the outcomes influence the impact of the project, in this case, the impact of the clinical mentoring program to improve pediatric HIV care and treatment services. The column titles in Table 5.1, describe the inputs and the process for carrying out and monitoring the project. Inputs: the resources needed to carry out the activity, e.g. staff, medications, equipment, printed materials, funding amount or cost, etc. Indicators: measurable variables used to track changes in a project over time. More on indicators in Section 5.2: Developing Indicators Means of Verification: the sources of information needed to measure the Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 195 of 222 indicator and how to obtain them, e.g., forms, reports, surveys, etc. Timeline: the time frame during which the activity or information collection for M&E will take place. The timeline should be feasible, given project deadlines and the length of time required to complete the activity or data collection. Responsible party: the person or people responsible for carrying out the activity or, in the case of M&E, carrying out the data collection and analysis See Tool 5-A: Sample logframe for clinical mentoring project. Related Tools Tool 5-A: Sample logframe for clinical mentoring project Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 196 of 222 5.2 Developing indicators Indicators An indicator is a measurable variable that represents project progress. Indicators must be developed for each level of the project: activity, output, outcome, and impact. The indicators for each respective level will assess the progress at that level. Objectively verifiable indicators Indicators should meet the following criteria in order to be appropriate for measuring project progress and impact, as well as to be independently verified. Each indicator must have a means of verification, i.e., a source of information for measuring the indicator and how that information is to be collected (see section 5.4 Methodologies for Monitoring and Evaluation). Table 5.2: Criteria for objectively verifiable indicators An indicator must be able to be measured in either quantitative or qualitative Measurable terms Feasible An indicator should be feasible in terms of finances, equipment, skills and time available Relevant and Accurate An indicator should reflect what we are trying to measure in an accurate way Sensitive An indicator should be capable of picking up changes over the time period that we are interested in Timely An indicator should be able to provide information in a timely manner From: Jackson, B. Designing Projects and Project Evaluations Using a Logical Framework Approach. IUCN Monitoring and Evaluation Initiative, IUCN-World Conservation Union. October 1997 Accuracy It is important to make sure that the formula for calculating an indicator is correct. For example, when calculating the percentage of HIV-exposed children who have been tested for HIV using DNA PCR, make sure to use the correct numerator and denominator: Numerator: # of HIV-exposed children tested using DNA PCR Denominator: # of children determined to be HIV-exposed Not e.g., # of HIV-exposed children tested for HIV (using DNA PCR or antibody) # of children assessed for HIV exposure In this example, the incorrect numerator includes children tested by a method the Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 197 of 222 project does not want to measure (antibody testing), which will give a result that overestimates testing. The incorrect denominator includes children that the project does not need to measure (those assessed but not found to be exposed) so the resulting percentage will underestimate testing. The more direct the indicator, the more reliable it will be. Types of Indicators There are different kinds and categories of indicators24. Therefore, indicators must be carefully designed and selected to ensure accuracy and appropriateness. Quantitative versus qualitative Quantitative indicators involve counting and aggregating data. Since they are a measure of quantity, quantitative indicators are usually numbers or percentages. Qualitative indicators are descriptive; they often measure attitudes, judgments, or perceptions about a subject. Both quantitative indicators and qualitative indicators may be tied to specific targets for achievement, e.g., the program may aim to mentor a certain number of clinicians within a specified time period, or 80% of mentee clinicians express satisfaction with the mentoring program. Indicators for the project cycle As stated above, the M&E plan should define indicators for each level of the project: activity, output, outcome, and impact. See Tool 5-A: Sample logframe for clinical mentoring project for an example of the use of indicators in a logframe. Input indicators Input indicators measure the use and distribution of resources for the activity or project level. Expenses and budget Number of clinicians eligible to receive mentoring Geographical distribution of mentors Process and output indicators Process and output indicators measure the extent to and means by which the project delivers the intended immediate results. In this example, they measure whether the mentoring activities have taken place and whether they have achieved their primary purpose (e.g., trained a certain number of mentees). Number of mentees trained in program Number of mentoring activities carried out at the facility per month Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 198 of 222 Number of mentors using participatory mentoring methods Number of clinical encounters observed by a mentor Outcome indicators Outcome indicators measure whether the activities have had the intended effects. Have the mentoring interventions improved clinician performance? Are clients satisfied with the level of service? Percent of mentees expressing satisfaction with the mentoring program Number of mentee clinicians at the facility achieving competency (per the competency checklist and other assessments) within 12 months E.g., number of mentee clinicians who demonstrate improved ability to diagnose and treat tuberculosis co-infection (See Section 4, Table 4.1 and Tool 4-E: Competency checklists) Number of mentee clinicians at the facility achieving excellence (per the competency checklist and other assessments) within 12 months E.g., number of mentee clinicians who demonstrate consistent ability to accurately diagnose and treat tuberculosis co-infection without assistance from mentor (See Section 4, Table 4.1 and Tool 4-E: Competency checklists) Number of clinical errors committed by mentees Number of appropriate clinical decisions made by mentees Number of clients rating the interaction with mentee clinicians as satisfactory or better Impact indicators Impact indicators measure the long-term results of the project, including effects seen long after the project has been completed. Has the clinical mentoring program had the desired effect on pediatric HIV service provision, both on the quality of care and the functioning of facility-level systems? Number of children assessed for HIV-exposure per month Percentage of HIV-exposed children tested for HIV using DNA PCR Percentage of HIV-positive children started on ARV therapy Percentage of clinic clients started on ARV therapy who are children Percentage of clients who rate their clinic experience as good or excellent For more sample indicators related to HIV care and treatment, see WHO Recommendations for Clinical Mentoring to Support Scale-up of HIV Care (2006). Related Tools Tool 5-A: Sample logframe for clinical mentoring project Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 199 of 222 5.3 Timing and Responsible Parties Timing of M&E The M&E cycle The project cycle begins with a baseline assessment to establish the starting point from which to measure the project’s progress and impact. The mid-term (if applicable) and final evaluations will be most informative if compared with the baseline, that is, the situation before the mentoring program was initiated. The baseline measurement for each indicator can be drawn from prior reports and documents, where they exist, or a baseline needs assessment (described in Section 2: Planning Program). Once the baseline is established, it informs the project goals, objectives, and activities. It also informs the targets set for the project, as well as the indicators used to measure Figure 5.1: The Project Cycle progress. The baseline will be a reference used over the course of the project to determine whether there have been changes in the indicators, for example, the number of children put on ARV therapy, or the self-reported confidence of the nurses providing pediatric care. The project activities are then implemented over a specified period of time. Monitoring begins simultaneously with the start of the activities and continues throughout the project timeframe. An evaluation typically uses monitoring data, as well as other sources of information (see Section 5.4 Methodologies for M&E) to assess progress and impact compared to the baseline. When done as a mid-term process, it allows for re-examination of the project interventions and permits the implementers to modify the project to better achieve its objectives. If the need arises in the course of the program, new indicators can be developed, and the data collection tools—such as reporting forms—modified accordingly. The revised activities continue, along with the regular collection of monitoring data, until the project’s completion. An evaluation of the completed project should be designed in such a way as to capture information about the longer-term impact of the project. This may mean conducting the evaluation several weeks or months — or even longer—after the project has ended. Assessment, monitoring, and evaluation must be planned from the very beginning of the project, as they will help shape project design and planning. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 200 of 222 Responsible Parties Baseline assessments are usually carried out by those who see the need for a project. This may be the Ministry of Health or other agency. Universities are valuable resources in designing and conducting baseline assessments and project evaluations. Outreach should be done early in the project planning stage if implementers wish to partner with academic institutions. Primary responsibility for monitoring the mentoring program falls to the program supervisor. However, all participants must be active in the monitoring process. Mentors and mentees are central in the collection of monitoring information. Mentors, mentees, and facility supervisors must complete their reporting forms regularly and in a timely manner. Clear policies and procedures for submitting reports (to whom, when, where) should be outlined at the start of the program. In addition, facility supervisors have an important role in collection data for evaluation, i.e., data that relates to the impact and long-term outcomes of the mentoring program. They often have access to needed information sources and can assist with the planning, permission, distribution, and collection of surveys, questionnaires, and focus group interviews. Assessing Quality of Mentoring Program implementers should prepare to assess an essential component of the clinical mentoring program: the quality of the mentoring itself. This should be included at the process or activity level. Mentor performance can be assessed both quantitatively and qualitatively. The former may include reviewing lists of mentoring activities conducted and improvements in mentee clinical performance. Qualitative evaluation may include observation by program or facility supervisors, review evaluations by mentees, and other methods. Mentorship skills checklists, for example based on Tool 3-D: Checklist—ten steps for giving feedback or the list of listening and learning skills in Section 3.4: Communication Skills, are useful for evaluating the quality of mentoring. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 201 of 222 5.4 Methodologies for M&E Means of Verification The means of verification for indicators refers to the various methods used for monitoring and evaluation. Different methods are appropriate for different indicators which assess the progress at different phases of the project. For example, quantitative and qualitative indicators often require vastly different means of verification. Methods for Monitoring Routine reporting is one means of data collection for use in monitoring. The reporting needs for the mentoring program may overlap with the reporting already used to track facility performance and clinical care targets. Daily reporting Daily mentoring activities should be tracked by the mentor. Each mentoring or training encounter should be recorded. Tool 5-B: Sample daily mentoring documentation form is an example of a reporting form that can assist the mentor, mentee, and program supervisor to track who has received mentoring services, which clinical topics have been covered, which teaching techniques were used, whether competency has been assessed, and the plan for follow-up. This form can be adapted to include other information identified by the program. The form can be used to: Track the mentor’s progress on the agreed timeline Track the topics on which the mentee has been assessed Remind the mentor and mentee of planned follow-up activities When cross-referenced with competency assessments, it may be able to give information on which techniques worked best with each mentee Daily mentoring documentation forms should be used to compile the periodic reports. If the mentoring team holds weekly meetings, it may be worthwhile to review a summary of the daily reporting forms at that time. Individual mentee reports Each mentee should have a file that tracks which topics they have covered during mentoring and training sessions, as well as their baseline, periodic, and final competency assessments. Periodic reporting Reports for each mentor and/or facility should be sent to the facility supervisor weekly and the central organizing agency monthly or quarterly (as agreed). These Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 202 of 222 reports should contain the following information: Mentor and facility progress toward the pre-determined goals and objectives List of healthcare workers trained/mentored Challenges identified and proposed solutions Lessons learned and identified best practices Other methods for monitoring Observation: on-site observation of clinical mentoring and/or patient care activities Clinical records review: collecting data from facility and patient records Regular program review: periodic, documented review of reports and discussion with participants to examine activities, challenges, successes, lessons learned, etc. Site visits: on-site visit that incorporates some or all of the following: staff interviews, observation, clinical record review Methods for Evaluation Evaluation methods should be carefully chosen to match the information needed for evaluation. Methods may include: Key informant interviews: interviews with mentors, mentees, program supervisors, other healthcare staff, and clients Focus group interviews: structured interviews with more than one key informant at a time Secondary analysis of monitoring data from reports and clinical records: analysis by another party besides the data collector or reporter (see section above, Methods for Monitoring, for more on reports) Surveys and questionnaires: questions posed to participants about the program. Surveys are usually administered orally and questionnaires in writing. Observation: on-site viewing of performance Clinical competency checklist review: review of all mentee clinicians’ performance as documented in checklists (see Tool 4-E: Competency checklists). Mentoring skills checklist review: review of all mentors’ performance as documented in checklists Review of clinical mentoring activity lists Site visits: on-site visit that incorporate some or all of the following: staff interviews, observation, clinical record review Table 5.3 Possible Evaluation Methods shows examples of methods tailored to the kind of information needed for analysis. The information wanted can be a project indicator or the information needed to calculate an indicator. See Tool 5-A: Sample logframe for clinical mentoring project for indicators and methods (means of Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 203 of 222 verification) in the same table. Table 5.3: Possible Evaluation Methods Information wanted Possible method Mentoring program outputs/short-term outcomes To find out if mentoring program Monthly reports has trained target number of clinicians Mentee self-report using survey/questionnaire before and after the mentoring program To find out if mentees are Focus group with mentees experiencing greater job Comparison of baseline findings with survey satisfaction conducted 6 or 12 months after mentoring program graduation Mentee self-report using survey/questionnaire before and after the mentoring program (see Tool 5D: Pre- and post-mentoring questionnaire (for To find out if mentees are more mentee) confident administering HIV care Mentor assessment and treatment to children Observation Ask mentee’s colleagues/supervisors by interview or questionnaire Mentoring program long-term outcomes/impact Comparison of the under 5 death rate and cause (using death certificates or hospital records) at To find out if children with HIV baseline and 1 year after mentoring program is are living longer completed Focus group To learn whether parents in the Survey/questionnaire community are aware of Compile indicator data: change in number of pediatric services available families attending clinic Patient record audit To learn whether more children Compile indicator data: change in number of are receiving certain elements of children receiving each HIV care and treatment HIV care and treatment service To learn if clients are more Focus group satisfied with their care than Client satisfaction survey/questionnaire before Related Tools Tool 5-B: Sample daily mentoring documentation form Tool 5-C: Sample quarterly report Tool 5-D: Pre- and post-mentoring questionnaire (for mentee)—can be used prior to mentoring to establish baseline and post-mentoring to measure improvement as an alternative to the competency checklists Tool 5-E: Mentoring evaluation (for mentor) Tool 5-F: Mentoring evaluation (for mentee) Tool 4-E: Competency checklists—can also be used to establish baseline Examples of other forms can be found in the I-TECH Clinical Mentoring Toolkit and the BIPAI Outreach Toolkit Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 204 of 222 Tool 5-A: Sample logframe for clinical mentoring project Inputs Indicators Goal/Impact Improved quality of pediatric HIV care and treatment at primary, secondary, and tertiary level facilities Outcomes: # of clinicians showing improved competence in pediatric HIV C&T - Number of 1°, 2°, and 3° level facilities offering comprehensive pediatric HIV services Number of eligible children on ART Number of HIV-exposed children tested and diagnosed - Number of children assessed for HIVexposure per month - Number of HIV-exposed children tested for HIV - Percentage of HIVexposed children tested for HIV using DNA PCR - Percentage of HIVpositive children started on ARV therapy - Percentage of clinic clients started on ARV therapy who are children - Percentage of clients who rate their clinic experience as good or excellent Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Means of Verification Clinic register; audit of patient records; patient satisfaction survey; clinic survey; site visits; observation Timeline Responsible Party (collects M&E data) March 2012 – February 2013 Chief clinical staff at each implementing agency, Ministry of Health, external partner Page 205 of 222 Inputs Purpose/ Outcome Increase number, competence and effectiveness of health workers to provide pediatric HIV care and treatment services Outputs: Clinicians provided with training Clinicians mentored Clinicians using ongoing support resources Indicators # of clinicians showing improved competence in pediatric HIV care and treatment # of mentee clinicians who demonstrate improved ability to diagnose and treat tuberculosis co-infection Means of Verification Training event registration lists; individual clinical competency assessments (checklists); patient record audits; observation; site visits; patient survey; mentee evaluation Timeline March 2012 – February 2013 Responsible Party (collects M&E data) Chief clinical staff at each implementing agency, CM program supervisors, clinical mentors # of clinicians reporting increased confidence in treating pediatric HIV # of clinicians who follow SOPs # of clinical errors committed by mentees # of appropriate clinical decisions made by mentees # of clients rating the interaction with mentee clinicians as satisfactory or better # of clinicians demonstrating increased motivation Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 206 of 222 Inputs Results/ Outputs Activities: Mentor orientation workshop 15 trained clinical mentors On-site clinical mentoring activities 30 mentored clinicians from 20 facilities in 10 districts Quarterly conference Indicators # mentors oriented # of clinicians who have completed the full mentoring program # of facilities with at least 1 mentored clinician Means of Verification Orientation registration list Facility monthly report; survey of facilities/districts by phone or mail Registration lists for ongoing CM activities; monthly CM reports Timeline April 2011 Responsible Party (collects M&E data) CM program supervisors, clinical mentors May 2011 – February 2012 # of districts with at least 1 mentored clinician Clinician participation in ongoing clinical mentorshiprelated activities # of clinicians (mentors and mentees) participating in ongoing CM activities Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 207 of 222 Inputs Indicators Means of Verification Timeline Responsible Party (collects M&E data) Process/ Activities Mentor orientation workshop On-site clinical mentoring activities - Clinicians and teaching experts for orientation - Copies of clinical mentoring manual - Stipend for mentors - Mobile phones - $200,000 budget - Conference facilities - $10,000 budget # of orientation workshops completed Orientation workshop report April 2011 Clinical mentor orientation team, CM program supervisors # of CM activities completed Mentor weekly, monthly reports Late April 2011 – March 2012 CM program supervisors, clinical mentors, chief clinical staff at each implementing agency # of quarterly conferences held Conference report June 2011 Program supervisors Quarterly conference September 2011 December 2011 March 2012 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 208 of 222 Tool 5-B: Sample daily mentoring documentation form Mentor name: ___________________________________________________________ Facility name: ___________________________________________________________ Facility address: _________________________________________________________ Date Mentee name and position DM= Demonstration BT= Bedside teaching/Rounds QA= Question & Answer Topic covered Activities conducted relating to topic (See codes below) CS= Case study OBS= Observation CC= Case conference Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Facility ID: ______________ Competency Follow-up/Next steps assessed? Y/N SP= Skills practice LT= Lecture Page 209 of 222 Tool 5-C: Sample quarterly report Quarter: ________________________________ Part 1: Mentorship activities Facility Name No. of 1-on-1 mentorship visits this quarter No. of Grand Rounds/Lecture/ Conference visits this quarter No. of mentoring visits (all) this quarter Total Adapted from BIPAI Clinical Outreach Toolkit “Quarterly Reporting Form”, Copyright Baylor Pediatric AIDS Initiative, 2009, all rights reserved. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 210 of 222 Part 2: Mentored staff Mentee name Facility Name Cadre Mentor name Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation No. of mentored visits this quarter No. of mentored visits TOTAL Mentorship program completed Y/N Page 211 of 222 Part 2: Narrative (Outline) I. II. III. IV. V. Progress this quarter a. Description of activities b. Mentor and facility progress toward the agreed goals and objectives Challenges and proposed solutions Lessons learned Best practices Anticipated steps for next quarter Part 3: Budget Include budget information here. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 212 of 222 Tool 5-D: Pre- and post-mentoring questionnaire (for mentee) Make 2 copies of this questionnaire: one should be completed by the mentee before initiating the mentorship program; the second should be completed upon graduation. Both questionnaires should be submitted to the mentor or facility supervisor upon completion of this form. Mentee Name: ___________________________ Date: __________________ Facility: ___________________________ Cadre: ______________________ Instructions: Each item is a statement regarding your knowledge and comfort level regarding pediatric HIV care and treatment. Please circle the number that best describes your knowledge or comfort level. 1= Strongly disagree 2= Disagree 3= Neutral 1. I am familiar with pediatric ARV formulations and dosing. 2. I am familiar with screening and diagnosis for HIV-exposed infants and young children. 3. I am comfortable using the WHO staging for infants and children. 4. I am familiar with the physiological differences between adults and children. 5. I am familiar with psychological differences between adults and children. 6. I am comfortable performing a physical exam on an infant and on a young child. 7. I am familiar with my country’s guidelines on infant feeding counseling. 8. I am knowledgeable about the nutritional needs of infants and children. 9. I am comfortable explaining HIV infection to a child. 10. I am familiar with ARV prophylaxis regimens for children. 11. I am comfortable taking Dried Blood Spot specimens from infants and young children. 4= Agree 5= Strongly agree NA= not applicable/don’t know 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 213 of 222 12. I am comfortable discussing a child’s HIV status and disclosure with his or her caregivers. 13. I am knowledgeable about the eligibility criteria for ARV therapy for infants and children. 14. I am comfortable taking and plotting growth measurements on children under 5 years of age. 15. I can describe the natural history of pediatric HIV infection. 16. I can explain strategies to support pediatric ARV adherence. 17. I can describe interventions for pediatric palliative care. 18. I am familiar with the treatment of TB and other co-morbidities in children. 19. I can explain the model of familycentered care. 20. I can explain my role in and my relationship to other members of the clinical team. 21. I am familiar with strategies to address psychosocial needs of families affected by HIV. 22. I am knowledgeable about the resources in my facility’s community for psychosocial support of children and families affected by HIV. 23. I am knowledgeable about the resources in my facility’s community for economic and educational support for children and families affected by HIV. 24. I believe my clinical training has prepared me to provide pediatric HIV care and treatment services. 25. I would like to improve my clinical skills in pediatric HIV care and treatment. 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1. Which areas or aspects of providing HIV/AIDS care and treatment do you feel are your strengths? 2. Which areas and aspects of pediatric HIV/AIDS care and treatment do you need additional practice, training, guidance or support for? (e.g., assessing OIs, TB coinfection, growth monitoring, nutrition counseling, adherence, ARVs, diagnosis) Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 214 of 222 Tool 5-E: Mentoring evaluation (for mentor) Mentoring program evaluation—mentor To be completed for overall program Mentor Name: ___________________________ Date: ___________________ Contact Information: ______________________________________________ Mentee(s): Name Facility Cadre Instructions: Please circle the number that best describes your response. 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly agree NA= not applicable/don’t know I. Program structure My role in the program was clearly communicated to me. I helped my mentee(s) identify learning needs. I was able to fulfill my reporting duties in a timely manner. We had mentoring activities on a regular basis. The frequency and duration of mentoring activities was sufficient. The duration of the mentorship was sufficient. I felt supported by the Mentoring Program Supervisor. I felt supported by the facility supervisor. There were sufficient resources to conduct the mentorship. If response is 1 or 2, please explain in the short answer below. 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA II. Performance My mentee(s) understood the goals of the program. My mentee(s) was interested and engaged in the mentorship process. I regularly gave my mentee(s) feedback. I helped my mentee(s) identify areas and strategies for improvement. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 215 of 222 III. Value of mentoring I have benefitted from the mentoring relationship. My mentee(s) made progress as a result of the mentorship. I have discussed additional learning and career goals with my mentee(s). I have received feedback from my mentee(s) about our mentoring relationship. Being a mentor has influenced my attitudes. I would like the mentoring relationship(s) to continue. 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA For the following questions use this scale: 1= Not at all useful 2= Somewhat useful 3= Very useful NA= Not applicable DN= Don’t know IV. Mentoring activities Activity Observation by mentor Demonstration by mentor Case studies Case conference Lecture Reading assignments Bedside teaching Rounds Conference Telephone or email support All mentoring activities % time in activity 1 1 1 1 1 1 1 1 1 1 Rating of usefulness 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 100% 1. Have your expectations for the program been met? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 2. What could be done differently? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3. What other suggestions or comments? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3. Would you be willing to meet with organizers to further discuss your suggestions for improving our program? THANK YOU! Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 216 of 222 Tool 5-F: Mentoring evaluation (for mentee) Mentoring program evaluation—mentee Mentee Name: ___________________________ Date: __________________ Facility: ___________________________ Cadre: ______________________ Mentor Name: __________________________________________________ Instructions: Please circle the number that best describes your response. 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly agree NA= not applicable/don’t know I. Program structure The goals of the program were clearly communicated to me. I had a role in identifying my learning needs. My mentor provided input into my learning needs. We had mentoring activities on a regular basis. The frequency of mentoring activities was sufficient. 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA II. Mentor performance My mentor used a variety of teaching methods. My mentor adapted the teaching methods to my learning style. My mentor gave me useful feedback. The frequency of feedback was sufficient. My mentor helped me identify areas and strategies for improvement. My mentor helped me better understand my role in the clinical team. My mentor was a good role model for me as a professional. III. Value of mentoring I have benefitted from the mentoring relationship. I have discussed additional learning and career goals with my mentor. My mentor has helped me develop my clinical skills. My mentor has influenced my attitudes. I would like the mentoring relationship to continue. Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 217 of 222 IV. Mentoring activities Activity Observation by mentor Demonstration by mentor Case studies Case conference Lecture Reading assignments Bedside teaching Rounds Conference Telephone or email support All mentoring activities % time in activity 1 1 1 1 1 1 1 1 1 1 Rating of usefulness 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 2 3 NA DN 100% 1. Have your expectations for the program been met? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 2. What could be done differently? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3. What other suggestions or comments? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ THANK YOU! Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit Section 5: Monitoring and evaluation Page 218 of 222 References and resources Section 1: Purpose of a Mentorship Program BIPAI Outreach Toolkit. Malawi Pediatric HIV/AIDS Treatment Support & Outreach (MPHATSO). Copyright © 2009 Baylor International Pediatric AIDS Initiative. http://bayloraids.org/outreach/malawi/ Accessed 16 March 2011. Bitarakwate, Edward. “Training and Clinical Mentorship to Support the Scale-Up of pediatric HIV Care: Lessons Learned from Uganda”. From the Ground Up: Laying a Strong Foundation. EGPAF, 2009. International Center for AIDS Care and Treatment Programs (ICAP). Clinical Systems Mentorship: The ICAP Guide to Site Support. Draft 1.1. 2007. http://cumc.columbia.edu/dept/icap/resources/tbhiv/Other%20ICAP%20Resources/I CAP%20Site%20Support%20manual.pdf I-TECH. Clinical Mentoring Toolkit. 2008. http://www.go2itech.org/HTML/CM08/index.html Section 2: Planning the Mentorship Intrahealth. Learning for Performance: A Guide and Toolkit for Health Worker Training and Education Programs. 2001. http://www.intrahealth.org/files/media/learning-forperformance/learning_for_performance_guide.pdf I-TECH. Clinical Mentoring Toolkit. “Training Curriculum.” http://www.go2itech.org/HTML/CM08/toolkit/training/index.html World Health Organization. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings. 2006. http://www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf Section 3: Communication Skills for Mentors Bitarakwate, Edward. “Training and Clinical Mentorship to Support the Scale-Up of Pediatric HIV Care: Lessons Learned from Uganda. ” From the Ground Up: Laying a Strong Foundation. EGPAF, 2009. Intrahealth. Learning for Performance. 2001. I-TECH Clinical Mentoring Toolkit, 2008. http://www.go2itech.org/HTML/CM08/index.html Langlois, John, and Sarah Thach. Teaching and Learning Styles in the Clinical Setting. Family Medicine May 2001. pg. 344. Accessed at: http://www.stfm.org/fmhub Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit References and Resources Page 219 of 222 Neher, J. O. , Gordon, K. C. , Meyer, B. , and Stevens, N. “A five-step “microskills” model of clinical teaching. ” Journal of the American Board of Family Practice, 5, 419-424. 1992. Southern New Hampshire AHEC and Dartmouth-Hitchcock Medical Center. Teaching Styles/Learning Styles, educational monograph, Faculty development program. [no date] Accessed via: UMDNJ Center for Teaching Excellence. www.cte.umdnj.edu/clinicaleducation/clinedrole-styles.cfm University of Virginia. Family Medicine Preceptor Development Program. Module 3. Interacting with Your Medical Student. http://www.med-ed.virginia.edu/courses/fm/precept/ University of Virginia. Family Medicine Preceptor Development Program. Module 2: Teaching and Learning Styles http://www.meded.virginia.edu/courses/fm/precept/module2/m2p3.htm World Health Organization. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings. 2006. http://www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf Section 4: Implementation Bitarakwate, Edward. “Training and Clinical Mentorship to Support the Scale-Up of Pediatric HIV Care: Lessons Learned from Uganda.” From the Ground Up: Laying a Strong Foundation. EGPAF. 2009. I-TECH. Clinical Mentoring Toolkit. 2008. http://www.go2itech.org/HTML/CM08/index.html Southern New Hampshire AHEC and Dartmouth-Hitchcock Medical Center. Teaching Styles/Learning Styles, educational monograph, Faculty development program. [no date] Accessed via: UMDNJ Center for Teaching Excellence. www.cte.umdnj.edu/clinical_education/clined_rolestyles.cfmwww.snhahec.org/documents/Styles.doc Wimmers, P.F. Doctoral thesis: Developing Clinical Competence. Erasmus Universiteit, Rotterdam, 2006. http://repub.eur.nl/res/pub/10631/Developing%20Clinical%20Competence.pdf Accessed 5 April 2011. World Health Organization. Core competencies: results from the International Consensus Meeting on HIV Service Delivery Training and Certification. 2004. http://www.who.int/hiv/pub/meetingreports/Corecompmeetrep.pdf World Health Organization. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings. 2006. http://www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit References and Resources Page 220 of 222 Section 5: Monitoring and Evaluation Baylor International Pediatric AIDS Initiative. Outreach Toolkit. 2009. http://www.bipai.org/educational-resources/outreach-toolkit.aspx CIDA. Guide to Gender-Sensitive Indicators. 1996. CIDA. Evaluation Guide. 2000. Côte d’Ivoire Ministry of Health and Public Hygiene. Pediatric HIV Training Manual for Medical Personnel, Facilitator’s Guide. 1st edition. 2009 I-TECH. Clinical Mentoring Toolkit. 2008. http://www.go2itech.org/HTML/CM08/index.html Johns Hopkins K4Health Fundamentals of Monitoring and Evaluation Online Course. http://info.k4health.org/elearning/mefundamentals.shtml World Health Organization. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings. 2006. http://www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf 1 2 3 4 5 6 7 8 9 10 11 12 13 WHO, WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings, 2006, p. 4 ICAP, Clinical Systems Mentorship: The ICAP Guide to Site Support, Draft 1.1, 2007, p. i. WHO, 2006, p. 4 WHO, 2006, p. 9 WHO, 2006, p. 9 WHO, 2006, p. 8 I-TECH as quoted in WHO 2006, Annex 4, p.47 WHO, 2006 Bitarakwate, Edward. “Training and Clinical Mentorship to Support the Scale-Up of pediatric HIV Care: Lessons Learned from Uganda”. From the Ground Up: Laying a Strong Foundation. EGPAF, 2009. Adapted from Tanzania Ministry of Health and Social Welfare. A Manual for Comprehensive Supportive Supervision and Mentoring on HIV and AIDS Health Services, 2010. p. 23 Family Health International Institute for HIV/AIDS. Baseline assessment tools for preventing mother-to-child transmission (PMTCT) of HIV. “Prenatal Care Assessment Tool”. EGPAF, 2003. Available at: http://www.fhi.org/NR/rdonlyres/ejkelmgqgkbumgmsmuzbeaiys3rjpgbnzed5jtygb26iny2v hlk4naexoprcwoy6u6e5vnsfcd4yga/PMTCTreportcorrectedFINAL.pdf Vella, Jane K. Learning to Listen, Learning to Teach: The Power of Dialogue in Educating Adults. San Francisco: Josey-Bass, Inc. 1994: 3 in FXB Center, Facilitator Training Guide, Workplace Wellness for Health Workers curriculum, 2008. Clark, D.R. (2008), Visual, Auditory, and Kinesthetic Learning Styles (VAK). Retrieved May 5, 2011 from http://www.nwlink.com/~donclark/hrd/styles/vakt.html Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit References and Resources Page 221 of 222 14 15 16 17 18 19 World Health Organization. 2008. Prevention of Mother-to-Child Transmission of HIV Generic Training Package. Available at: http://www.womenchildrenhiv.org/pdf/p03-pi/pi60-00/Intro_PM_2-05.pdf Adapted from Tanzania Ministry of Health and Social Welfare. A Manual for Comprehensive Supportive Supervision and Mentoring on HIV and AIDS Health Services, 2010. p 20 and Allison Morton-Cooper and Anne Palmer, Mentoring, preceptorship and clinical supervisions: a guide to professional support roles in clinical practice, 2nd edition. Blackwell Publishing Ltd. Oxford. 2000. p. 59 Source: Reilly B. “Viewpoint: Inconvenient truths about effective clinical teaching.” Lancet. 2007. 370:705-711. (In I-TECH CMT Session 5 Clinical Skills, 2008) University of California at Irvine, Bringing Teaching and Service Together (BEST) Curriculum. Accessed at http://residentteachers.usc.edu/Content Swinny, B. “Assessing and Developing Critical-Thinking Skills in the Intensive Care Unit.” Critical Care Nursing Quarterly. Vol. 33, No. 1, pp. 2-9, 2010 Whitman and Schwenk, 1984 20 Violari, A., et al. Antiretroviral therapy initiated before 12 weeks of age reduces early mortality in young HIV infected infants: Evidence from the children with HIV early ART (CHER) study. In 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention. 2007. Sydney, Australia. 21 Brahmbhatt, H., et al., Mortality in HIV infected and uninfected children of HIV infected and uninfected mothers in rural Uganda. J Acquir Immune Defic Syndr, 2006. 41(4): p. 504508. 22 Newell, M.L., et. al. Mortality of infected and uninfected infants born to HIV infected mothers in Africa: A pooled analysis. Lancet, 2004. 364 (9441): p. 1236-1243. 23 Adapted from I-TECH Clinical Mentoring Toolkit, 2008. CIDA. Guide to Gender-Sensitive Indicators. 1996. 24 Family-Centered Care of HIV-Exposed and HIV-Infected Children Clinical Mentoring Toolkit References and Resources Page 222 of 222
