Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women’s alcohol consumption during pregnancy

Internationally, clinical practice guidelines recommend the implementation of antenatal care addressing alcohol consumption by pregnant women [1, 2]. However, research from countries including Canada [3], the United Kingdom [4] and Australia [5‐10] indicates provision of such care is limited, including lack of routine assessment of alcohol consumption by pregnant women [5‐7] and inconsistent provision of advice on potential harms of such consumption [3‐6].

Clinician capability has been identified as a significant barrier to clinicians routinely providing recommended best practice care [11]. In Australia and internationally, studies have found lack of knowledge [12], skill [7, 10, 13] and confidence [10, 11] to be significant barriers to the provision of care according to care delivery guidelines generally [14], as well as a barrier to clinicians providing recommended antenatal care addressing alcohol consumption during pregnancy [7, 11, 12].

Clinician training has been identified in multiple systematic reviews as a key intervention strategy for addressing clinician barriers related to the implementation of evidence-based care [15, 16]. A Cochrane systematic review of 81 trials including over 11,000 health professionals found increased compliance with recommended clinical practice guidelines (improvements in compliance from 2.9 to 15.3%, median of 6%) following educational meetings [15]. A further Cochrane systematic review that included 69 studies involving more than 15,000 health professionals in educational outreach visits (onsite education/training) found that such training increased compliance with desired practice by 5.6% (risk difference; interquartile range 3.0 to 9.0%) [16].

Significant challenges have been reported in ensuring all targeted clinicians participate in training [17‐19]. Reviews have reported an average of only 53% of targeted clinicians participate in training in clinical settings generally [15] and 15–75% of clinicians in maternity service settings [17, 20, 21]. Reviews have reported that factors contributing to less than optimal training participation including organisational constraints (e.g. available resources, time) [18, 19, 22], lack of tailoring to local context and different users [21], lack of integration of training into routine organisational meetings and opportunities [18], and lack of organisational support for training to occur [22]. To address these barriers and maximise the effectiveness of training, Cochrane and other systematic reviews recommend that clinician training initiatives address the following six principles: varied structure (one-on-one and group) [22]; multiple modes (online and face-to-face) [23]; multiple formats (interactive and didactic) [15]; mixed content (educational and instructional) [15, 20, 23, 24]; varied facilitators (peers and experts) [16, 25]; and total training of ≥1 h [22]. Participating in training based on these principles individually has been shown to significantly improve practice outcomes, including improvements in care [16, 22, 25‐28], increased patient-centred skills [20], and positive effect on patient health behaviours and health status [20]. However, no studies could be located of training initiatives that included all six evidence-based principles, nor any studies of clinician participation in such a training initiative.

We could locate a few studies that incorporated some, but not all of the recommended principles in the design of training programs. For instance, a study in general practice in Australia covered four of six of these evidence-based principles. This study included a weekly group-based training sessions with duration ≥1 h (2.5 h per session, for 6 weeks) that had multiple formats (didactic and interactive), mixed content (educational and instructional) and varied facilitators (peers and experts). This training resulted in 41% of the General Practitioners (N = 108) that had self-selected into the training receiving all components of the training program (totalling 15 h of training) [29]. The study did not report receipt of the incorporated evidence-based principles of training. A further study, also in general practices in Australia, qualitatively evaluated a multi-component training program that included content that was delivered through multiple modes (online and face-to-face), with mixed content (educational and instructional) and included peer delivery. Fifteen general practitioners self-selected into the training program, however the percentage of practitioners who participated in the training was not reported, nor was receipt of the incorporated evidence-based principles of training [30]. The ability to achieve sufficient clinician participation in a training initiative implementing all six evidence-based principles of training has not been reported.

The aims of this study were to assess the extent of participation by antenatal clinicians in evidence-based training on care for women for alcohol consumption during pregnancy, and to assess any differences in participation by profession.

This study aimed to assess the extent of antenatal clinician participation in a multi-component evidence-based training initiative designed based on six principles of training, and to assess differences in participation by profession. The comprehensive training initiative was effective in achieving substantial levels of clinician participation, with 98% of clinicians participating in some training and approximately two thirds of clinicians (68%) participating in at least 1 h of training across the training components. Few clinicians (7%) received training that satisfied all evidence-based principles of training. The training principles related to content (82%), duration (68%) and format (58%) were able to be satisfied for more than half of antenatal staff, whereas the principles related to mode (42%), structure (37%) and facilitator (35%) were not.

As noted in systematic reviews, data on level of participation in training is not often clearly reported in included studies (44%) [15]. For those studies that have reported training participation, reported participation rates for training with maternity services clinicians range from 15 to 75% [17, 20, 21]. The present study found the proportion of staff to receive any training to be 98%; a result notably high in comparison to these past studies. None of these past studies reported on training participation in terms of any of the principles of training that were reported in this study.

There were a number of factors that may have resulted in different levels of clinician participation in training incorporating each of the principles. In terms of facilitator, 98% of staff received training from a peer, whereas only 36% received training provided by an expert. This may have been due to less opportunities (two face to face group sessions) provided by an expert, compared to the 7-month presence of a Clinical Midwife Educator as a peer facilitator. The use of additional modes (e.g. online or pre-recorded sessions) for delivering expert-delivered training may be needed to be implemented to enable this principle to be satisfied by a greater proportion of staff.

In respect to structure, 84% of staff attended a group session compared to only 47% of staff participating in one-on-one training sessions. This was impacted by logistical challenges in reaching all 186 target staff with one-on-one sessions, including changing rosters, staff rotations, limited dedicated time for such sessions and complexity of opportunistic one-on-one sessions at outreach sites. In contrast, group training sessions, are able to be justifiably attended for training purposes. If the principle of mixed structure (one-on-one and group) is to be satisfied, there needs to be identification of further opportunities for one-on-one training in such clinical settings as well as organisational support and recognition to allow time to be dedicated to such sessions and their role in training legitimised.

In terms of training mode, 95% of staff were able to attend face-to-face training. Such training was able to be provided with greater flexibility in terms of session length and format, which may have assisted with reach. This compared to online training which was only undertaken by 45% of staff. Digital literacy could have contributed and has been identified in existing literature [39]. Also, limited availability of computers within clinical spaces that were able to be utilised to undertake training and limited time allowed to undertake online training were both recognised issues identified by participating clinicians that may have contributed to this result. Additional dedicated computing resources may be required to overcome these barriers and assist in the principle of mixed mode (online and face-to-face) being satisfied.

There were significant differences in receipt of principles of training by clinical profession with a higher proportion of midwifery compared to medical receiving the following principles of training: multiple modes; multiple formats; ≥1-h duration of training; and mixed content. Despite being offered the same training opportunities no medical staff received training that satisfied all training principles. This aligns with barriers to participation in training by medical staff cited in related literature including: organisational constraints (e.g. available resources and organisational support for training to occur) [18, 19, 22], lack of tailoring to different contexts and users [21], and lack of time to participate in training due to increasing workloads, pressures and staff shortages [18]. During consultations held with maternity staff during planning of the training program, consideration was given to potential differences in training needs by clinical profession. It was noted that medical staff required delivery of the training content in short (5–15 min) sessions to fit within existing shifts and training schedules, compared to midwifery staff who had longer blocks of time (30–120 min) available within existing schedules (e.g. mandatory full training days). Despite adapting training to such profession-specific needs, difficulty securing time for training with medical staff was a key barrier in ensuring this profession group received the same duration of training as midwifery staff and therefore exposure to training that satisfied the training principles. This variability of receipt of training suggests further research is needed to better understand the barriers that different professions (particularly medical staff) face in participating in training programs and to test the effectiveness of strategies to overcome such barriers.. To encourage greater uptake of training for medical staff, it is likely that such strategies will need to include protected time for staff to complete training programs and funding to backfill clinical shifts.

The study has a number of strengths including delivery of training as part of routine clinical education, the use of observed training attendance data and coding of training content based on evidence-based principles. The study should also be considered in light of its design and methodological characteristics. The study was undertaken within a single maternity service in a metropolitan hospital. It is unknown how comparable the training opportunities or clinician response in this setting are to other clinical settings without further evaluation across multiple sites. However, the hospital setting in which this trial was conducted was inclusive of varied antenatal models (hospital based, community outreach, AMIHS) and staffing types. The size of the sample was limited to the number of staff within the service and more precision of the findings would have been achieved with a larger sample.

This comprehensive, multi-component, evidence-based approach to clinician training was effective in achieving substantial clinician participation in training opportunities, and at a level that is greater than previously reported. Variability between professions suggests further tailoring of training is required, particularly for medical staff. Further research is required to determine whether participation in training was able to address the clinician barriers to care delivery that it was designed to address, including knowledge, confidence and skill, and to evaluate the contribution that the training program made to changing clinician practices as a component of a multi-strategy practice change intervention [31]. It is likely well-designed training programs, when delivered together with other practice change strategies, including reminders and audit and feedback, that address other clinician barriers to care delivery will increase levels of recommended care [40].