mental health report on pfa and mhgap base course … south sudan mh...report on pfa and mhgap base...
TRANSCRIPT
Mental Health
Report on PFA and mhGAP Base Course Training for PHC staff
(Maban, Malakal and Awerial)
Juba, South Sudan
November 13-18
2014
Esubalew Haile, M.D.
Mental Health Specialist
Email:[email protected]
Acknowledgements: I want to thank Dr. Meroni Abraham who was very supportive and has been covering the seizures and epilepsy section of the training. I would also like to thank Felicia
Jones who has been assisting me a lot in making things ready for the training.
Contents
i. List of acronyms ii. Introduction
iii. Background Information iv. Training needs v. Training approach
Basic adaptation of topics Selection of trainees Training objectives Theoretical training Training attendance
vi. Improvement in knowledge and skills vii. Participants’ evaluation of the training
viii. Conclusion and Recommendations ix. Appendixes
Curriculums Pre and Post test questions End of training workshop evaluation
List of acronyms
BPHS………………………….Basic Package of Health Services
IMC …………………………..International Medical Corps
mhGAP ………………………mental health Gap Action Program
mhGAP-IG …………………. mental health Gap Action Program
MHPSS………………………...Mental Health Psychosocial Support
MSF……………………………..Medicine San Frontier
PFA……………………………..Psychological First Aid
PHC……………………………..Primary Health Care
PTSD……………………………Post Traumatic Stress Disorder
WHO…………………………..World Health Organization
WTF……………………………War Trauma Foundation
WV…………………………….World Vision
Introduction
In emergencies, providing mental health as part of general health care is more accessible, cost effective and less stigmatizing. IMC has contributed to the development of the WHO mhGAP intervention guidelines on training general health care providers in addressing mental health priority conditions cases and IMC is a working group member of the WHO mhGAP Guidelines Development Group (GDG).
As part of the mental health and psychosocial support (MHPSS) program implementation in five IMC operation sites in South Sudan, mhGAP base course training for primary health care (PHC) staff is well underway. Prior to the training, curriculums were developed on PFA and mhGAP base course to include four WHO mhGAP priority conditions. The four priority conditions, namely; moderate –severe depression, psychosis, seizures/epilepsy and conditions specifically related to stress (PTSD & Acute Stress) were selected based on base line assessments done earlier, available data and in line with the basic package of health services for South Sudan, Ministry of Health.
For successful integration of mental health care services in the PHC facilities, it was necessary that selected PHC staff to be trained on the selected mhGAP priority conditions as well as basic psychosocial interventions. Therefore, this report is on both PFA and mhGAP base course.
1. Background information
In the first cycle of mhGAP base course training, eleven primary health care providers from Maban, Malakal and Awerial were trained focusing on PFA and selected four WHO mhGAP priority conditions.
2. Training needs
Earlier in April 2013 and February 2014, IMC conducted assessments of mental health PHC integration in PHC facilities in Maban & Awerial and Malakal, respectively. The results regarding staff training and skills have shown the following.
• None of the health staff at health facilities has received training and supervision in mental health BPHS priority conditions in line with WHO mhGAP Intervention guidelines and none of the staff had heard of those guidelines before.
. • MSF-B in Doro, Maban has conducted in-service training for PHCC and
PHCU staff in basic mental health case detection and referral (using 5 screening questions), followed by two afternoon refresher trainings. However, training has been limited to identification and there has been no training in managing mental health cases for general health staff.
• In terms of MHPSS capacity, MSF-CH in Awerial was conducting in-service training for their OPD staff in basic mental health case detection and psychosocial support. Otherwise none of the health staff at health facilities in Malakal and Awerial has received training and supervision in mental health in line with WHO mhGAP Intervention guidelines and none of the staff had heard of those guidelines before.
• None of the participants who attended this training has received training on PFA or heard of PFA before.
With regard to staff skills, the assessment indicated that most of the PHC service providers lack the skills to practice proper assessment and management of mental disorders including mhGAP priority conditions and rarely or never used the skills needed.
3. Training Approach
3.1 Basics and adaptation of topics
Curriculums were developed focusing on the four WHO mhGAP priority conditions and PFA. Minor changes were made in the power point slides and guides to make it more relevant to South Sudan context. The following table shows the main topics covered in this training.
The topic on IMC’s MHPSS approach in the three sites has emphasized on how PHC workers (the trainees) are expected to work in coordination with IMC mental health and psychosocial officers who are also the case managers.
Table-1: PFA and mhGAP training topics
PFA Training S.N Agenda Readings 1. Registration and pre-test 2. PFA Definition and Framework
Applying PFA Action Principles Self and Team Care
PFA for field workers (WHO, WTF, WV)
3. Post-test and training evaluation mhGAP Base Course
S.N Topic Readings
1. Registration Pre-test
2. IMC MHPSS approach in South Sudan Power Point Slides
3. Introduction to Mental Health
o Concept of Mental Health and Mental Disorders
Power point Slides
4. Communications
o Communication Skills and Effective Interaction
Why Integrate Mental Health Into PHC?
o Rationale
o Global Perspective
o What is mhGAP ?
o What is mhGAP-IG and why train on mental, neurological and substance use disorders?
o Base Course
General Principles of Care
WHO mhGAP Intervention Guideline
Participants’ Guide
5. Psychosis
o Establish Communication and Build Trust
o Assessment
o Management Plan and Initiation of Treatment
Pharmacologic
Non-pharmacologic
o Follow Up
WHO mhGAP Intervention Guideline
Participants’ Guide
6. Depression
o Establish Communication and Build Trust
o Assessment of Moderate-Severe Depression
o Management Plan and Initiation of Treatment
Pharmacologic
Non-Pharmacologic
o Follow Up
WHO mhGAP Intervention Guideline
Participants’ Guide
7. Epilepsy/Seizures
o Define seizure and Epilepsy
o Emergency Management of Seizures
o Assessment of Epilepsy
o Management Plan and Initiation of Treatment
Pharmacologic
Non-pharmacologic (psychoeducation…)
o Follow up
WHO mhGAP Intervention Guideline
Participants’ Guide
8. Conditions specifically related to stress
o Define Acute Stress and PTSD
o Establish Communication and Build Trust
o Assess for significant symptoms of acute stress and PTSD
o Management Plan and Intervention
o Stress management-Breathing Excercise
o Follow Up
WHO mhGAP
Participants’ Guide
9. Post Test and training Evaluation
3.2 Selection of participants
General practitioners, medical officers, clinical officers, mental health officers and nurses who are actively working in the outpatient clinics from Maban, Awerial and Malakal were invited to attend this first cycle mhGAP base course and PFA training. The following table shows the list of participants.
Table-2: List of training participants
S.N Name Qualification Address
1. Dr. Yvonne Wekesa Medical Doctor Awerial
2. James Clinical Officer Awerial
3. Patrick Irama Mental Health Officer Awerial
4. Mary Clinical Officer Awerial
5. Abraham Clinical Officer Malakal
6. Patrick Tombe Mental Health Officer Malakal
7. Joseph Clinical Officer Malakal
8. Kulang Phillip Clinical Officer Maban
9. Okot Clinical Officer Maban
10. Victor Clinical Officer Maban
11. Moses Clinical Officer Maban
3.3 Training objective
PFA teaches on how participants should provide supportive and practical assistance to fellow human beings who recently suffered exposure to serious stressors or crisis situation.
The mhGAP base course training primarily teaches the skills and knowledge needed to provide assessment and management of people with the selected mhGAP priority conditions. The training teaches on both non-pharmacologic and first line pharmacologic interventions for people with mental and neurological disorders. In addition, the training addresses when and how to refer cases of mental health problems and disorders according to the mhGAP Intervention Guideline.
3.4 Theoretical Training
The theoretical training was conducted for five consecutive days in a training hall in Juba, Regency Hotel. The training duration was seven hours per day.
IMC mental health specialist was the lead facilitator for both PFA and mhGAP base course trainings. The section on seizures and epilepsy was covered by IMC pediatrician who received orientation on the subject from the mental health specialist prior to the training.
Color print WHO’s Intervention Guideline on mhGAP (mhGAP- IG) was given for each participant on the first day of the training. Printed copies of participant’s guide were also given for each trainee a day before the beginning of the session on that particular subject.
Training methods included: power point slide presentations, role plays, group discussions and presentations using flip charts. Downloaded videos for the mhGAP Base Course training on the specific priority conditions were also used.
3.5 Training attendance
All participants completed the training period with no absenteeism except one who has who missed the 2nd day of the training due to ill health.
4. Improvement in knowledge and skills
4.1 Pre & post training perceived competencies on PFA
A questionnaire containing eight items, 5 point Likert scale which is designed to assess participants’ perceived competencies on PFA knowledge and skills was administered to all participants. The average pre training and post training ratings were 3.56 and 4.44; respectively.
Contrary to the relatively high self-rating of participants on perceived competencies, the average score on PFA pre-test was a little above 50 percent.
Fig.1-Participants’ perceived competencies (average)
4.2 Pre – post test scores on PFA
Fig.1-Individual pre-post results Fig.2-Average pre-post results
0
1
2
3
4
5
pre-training post-training
4.3 Pre – post test scores on mhGAP base course
Participants showed significant improvement in knowledge with 49.5% increment from their average pretest score. The average pretest and post test results are 52.7% and 78.8%; respectively (Figs. 3 & 4).
Fig.3-Individual pre-post results Fig.4-Average pre-post results
5. Participants Evaluation of the Training
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11
Pretest
Posttest
0
10
20
30
40
50
60
70
pretest posttest
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11
pretest
post test
0
20
40
60
80
100
pretest posttest
5.1 Rating of the PFA training Table-3: Summary of PFA training evaluation
Training evaluation questions
Participants' response Total # of respondents Strongly
disagree Disagree Neutral Agree Strongly
agree The information was clear and easy to understand
0 0 0 5 (41.7%)
7 (58.3%)
12
The information I received is useful to my work
0 0 0 2 (16.7%)
10 (83.3%)
12
The orientation increased my confidence to offer PFA in crisis situation
0 0 1 (8.3%)
5 (41.7%)
6 (50%)
12
The orientation gave me practical skills and knowledge to apply in crisis situation
0 0 1 (8.3%)
4 (33.4%)
7 (58.3%)
12
The teaching methods used by the facilitator were effective
0 0 0 5 (41.7%)
7 (58.3%)
12
The orientation was engaging and fun 0 1 (8.3%)
0 7 (58.3%)
4 (33.4%)
12
I would recommend this orientation to others
0 0 1 (8.3%)
2 (16.7%)
9 (75%)
12
5.2 Participants’ evaluation of the mhGAP base course training
At the end of the mhGAP base course training, participants were asked to complete the training workshop evaluation form and the results are summarized in the Table 3 below. Participants were told not to write their names or any other identification on the evaluation form.
Table 4-Summary of participants’ mhGAP base course workshop evaluation
Training evaluation questions Participants’ response The facility/venue where training took place Very good
Adequate Inadequate
11 (100%) 0 0
Number of participants in workshop Too much Adequate Too few
0 10 (90.9%) 1 (9.1%)
Length of the training workshop Too short Adequate Too long
2 (18.2%) 9 (81.8%) 0
General quality of the training Very good Moderate
11 (100%) 0
Not good 0 The training was helpful in understanding how to use mhGAP-IG
Very helpful Helpful Not helpful
10 (90.9%) 1 (9.1%) 0
Use of participatory training (role plays, case studies etc.)
Very good Adequate Not good
10 (90.9%) 1 (9.1%) 0
Are you confident in providing service based on mhGAP-IG in clinical practice?
Significantly confident Somewhat confident Not confident No response
9 (81.8%) 1 (9.1%) 0 1 (9.1%)
5.3 Usefulness of the mhGAP base course training
Participants were asked, “What are the three most important things you learned during this training, and will use in your clinical practice?” The following points are among the most frequently mentioned:-
• “How to assess, manage, treat and do follow up of people with the priority conditions (psychosis, depression, seizures and PTSD & acute stress.”
• “Knowing each other with friends and colleagues from different sites” • “Involvement of family and social supports in managing people with mental illness” • “Importance of not promising what you cannot fulfill.” • “Having information about various services in my area to help refer or link patients to
meet their needs” • “How to use the mhGAP master chart” • “General management principles of people with mental health problems.”
5.4 Suggested improvement
Participants were asked “What would you suggest to improve the training? Are there any other comments or any suggestions for improvements?” The following list includes the suggestions given by participants:
• “More days of training” • “Best training and I suggest the same training for others in my work area” • “Time management and sitting allowance” • “Duration of the training for the future to be extended to two weeks”
• “Very helpful training, quite relevant to day to day practice. Well organized and adequate reading materials and resources provided.”
• “More training for all the staff” • “More training to cover the remaining WHO priority conditions like dementia, alcohol
and drug use/disorder.”
6. Conclusion and recommendations
Generally the training was success. The participant showed significant improvement in their knowledge and skills on both PFA and mhGAP priority conditions at the end of the training. Providing subsequent refresher trainings as well as individual clinical support and supervision for all trained staff appears to be crucial for a successful integration of mental health services in the primary health care system.
Logistic supply and coordination should be improved. This includes printing and preparation of training materials as requested. The WHO mhGAP intervention guide was intentionally designed in colorful manner to enhance easy learning for participants. Therefore; logistics personnel need to make sure that suppliers are fulfilling their obligations and promises.
In addition to individual clinical support and supervision, a group approach would be appropriate so that most trained staffs working in other units of the health facility would learn from their colleagues working in the adult OPD and apply their theoretical training in practice.
There is a need to continue the training to address problems related to high turnover of trained staff as well as to include those PHC workers who didn’t receive the training while they were most relevant to the program.
7.Appendixes
Appendix 1- curriculums Psychological First Aid
Training duration: 8 hours Overview Topic/Activity Section one
PFA Definition and Framework
What comes to your mind when you hear “PFA”? Starting with care for ourselves Crisis event simulation and discussion What PFA is and is not PFA in framework of MHPSS Responses to critical incidents Key resilience factors PFA: who, when and where? PFA Overview Frequent needs of survivors What helpers need Prepare - Look, Listen and Link Overview Case Scenario Group Work
Section two Applying PFA Action Principles
Prepare and Look Group presentation, discussion, recap
mhGAP BASE COURSE Curriculum IMC South Sudan
Overview Topic/Activity
Section one
Introduction to mhGAP • 2 hour • Mental Health and Primary Care
• What is mhGAP? • Defining the challenge;
Treatment Gap • Objectives and Scopes of
mhGAP • mhGAP priority conditions
and mhGAP Intervention Guideline
• How to use mhGAP-IG • Training methods and
materials for mhGAP
General principles of care
• 4 hours • Objectives • Stigma and Discrimination • The effects of stigma and
Listen Group presentation and discussion Role play Listen Role play “help people feel calm” Good communication Link Group presentation, discussion, recap Role play link with social support, coping Recap Role play link with information Ending assistance
Section three PFA Wrap-Up, Self and Team Care,
PFA Review and Video on PFA Final Simulation and Discussion Self and team care Post Test, Training Evaluation and closing
Section two
discrimination • Stigma in the health care
system • Communication with people
seeking care and their care givers
• Assessment, Treatment and monitoring
• Mobilizing and providing social support
• Community services • Protection of human rights
Section Three
Specific Priority conditions
I-Psychosis • 6 hours • Introduction (What is psychosis? Natural history of psychosis; local names for psychosis; decreasing stigma and discrimination)
• Learning Objectives • Establishing communication
and build trust and barriers for effective communication
• Assessing for psychosis (using the master chart; signs and symptoms of psychosis; Conditions that may cause psychotic symptoms and their management; ; Role plays and case studies)
• Plan and start management; Psychoeducation for people with psychosis and their family/care givers; initiating antipsychotic medications; Side effects of medications and their management)
• Follow up II-Moderate-Severe Depression
• 6 hours • Introduction (what is depression?)
• Establish communication and build trust
• Conduct assessment (presenting complaint; common features of depression; exploring symptoms; assessing for
imminent risk of suicide; assess for alcohol use and self-treatment; mild vs. moderate-severe depression; what to look for on physical exam; what is manic episode? ;
• Plan and start management (psychosocial support; when not to prescribe antidepressants; common non-permanent side effects of antidepressants; precautions for TCAs; monitoring people on antidepressants; pregnancy and breast feeding)
• Link with other services and supports
• Follow up III-Epilepsy and Seizures
• 7 hours • Introduction (What is the local beliefs and local names? ;Definition of seizures and Epilepsy; what causes epilepsy; Reducing Stigma and Discrimination)
• Learning Objectives • Emergency management of
Seizures ( Using the mhGAP for acute seizures)
• Management of simple febrile seizures
• Establishing communication and build trust
• Conduct assessment (when to suspect epilepsy)
• Plan and start management (medication choice and education
• Common side effects, dangerous side effects and drug reactions
• Common drug interactions • Management of a child with
epilepsy and developmental disorders
• Special management of
women with epilepsy • Advice, Education and
Support • Epilepsy and Safety Risks • Link with other services and
support • Follow
IV-Conditions specifically related to Stress -Acute stress -Post traumatic stress disorder(PTSD)
• 6 hours • Introduction (What are stressors? Symptoms of acute stress and grief)
• Learning objectives • Establishing Communication
and build trust Conduct assessment (common presentation of acute stress and PTSD ; Features associated to PTSD)
• Plan and start management (management of acute stress symptoms; Relaxation techniques; Problem solving; addressing current stressors; management of PTSD)
• Linking with other Services • Follow up
Appendix 2-Pre and post test questions
Psychological First Aid (PFA) Perceived Competencies
Code:------------------------- Please circle the number that best corresponds to how you rate your perceived…
Very Low Low Medium High Very High
1.Ability to support people who have experienced disasters and other stressful events
1 2 3 4 5
2.Understanding of what influences how someone responds to crisis
1 2 3 4 5
3.Overall knowledge of what to say and do to be helpful to someone in distress.
1 2 3 4 5
4.Ability to take care of yourself and support your team members when assisting people affected by crisis
1 2 3 4 5
5. Ability to listen in a supportive way 1 2 3 4 5
6. Knowledge of how to find information that can 1 2 3 4 5
help people affected by a crisis event 7. Ability to link people affected by crisis to needed services
1 2 3 4 5
8. Knowledge of what not to say or do so as not to cause harm when helping people affected by crisis
1 2 3 4 5
Code………………… Please check the best correct answer (yes or no) for each statement below…
Which of the following is true for people who have experienced crisis events?
Yes No
1. Most people affected will develop mental illness.
2. Most people affected will need specialized mental health services.
3. Most people affected will recover from distress on their own using their own supports and resources.
Which of the following can be helpful for people who experienced very distressing events?
Yes
No
4. Providing referrals and linking people with basic services (e.g. social services).
5. Asking people to recount their traumatic experiences in detail.
6. Listening in a supportive way without interrupting.
7. Conducting psychological debriefing (assembling a group of people and asking them to
Duration of the test: 20 min. A. Put in the correct column. True False 1. People with mental disorder usually cannot make decisions concerning their health 2. People with mental disorder are best cared for in mental hospitals 3. All people with depression should be treated by antidepressants 4. Mental disorders are common in children and adolescents 5. To stop acute seizures, diazepam by intramuscular route is the routine treatment of choice 6. Severe chronic depression in a mother may lead to developmental delay in her children 7. Symptoms of acute stress vary greatly and involve being severely distressed after a recent
potentially traumatic event
8. Vitamin injections should be routinely used for somatic complaints with no organic cause 9. Asking people about suicidal thoughts increases the likelihood of suicide 10. People affected by posttraumatic stress disorder my feel constantly in danger
share their stressful experiences). 8. Telling them the story of someone else you just saw so that they know they are not alone.
9. Giving any reassurance to help people feel better (e.g. your house will be rebuild soon).
10. Telling an affected person that everything will be fine and they should not worry.
11. Judging the person’s actions and behavior (e.g. you should have stayed) so they won’t make the same mistakes next time.
12. Finding out more about the situation and available services so that you can assist people in getting their needs met.
13. Tell an affected person how they should be feeling (e.g. you should feel lucky you survived).
As someone providing assistance to others you should…
Yes
No
14. Focus only on the people you are helping, and try to forget your own needs and concerns until after the crisis situation is over.
15. Practice self-care by taking regular breaks.
B. Circle the correct answer. There is only one correct answer for each question.
11. Which one of the following statements concerning depression is correct
____ a. Depression often presents with vague physical pain and fatigue ____ b. Depression often presents with delusions and hallucinations ____ c. Depression often presents with confusion
12. Concerning antidepressants which of the following is correct
____ a. The treatment should be continued even if the person suddenly becomes manic ____ b. The treatment should be continued for 2-3 months ____ c. The treatment should usually only be offered if the depression affects the person’s daily
functioning
13. Which of the following messages should be given to a person with depression ____ a. Try to reduce your physical activity as much as possible ____ b. Try to participate in social activities as much as possible ____ c. Try to sleep as much as possible
14. A 22 years old girl says that she hears voices that no one else can hear and is convinced that someone
wants to hurt her, which of the following disorders is most likely present ____ a. Psychosis ____ b. Depression ____ c. Mania
15. Concerning the management of acute psychosis
____ a. Medicines by injection will be required for most cases ____ b. The person needs to be followed up at frequent interval ____ c. The person should always be restrained (e.g. chained)
16. Concerning epilepsy, which of the following is correct
____ a. For making diagnosis of epilepsy, first step is to do electroencephalography (EEG) ____ b. Two seizures in last year are reason enough to start antiepileptic medicine ____ c. Once the diagnosis of epilepsy is made in a women with epilepsy, she should not marry
or have a children
17. Concerning antiepileptic medications, which of the following is correct ____ a. Antiepileptic medication should be started at a maximum dose and then decreased ____ b. Antiepileptic medications should be combined for faster treatment ____ c. Antiepileptic medication can be stopped two years after the last epileptic seizure
18. After a suicide attempt
____ a. Leave the person alone resting in a quiet room ____ b. Restrain visits from family and friends ____ c. Remove means of self-harm
19. Post-traumatic Stress disorder (PTSD) involves which of the following clusters of traumatic stress
symptoms ____ a. Re-experiencing symptoms ____ b. Avoidance symptoms ____ c. Symptoms related to a sense of heightened current threat ____ d. All of the above
20. Which one of the following is NOT true about Psychological First Aid (PFA) ____ a. Listening to the person without pressuring them to talk. ____ b. Providing practical care and support without asking intrusive questions ____ c. Assessing their needs and concerns is not important ____ d. Helping people connect to services, family, social supports and accurate information
21. Concerning the management of an adolescent with persistent aggressive and disobedient behavior, which of the following is correct
____ a. Provide advice to family and teacher ____ b. Punishment for unwanted behaviors is the best method to improve behaviour ____ c. Medication should be considered as soon as possible
22. Which of the following statements concerning pharmacological treatment for people with mental
disorder is correct ____ a. You usually do not need to obtain consent since the person does not understand ____ b. Antidepressants should only be given to adolescents after trying psychosocial treatment ____ c. Once the antipsychotic treatment starts, the person needs to continue taking the drug
throughout life
Appendix 3- End-of-the training workshop evaluation forms
Psychological First Aid (PFA) Training Evaluation Form
(please do not put your name on this form)
Date:______________
Please circle the number that best corresponds to how you feel about the orientation…
Strongly disagree Disagree Neutral Agree Strongly
agree 1. The information was clear and easy to understand. 1 2 3 4 5
2. The information I received is useful to my work. 1 2 3 4 5
3. The orientation increased my confidence to offer PFA in crisis situations.
1 2 3 4 5
4. The orientation gave me practical skills and 1 2 3 4 5
knowledge to apply in crisis situations.
5. The teaching methods used by the facilitator were effective.
1 2 3 4 5
6. The orientation was engaging and fun.
1 2 3 4 5
7. I would recommend this orientation to others.
1 2 3 4 5
1. Please say in a few words what you found most useful in this training. 2. Please say in a few words what was least useful in this training. 3. What suggestions do you have to improve the training for future participants?
Thank you for your participation and comments!
End-of-the-mhGAP training workshop summary
evaluation
Your details Name Affiliation Area(location) Discipline
Doctor Clinical Officer Nurse Other ( )
Training work shop Please answer to below questions: Remarks 1. The facility or venue where training
took place Very good Adequate Inadequate
2. Number of participant in workshop Too much Adequate Too few 3. Length of the whole training
workshop Too short Adequate Too long
4. General quality of the training Very good Moderate Not good 5. The training was helpful in
understanding how to use mhGAP-IG Very helpful Helpful Not helpful
6. Use of the participatory training Very Good Adequate Not good
Code:
(role plays, case studies etc.) 7. Are you confident in providing
service based on mhGAP-IG in clinical practice?
Significantly confident Somewhat confident Not confident
8. What are the three most important things you learned during this training, and will use in your clinical practice? A
B
C
10. What would you suggest to improve the training? Are there any other comments or any suggestion for improvement?
Thank you