CHAPTER 2: An overview of the problem

· The purpose of a training programme is to teach students to do a job.

· Teachers should concentrate on the essential facts, skills and attitudes. It is neither possible nor desirable to teach everything.

· Teachers should base their teaching on the health problems of the community and on the work their students will be expected to do.

· Teachers should plan courses and lessons using situation analysis and task analysis.

A story

A community nurse completed her training and passed all the exams at the end of the course. She was given two weeks leave before starting work, so she went back to her village to spend some time with her family. It was a long journey because the family lived in a remote village, but everybody was pleased to see her again. Her mother was specially pleased and very proud that her daughter had done so well.

After the first greetings, the mother said "It is good that you are back because your baby cousin is ill. The baby has diarrhoea and doesn't look well to me. Do you think that you could help?" The nurse went to see the baby and realized that it was very dehydrated. She thought the baby should go to a health centre, but the journey was too far. So she thought about what she had been taught. She could remember details about the anatomy of the gastrointestinal tract and the balance of electrolytes. She also remembered that a mixture of salt and sugar in water would help to rehydrate the baby, but she couldn't remember what amounts to use.

She was very worried that the amounts would be wrong. She didn't know whether to send for help or to guess the amounts. By this time, the baby was very ill. She made up the solution and gave it to the baby. The solution contained the wrong proportions of salt and sugar. The baby died.

Moral

Some courses for health workers may be ineffective or even harmful because they spend a lot of time teaching facts that are not important. The courses may fait to spend enough time teaching the skills that are really needed.

2.1 Some basic principles

The story shows what can happen when a course for training health care staff is unsuccessful. But what makes a course successful? The following are basic principles.

Basic principles

1. The main aim of a course should be to train students to do a job.

2. The job determines what the students should learn.

3. Only those facts, skills and attitudes that are relevant to the job should be taught and learned. Those that are not essential should not be taught.

These may seem very obvious points, but they do have important consequences, which are briefly explained in the next few paragraphs.

2.2 The main aim of a course should be to train students to do a job

This is the basic principle on which this book is based. It means that if students can do their job competently at the end of a course then it has been successful. If they cannot do the work they have been trained for, then the course has failed.

This means that the teachers must know a lot about the work which the students will be doing. The teachers should watch experienced health staff doing their work. They should ask them about the problems of providing health care. The whole course should be closely linked to the way in which health care is provided. Chapter 3 explains how this may be done.

If this principle is followed, students will be able to do a job at the end of the course rather than just know about it.

Some people feel that this aim of "training to do a job" is too limited. They feel that there should be much more to education than this. While there is some truth in this point of view, the wider goals should be secondary. The first and most important goal is that the students should be able to do their work in an intelligent, understanding and competent way. This is the whole emphasis of this book.

For example, a broadly educated health worker who infects patients because he or she does not follow aseptic techniques is a danger to the community. So it is important that students get the basic competence first. When this has been achieved, other aspects may be added to the training if time permits.

2 3 The job determines what the students should learn

In all courses, choices have to be made about what facts, skills and attitudes students should learn. Choices also have to be made about what details should be left out of the course. It is simply not possible to learn everything that is known about medical sciences and health care. So some selection is essential.

Figure

“Must learn” is the target. Theses are facts and skills that all students need to learn in order to be competent in their work. Teachers should stress the importance of these facts and skills when they are helping students to learn. These facts and skills should be tested in examinations.

There are very many other facts and skills that are "useful to learn", but they do not need the same emphasis. Nor should they be tested as thoroughly in examinations.

There are also very many other facts and skills that are "interesting to learn". Of course, teachers should not prevent students learning anything. In fact they should show students how to learn from books, conversations and their own and other people's experience of the world. However, the teacher's main responsibility is to decide what students must learn and to make sure that they learn it.

Facts and skills that must be taught are those that are needed to do the job competently and thoughtfully. These are discussed in Chapters 3 and 4.

2.4 Learning objectives

An important idea which should be introduced now is the concept of "learning objectives".

A learning objective is a statement that describes what the student should know, feel or be able to do at the end of the course.

This definition includes some important points. First of all, the learning objectives concern the student and not the teacher. Second, the learning objectives describe the state of the student at the end of the course. The learning objectives therefore do not describe what the teacher will teach or the experiences the student will have during the course. The learning objectives are therefore a statement of the targets which the course is trying to achieve.

Some writers also use the phrases "learning goals" or "aims". Some writers make distinctions between "specific" and "general" objectives. The distinctions between these terms are not very clear and are probably not important.

2.5 Making use of learning objectives

The crucial importance of learning objectives is that they define what the students must learn.

They can do this at a very general level, e.g. "the learning objective of this course is that the students should be able to do the work of a maternal and child health (MCH) assistant".

Or at a very specific level, e.g. "the students should know the quantities of each ingredient in home-made oral rehydration solution".

So the learning objectives can refer to a whole course or to just a few minutes of a lesson - or anything in between.

In all these situations, the learning objectives are vital because they control (or should control) the whole process of teaching and learning. The learning objectives determine:

· what is included in a lesson or course,
· how the teaching is done, and
· how the students are tested.

For example, if the learning objective is that "the students will be able to diagnose anaemia from clinical signs", then:

· the students must be taught about the clinical signs of anaemia, how to observe them, and how to distinguish between people who are anaemic and those who are not. For this objective there would be no point in teaching students about the structure of haemoglobin or how to test for anaemia using laboratory methods.

· the students must be able to practice their skills of clinical diagnosis on some patients with anaemia and some who are not anaemic. There will be little need for lecturing.

· each student should examine some patients and decide whether they are anaemic or not. The teacher will then be able to assess whether the students have achieved the learning objective. The students should not be asked to write essays on anaemia, because this is not related to the learning objective.

Figure

2.6 How can you decide what are the learning objectives?

The most important thing about learning objectives is that they should be relevant to the job that students are being trained to do. Because learning objectives determine what is included in a course, they can damage all aspects of it if they are not relevant. The way in which teachers and course designers decide what the learning objectives should be goes back to the basic principle stated in Section 2.1.

The main purpose of a course should be to train students to do a job.

Therefore the learning objectives should be based on the job description.

In summary, this is done by making a list of all the tasks that the health worker will be expected to do. This process is called situation analysis in this book, and is described in Chapter 3. Then each task is analysed to find out what skills are involved and what knowledge and attitudes are needed in order to do it competently. This process is called task analysis and is described in Chapter 4.

These two processes together give a list of all the learning objectives for a course - i.e., the skills, knowledge and attitudes that should be learned. If all the learning objectives are achieved, the health worker will be fully competent to do his or her work and the overall purpose of the course will have been achieved.

CHAPTER 3: Situation analysis

Figure

This chapter explains how teachers can find out more about the job that their students will be doing.

A story

A maternal and child health (MCH) worker completed her training at college and went to work at a family welfare centre as the leader of the MCH team.

One of her responsibilities was to "work with the community", but she found this very difficult to do, so she spent her time in the family welfare centre waiting for clients to come. A few clients came, but for a lot of the time she sat and waited. When I talked to her and asked her why, she told me that her boss expected her to be at the centre during all working hours. If she was not there she would get into trouble. Further, she didn't really have any idea about the work she could do in the community. She had listened to lectures on community analysis and development, and the principles of communication. However, she had not been told what work she was expected to do.

Moral

People will only work effectively if they are told precisely what their work involves and are given opportunities to practice during their training.

3.1 The purpose of this chapter

The main purpose of the previous chapter was to emphasize that courses should train students to do the job of a health worker. So it is obvious that the people who design or teach the courses should know exactly what the job involves. Unfortunately they often do not have this knowledge. This may seem very surprising. Why not test yourself to see if you are clear about the job that will be done by the students you are involved with?

Exercise

Many health workers in primary health care have responsibility for some of the following:

- managing a health centre,
- intersectoral cooperation,
- community involvement,
- treating common diseases, and
- preventing and controlling disease.

For all of the responsibilities above that are part of your students' work, ask yourself:

What should be the first daily task of health workers who manage a health centre?

What should they do in order to cooperate with other sectors? What should they do in order to involve the community?

Exactly which diseases are common and which are not? Which diseases can be controlled or prevented? What should health workers do to control or prevent disease?

Comment

First of all check that you have answered what the students should do (e.g. act as a chairperson at weekly staff meetings) rather than what they should achieve (e.g. the health centre team should be well motivated).

Maybe you would like to have a second attempt at the questions.

If you are able to give clear and precise answers to all these questions then you are in a strong position to plan effective courses and to teach your students relevant facts and skills. If not, you are like the vast majority of teachers! This chapter will help you to think through the problems so that you will be able to answer the questions better.

More importantly, if you cannot answer the questions, you will not be able to make good decisions about what students should learn. So, the important purpose of this chapter is to help you think through exactly what the job of the health worker involves.

3.2 Starting from a job description

In many countries the ministry of health will probably be responsible for deciding what the job of the health worker should involve. Even in these countries, it may be necessary for teachers or course committees to make clear what the employer intends.

The employer usually provides a description of the work that each category of health worker is expected to do. This is called the job description or job specification.

So the teacher or course committee must start by looking at the job description. This usually defines various administrative matters such as the grade of the job and conditions of service. But the key information for the teacher is the list of responsibilities (which may be given other names such as duties or functions). Some job descriptions are precise and detailed, and can be very useful in guiding teachers. Others tend to be rather vague and may be very brief.

The aim is to start from the job description and end up with a list of tasks that the health worker must be trained to do. It is usually convenient to have between 50 and 100 tasks on the list. This is not a matter of right or wrong - it is simply a matter of convenience. The exact number of tasks depends on the scope of the work and the level of detail which you choose.

3.3 An example of a list of tasks

The job description gives a general idea of what health workers should do. For example, the job description of an MCH nurse in one country included "monitor the growth of children" as one of the responsibilities.

The teachers observed MCH nurses doing this work and drew up the following list of tasks for this responsibility.

List of tasks

· Keep a list of all children in the community who are under 5 years of age.

· Train community health workers to weigh children, record their weights on growth charts and decide when children are at risk.

· Organize MCH clinics in the community for children to be weighed as part of the MCH care programme.

· Maintain a register of children who are "at risk" because they have not been brought to the weighing sessions or because they are showing signs of malnutrition.

· Arrange follow-up visits to all at-risk children.

The list of tasks is simply a more detailed and more precise version of the job specification.

This example shows that "monitoring the growth of children" involves training, organizing, managing and record-keeping. The list of tasks therefore gives a much clearer and more precise picture of the real nature of the work - and of what the students need to learn.

3.4 How to prepare the list of tasks

Visiting employers

Unfortunately it is not possible to give a fixed list of steps for teachers to follow.

In preparing the list of tasks, teachers should start with the official job description. From there it is a matter of thinking, asking, discussing and observing until the meaning of each part of the job description is clear and precise. First of all, the employers (often the Ministry of Health) should be asked what they think is involved in each part of the work. Useful questions to ask are:

· " When health workers start work at 9 o'clock on Monday morning (or whenever work starts) what should they do in order to...?"

· "How should that be done?"

· "Should they actually do...?"

· "What exactly do you mean by...?"

· "Which are the common diseases/conditions/problems?"

The point of this exercise is not to get into the fine details of how to give an injection or conduct a vaginal examination. On the other hand, teachers do need to find out certain facts, such as which examinations should take place during an antenatal visit.

There is a risk that this type of approach may be too aggressive and make the employer act in a defensive manner. It is quite likely that these questions will not have been considered in detail by the Ministry of Health, so staff may not know the answers. The mood of the discussions should, therefore, be of shared problem-solving and not that of an interrogation.
Visiting health workers

After visiting the employers you should visit the health workers in the community and watch them at work. You should ask them questions such as:

· "How do you involve the community in health education?"
· " What do you do when you...?"
· "Which diseases can you treat?"

Again, you are not looking for fine details, but you do need to be clear. It is no good being told, "I inform the community". You need to know what this involves.

Asking for advice from "experts"

There may be some experts whom you could ask. They may work in academic institutions such as medical schools or nursing colleges. You should ask them how they think that the job should be done. The aim here is not to get an "official" answer but to find out their ideas for better ways of doing the work.

3.5 Bringing the information together

When you have collected the information from the different groups, you need to compare the answers they have given. There are likely to be quite large differences in opinion.

The next step is to produce your own list of tasks based on these different sources of data. Be realistic. Take account of how much time the health worker has available. (In one study, the health worker would have spent more than 100 hours per week on just one part of the job if he or she had done the work according to the official job description!). Take account of the resources available (such as what equipment is available for health workers to sterilize instruments). When you have completed the list you should then discuss it with the employers, health workers and experts to check that it is realistic, that it does help to solve the most important health problems of the community, and that it is consistent with what could reasonably be expected of the health worker.

This review is likely to lead to quite a lot of changes.

Above all, check that the final list of tasks is precise and clear and that you know exactly what is involved in each task.

3.6 What is the value of the list of tasks?

The list of tasks for a job is the list of learning objectives for the course that trains people to do that job.

This is an absolutely crucial point.

If this principle is accepted and applied many courses for health workers will need to be changed. Students are often taught about facts and skills that are not relevant to their work. For example, in a recent review of one curriculum for health workers, it was shown that more than 30% of the teaching in the curriculum was of no relevance to the actual tasks that the health workers were expected to do. The curriculum was therefore changed to include more relevant teaching concerning tasks that the health workers had not previously learned about.

The list of tasks is used to plan the overall curriculum, including the assessment methods (this is discussed in Chapter 5). However, when teachers plan individual teaching sessions or units of a course they will need more detailed learning objectives. They can obtain these by analysing each of the tasks. This process is called task analysis and is described in Chapter 4.

3.7 Summary

Teachers help their students learn how to do a job. Therefore, the teachers must know exactly what this job is.

Situation analysis helps teachers to find out more about the job. Teachers can do a situation analysis by talking to health workers, employers of health workers, and experts.

The list of tasks produced at the end of the situation analysis is a list of the learning objectives for the course.

CHAPTER 4: Task analysis

Figure

This chapter explains how teachers can look at each of the tasks in more detail to find out exactly what needs to be learned.

A story

Mr W. a teacher in a college of health sciences, was asked to teach a group of trainee nursing orderlies about weighing babies in an MCH clinic. He carefully planned a series of lectures about child development and told the students about nutrition and malnutrition. He explained why babies should be weighed regularly and he brought scales into the classroom and demonstrated, using a doll, how to weigh a baby At the end of the course the students took an examination in which they wrote short notes on questions such as " What are the major causes of ma/nutrition?" and "List three reasons for weighing babies regularly". The students ail answered the questions quite well and Mr W was pleased with their performance

However, when the nursing orderlies started to work in the MCH clinics there was chaos They did not know how to organize the queue of mothers and children because the teacher had not told them They had great difficulty picking up and weighing the babies, because they had only seen the teacher weigh a doll. They did not know how to record the weights on a growth chart, because they had never used graphs and did not understand them.

What went wrong? Even though the task was specified (weighing babies), Mr W had not thought in detail about how the students would do the task - he had not done a task analysis.

This chapter describes how to do a task analysis. Task analysis will help teachers to make sure that their students learn exactly how to do each of the tasks in their job.

4.1 What is task analysis?

Task analysis involves looking at some part of a person's job (a task) and writing down exactly what is done. This description is then analysed to find out what students need to learn in order to do the task well.

Task analysis can be done in great detail by professional teams who may take years to do a full task analysis. However, it can also be done in much less detail and much more quickly by teachers. This less detailed approach will still be extremely useful and will be described in this chapter.

4.2 An example of a task analysis

If Mr W had analysed the task of weighing babies in an MCH clinic, he might have produced something like the example overleaf.

This task analysis was done for a specific category of health worker in one country. Health workers may do the task in a different way in other countries. Some may not use the weighing

Task analysis form trousers or may not examine the baby at all when it is weighed. Some may carry out a thorough examination. The example is intended to show how to write down a task analysis. It is not meant to be a perfect model for weighing babies in every country.

Category of Worker Nursing orderly
Task Weighing a baby in MCH clinic

Sub-Tasks	Knowledge	Attitudes
Actions (A) Decisions (D) Communications (C)
1 Ask the mother to dress the baby in weighing trousers (C)		Friendliness to mothers
2 Check and adjust the zero point on the scale (A and D)	Location of the zero adjuster	Concern for accuracy
3 Place the baby on the scale (A)		Gentleness and caring
4. Read the scale (D)	The need to look at the scale from straight in front	Concern for accuracy
5 Help the mother take off the weighing trousers (A)
6. Examine the baby for physical signs of abnormalities (mainly D)	Which signs to look for	Thoroughness
7. Record the weight on the growth chart (mainly D)	How to read and plot graphs	Accuracy
8. Decide what comment to make to the mother (D)	Criteria for malnutrition, weaning methods, locally available foods
9. Make a comment (C)	Ways of communicating effectively	Sympathy for the problems faced by mothers

What does this example show? First, the task - weighing a baby - involves much more than simply putting a baby on a weighing scale and making a note of its weight. A task analysis can show the whole range of skills involved in doing a task.

Second, the task analysis shows which facts and attitudes need to be learned by the students in order to do the task. This also helps teachers to decide which facts must be learned and which are less important.

The rest of this chapter explains how teachers can prepare a completed task analysis like the example shown, and how they can make use of it. No teacher has enough time to do a full task analysis for every task that he or she teaches. However, it will certainly be useful for teachers to do at least two or three task analyses in full. This will help them to think more in task analysis terms and so make their teaching more practical and more purposeful.

4.3 The stages in doing a task analysis

Select the task for analysis	Section 4.4
Select the sources of information	Section 4.5
Collect the information	Section 4.6
List the sub-tasks	Section 4.7
Decide on the knowledge and the attitudes needed	Section 4.8
Check the task analysis table	Section 4.9

The diagram shows the stages which are described in turn in Sections 4.4 to 4.9.

4.4 Selecting the task

The first stage is to select the task for analysis. In this book two examples are used. One is "weighing a baby" and the other is "persuading an unwilling mother to take her child for immunization". These are both tasks.

The situation analysis leads to a list of tasks. Ideally, a task analysis should be done for each of these tasks. In practice, this takes too much time, so just a few tasks should be chosen to start with. It does not really matter which tasks are chosen, but it might be sensible to start with tasks that are familiar or are carried out frequently by health workers.

4.5 Selecting the sources of information

When you have decided on the tasks that you wish to analyse, you should decide how you will find out about the way the tasks are done. To do this you should choose one, or preferably several, of the sources listed below:

Sources of information for task analysis

A Yourself
B Manuals and textbooks
C Observation of health workers
D Discussion with teachers, administrators and advisers
E Discussion with health workers

Suppose you wished to analyse the task of giving intramuscular injections. If you had a lot of experience of this task, you might use that experience as the main source of information. You could compare your description of the task with that given in a textbook or manual. You could also check that your analysis was accurate by watching several health workers giving intramuscular injections.

The advantages and disadvantages of each source of information are given below.

A Yourself

You are likely to have some experience of the tasks to be analysed. Therefore you should use it. You are certainly the most convenient source of information.

But remember:

you may not have enough experience or the right experience. Have you been working under the same conditions as your trainees will be working under? Have you been working with the same kind of patients? Is your method of doing the task really the best?

Even if you are able to answer "yes" to these questions, you should always check your analysis with at least one of the other sources.

B Manuals and textbooks

Many of the tasks carried out by health workers are described in medical textbooks, teaching manuals and guidelines issued by the ministry of health or WHO. A task analysis can therefore be prepared, based on one or preferably several sources of reference.

But remember:

the manuals or textbooks may be intended for trainees at a different level of the health system, in which case the skills will be described in too little or too much detail. Furthermore, they may have been written for different countries or different circumstances.

The tasks will not be described in the form of task analyses and so you will always have to change the format and add your own experience. For example, you may have identified the task of "monitoring the growth and development of children". A textbook will probably give all the background information but it is unlikely to say exactly what health workers in your country should do. It might also describe the normal changes in body weight and the need for a suitable diet. You would have to rewrite these details as a series of tasks such as weighing and recording the weight of children, or examining them for signs of malnutrition.

C Observation of health workers

In this method you would choose health workers who are regarded by their colleagues as being good at their job. You then watch the workers doing the task to be analysed, noting down everything that they do or say. At the end of the task you will probably need to ask the workers to explain why certain actions were done and what would have happened if the circumstances had been slightly different. Ideally, you should watch the same person doing similar tasks several times, and also see other people doing the same task. In practice, this may take too much time.

If you have seen two or three people doing the task in the same way, then this is enough.

But remember:

competent workers will be especially careful to do a good job while you are watching. They may take unnecessary precautions. On the other hand, workers may be generally very competent but may not be very good at the particular task you are watching. A further problem is that there may be unusual circumstances when you are watching - for example, the patient may be particularly uncooperative. So what you see may not be typical.

A further difficulty is that you might not be able to identify all the different stages of the task or the events may take place too quickly to record them all. For example, if you watch a midwife delivering a baby, you will probably see her place her hand on the baby's head as the head comes out. In this case, you will have to ask the midwife why she does this, in what direction she is pressing and how hard she presses.

D Discussion with teachers' administrators and advisers

It will often be helpful to talk about the task with teachers, doctors, nurses, training advisers or officials from the ministry of health.

When talking to one of these experts, do not ask them what they would teach. Instead, use a role-playing method.

For example, you could start by saying - "Imagine that you are a health worker working in the field. Suppose that I come to you and tell you that I have been coughing a lot. What is the first thing you would do?"

The expert might tell you " Well, I would start by taking a history."

This is much too vague, so you would need to follow this up by asking, " Yes, but what would you actually say to me?"

The expert might then reply " When did your cough start?"... and so on.

In this way you can piece together the specific actions, decisions and communications involved in the task.

But remember:

the experts may not realize what conditions are really like in the field. They may have a good understanding of the overall job of a health worker but may not be good at actually doing it.

E Discussion with health workers

In this method you would select a worker or a group of workers who are generally regarded as being good at their job. You would then discuss a specific task with them in the same way as described above, i.e. using role-playing and talking through specific case histories.

This method has the advantage that you will be told what is practical and realistic in the field. You will also hear about other people's experiences.

But remember: the workers may not be using the best techniques because they may have been trained some time ago. They may also have developed poor habits after training.

From the previous sections you will realize that each source has advantages and disadvantages. Ideally, several different sources should be used, as suggested overleaf.

4.6 Collecting the information

The next stage is to collect the information from the sources which you have decided to use.

Use your own experience

Note down how you think the task is done. This will be useful in putting your own experience on paper and will help you to organize your thoughts. It may also make you realize that there are some details which you are uncertain about.

Consult the manuals

Use them to fill in any gaps in your own experience and compare what you think is correct with the textbooks or manuals.

Discussion

Discuss any differences between your opinion and what is written in the manuals or textbooks with experts or health workers. This will help you to decide what actions are involved in the task.

Observation

Check your task analysis by watching the good workers doing the job. Make sure that the sequence of actions you have noted down is the one used by the workers. You should not include actions which they are not trained to do or for which they do not have equipment.

Collecting the information simply means writing down the various stages (the sub-tasks) of the task. While you are writing these down, it is a good idea to ask the following questions.

· How is the sub-task done? Are there any special points to note about the technique?

· What is the reason for doing the sub-task? For example, when weighing a baby, the nurse orderlies should examine the baby to detect early signs of malnutrition. This will allow preventive treatment to be provided before the condition becomes serious.

· What might go wrong? What would happen if the sub-task was poorly done? For example, mothers might be discouraged from bringing children to the clinic if they are treated rudely or have to wait for a long time.

All these points should be noted down. They will be put in order in the following stages.

4.7 Listing the sub-tasks

At this stage you should draw up an organized list of sub-tasks using the notes you have taken. You can write this list on a task analysis form such as the one shown below.

Task analysis form

Category of Worker	Nursing orderly
Task	Weighing a baby in MCH clinic
Sub-Tasks Actions (A) Decisions (D) Communications (C)	Knowledge	Attitudes
1. Ask the mother to dress the baby in weighing trousers (C)
2. Check and adjust the zero point on the scale (A/D)
3. Place the baby on the scale (A)
4. Read the scale (D)
5. Help the mother take off the weighing trousers (A)
6. Examine the baby for physical signs of

The sub-tasks are the things that happen:

· the actions
· the communications
· the decisions.

You should record these on the form in the order in which they occur. So for the task of "weighing a baby" you should have a form like the example shown.

The sub-tasks are the skills that students should learn. They are the learning objectives of the course, but they are not the only learning objectives. Other learning objectives are described in the next section.

4.8 Deciding on knowledge and attitudes

The sub-tasks are the key to successful teaching. If students are able to do each of the sub-tasks successfully then the course will have been successful.

So why bother to do a further stage?

The reason is that some of the sub-tasks require knowledge or attitudes that must be taught. For example, health workers must know what a graph is in order to "record the baby's weight on a growth chart". The health workers must also learn about correct attitudes towards mothers before they can "ask the mother to undress the child". Otherwise they may be rude or bossy and do the sub-task in an unsatisfactory way.

The sub-tasks are the performance objectives for the course. Knowledge and attitudes are also important to enable the health workers to do the sub-tasks. These are the enabling objectives for the course.

How can you decide what the enabling objectives should be?

To make this decision, you need to consider questions such as "Why might a student do this sub-task poorly?" or "What rules or facts must the student know before making that decision?"

For example, consider the sub-task "decide what comment to make to the mother" (after weighing the baby). Here the health worker has to decide whether the baby is growing properly or is at risk of malnutrition. This decision requires knowledge of normal weights for babies of different ages and clinical signs of malnutrition. These topics must be taught and are the enabling objectives for this subtask.

Consider the sub-task "make a comment" (after weighing the baby). Here the health worker may need to give the mother some nutritional advice. This involves knowledge of feeding practices, weaning foods, foods available locally, etc. The health worker will also have to give this advice in the right way and try to support the mother. This requires sympathy for the difficulties that mothers face - an attitude.

In this way, you can list the knowledge and attitudes needed for each of the sub-tasks on the task analysis form. When completed, it should look something like the form on page 22. Note that some tasks do not require specific knowledge or attitudes. Do not feel that you have to put something in every space on the form.

4.9 Checking the task analysis table

The task analysis table is now complete. However, it should not be used until it has been checked.

If you have used yourself, books or discussion as the sources of information, you must check that what you have written describes what health workers actually do. The only way to check this is to observe health workers doing the task in the field.

Remember also that health workers may be using old methods or may not have been trained how to do the task in the best way. So check with experts about the best way of doing the task.

You may find that the best way of doing the task is not realistic because the health worker does not have enough time, resources or training. In these cases teachers have to decide whether to train their students in the best method or to limit the training to what is realistic now. Task analysis does not help in making this decision but it does help in making the differences clearer.

4.10 Using the task analysis table

The value of the task analysis is that it gives teachers a very clear statement of the objectives for the course. These objectives have been worked out from the job description and from watching experienced health workers doing the job. So they must be relevant in helping the trainee health workers to learn.

Task analysis Relevant objectives

What is the advantage of having relevant objectives?

The objectives tell teachers exactly what the students must learn. So they help teachers to make sure that all the necessary content is included in the curriculum. They also help them to decide which details can be left out.

Task analysis Relevant content

The objectives are also useful in assessing the students. The subtasks or tasks should be used as the examination questions whenever this is possible. For example, the best way to test whether students can do the task of "weighing a baby" would be to ask them to run a session at a clinic where babies are weighed. While this is the ideal test there may be difficulties in organizing it. So teachers could ask students to do some of the sub-tasks instead. For example, the students could be asked to record a baby's weight on a chart or decide what advice to give a mother whose 12-month-old baby weighed 7 kg.

Task analysis Relevant assessment

The final point is that a task analysis is the first stage in choosing teaching methods. If students are learning facts or knowledge, lectures may be a good way of teaching them. However, if they are learning a skill, they must be able to practice the skill - lectures will not be of much use. So when teachers think about whether students must learn skills, attitudes or knowledge they need to think about teaching methods.

Task analysis Choice of teaching method

4.11 How can teachers find time for task analysis?

Teachers are very busy and very few will have time to analyse more than one or two tasks. So here are some practical suggestions.

· Do one or two task analyses as described in this chapter. Use several sources of information and check the results in the field. This will take quite a lot of time, but it will be time well spent.

· Think in terms of task analysis. For example, when planning a lesson decide which facts must be learned and which are less important. If the fact would appear in the "knowledge" column of the task analysis form, it should be taught. If not, it should probably be left out.

· Teach your students to do task analysis. This is one of the best ways of learning how to do a task. When one group of students have analysed a few tasks, they will be able to teach other groups. (This must be supervised of course).

4.12 A less straightforward task

"Weighing a baby" is a fairly straightforward task. It can be analysed by watching health workers, most of whom follow the same sequence of steps or sub-tasks. Other examples of straightforward tasks are "giving an intramuscular injection" and "building a pit latrine".

Other tasks are much less precise, however, and different workers will follow different methods. For example, consider the task "persuade a mother to breast-feed her baby". This is much more vague. There are many ways of doing this task. None of them is guaranteed to work every time and each health worker will need to develop his or her own method.

So is it worth analysing this kind of task? The answer is definitely "yes", because students have to learn how to do these less precise tasks. The minimum responsibility for teachers is to teach the students one way of doing the task, even if there are several possible ways.

It is also important to do the task analysis because it will often show that the student needs a lot of practice in communication skills and that attitudes are extremely important. While task analysis will not show the only way to do the task - nor even possibly the best way - it will show a way that is acceptable and that includes the basic skills, knowledge and attitudes that the students must learn.

Look at the example below which analyses how a health worker might do the following task: "persuade an unwilling mother, in a remote area, to take her child for immunization".

Example

Task: To persuade an unwilling mother, in a remote area, to take her child for immunization

Sub-tasks Actions (A) Decisions (D) Communications (C)	Knowledge	Attitudes
1. Greet the mother (A)	Friendliness, lack of prejudice
2 Find out reasons for refusal (C)	Common reasons for refusal (cultural, procedure, prejudice due to reported experience)	Sympathy, patience
3. Explain why immunization is beneficial to the child	Reasons for immunization, effects, simple facts about illnesses prevented by immunization
4. Explain importance to community of protection of all at-risk children (C)	How disease may spread, simple facts about immunity, epidemics in community	Confidence in ability to help
5 If successful, arrange clinic appointment for mother (A)	Fully conversant with immunization programme (dates, times, place)	Sympathy, friendliness
6. If unsuccessful, seek an appropriate decision- maker (A)	Decision-maker in local culture (husband, grand mother, council elder)	Tact
7. Repeat 3 and 4 (C)

While this task may be performed in different ways, the example given does show some important points which are likely to apply to all countries.

1. The task involves little knowledge of "medical topics" such as types of vaccine or mechanisms of immunization.

2. There is a great emphasis on communication skills - i.e. the ability to talk, explain, persuade, and listen to people.

3. The learning experiences which will help students to learn the relevant skills knowledge and attitudes are practice in talking and listening, in preparing information material, and in writing reports.

4.13 Summary

1. Task analysis is a method for describing exactly how parts of a job (tasks) are done.

2. Teachers should use task analysis in:

· stating the objectives of a course
· deciding on the content of courses
· choosing questions for examinations and tests
· choosing teaching methods.

3. Teachers should analyse at least one or two tasks in full. They should consider teaching their students how to do task analysis.

CHAPTER 5: Curriculum design

Figure

This chapter describes how the results of the situation analysis and task analysis can be used in planning and evaluating the curriculum.

5.1 What is a curriculum?

The word curriculum can be used in two different ways. It can be used to mean what actually happens during the course - the lectures, the work with patients and so on. The other meaning is the written description of what happens. This chapter will use "curriculum" to mean the written curriculum.

What should a curriculum include?

A written curriculum is needed to help teachers to organize the course. It should contain the necessary information to keep the course well run, such as:

1. The objective of the course - i.e. the tasks and sub-tasks that the students must learn.
2. The general methods that should be used to teach the students the various objectives.
3. The time and place where the students will learn - i.e. a time table.
4. The methods used to assess the students.

5.2 Lesson plans and the curriculum

The written curriculum is needed to keep the course as a whole well organized. In the same way a lesson plan is necessary to organize a shorter period of teaching. It will need the same kind of information about the objectives, teaching methods, timetable, and possibly some note about the assessment methods.

It is essential to write down the curriculum for a course. On the other hand, many good teachers do not need to write down their lesson plans. There are many good reasons why teachers should record a lesson plan. In practice, time is usually limited and experienced teachers can often manage without a written plan or with just very brief notes.

A lesson plan is a small curriculum.

Suggestions for ways in which teachers can plan teaching sessions (i.e. make lesson plans) are given in Chapter 10.

5.3 When should teachers be involved in planning curricula?

Teachers are often involved in planning the curriculum. They may be involved as a member of a team planning a completely new course or planning improvements in existing courses. Alternatively, they may be asked to comment on a curriculum planned by other people.

They must be involved when they are teaching a curriculum, because they should be trying to find ways to improve it.

5.4 Planning the course outline

Courses for health workers require a great deal of planning. The first stage should be to plan a course outline. This breaks the course down into smaller parts which can be analysed more easily.

It is obviously very important to make sure that this outline will make it as easy as possible for the students to learn. Look at the example below where learning is made difficult.

An example of a poor course outline
Course for community health nurses

Subject	Hours
Anatomy and physiology	90
Microbiology	30
Psychology	60
Sociology	60
Hygiene	60
Nutrition	60
Fundamentals of nursing	210
Community health nursing I	225
Community health nursing II	120
Community health nursing III	345

This course outline has a number of poor features:

· The basic science courses probably give much more detail than is necessary for the job. This means that students waste time learning unnecessary facts.

· The basic facts (e.g. sociology, nutrition) are taught quite separately from their application (community health nursing).

· The separate courses - microbiology, psychology, sociology, etc. - mean that the timetable is probably based on short fixed teaching periods.

A better way of planning the curriculum would be to base it on the tasks of the community health nurse.

Example - A course outline based on tasks

Community health - water supply, food storage and waste disposal
Family health - nutrition and health education
Maternal and child health care
Midwifery
Prevention and control of communicable diseases
First aid and emergency medical care
Training village health workers
Promotion of community development

This outline is designed to train students to do exactly the same job as the previous example, but it has a number of important differences.

· The whole course is designed to give the students the necessary skills to do the job.

· The underlying theory is learned at the same time as the practical applications. This is likely to lead to faster and more thorough learning because the students can understand exactly why the theory is needed.

· The timetable can be much more flexible. This makes it easier to arrange longer periods of work such as project work or supervised practical work in the community. It gets away from the rigid pattern of one-hour lectures.

Base the curriculum on the tasks that the students need to learn.

5.5 What kinds of teaching methods will be used?

Many courses for health workers include too much classroom teaching and concentrate too much on teaching facts.

If you prepare a list of tasks for any category of health worker you will find that most of the tasks involve:

· using the hands (e.g. giving an injection)
· making decisions (e.g. deciding whether a cough is a symptom of pneumonia)
· communication (e.g. explaining to a mother the need for protein in the diet).

You must give students opportunities to practice these skills during the course. Unfortunately this practice often takes a lot of time and effort to organize. It may be quicker and easier to give a lot of lectures, but the students will not learn the necessary skills.

The curriculum should include enough time for students to practice the tasks they need to learn. Sometimes this will involve them in working in the community, for example, in a hospital or nearby health centre. Sometimes they can practice on each other in the classroom. Specific suggestions for teaching methods are given in Part 2. In planning the curriculum, teachers must allow enough time for this practice.

It is impossible to specify how much time is required for every course. However, most courses should allow much more time for practicing skills than for theoretical teaching.

More time for practice Less time for theory

5.6 What kind of assessment methods should be used?

It is important that the course should be based on the job that the students are learning to do. Therefore the assessment must test whether they can do the job. This approach is called performance testing. It means that assessment methods such as those based on multiple-choice questionnaires and essays are used less often. Such methods usually only test the students' knowledge. Other assessment methods such as those based on case-studies and casebooks are used more frequently. These methods test the important skills and attitudes.

More details on methods of assessment are given in Part 3.

5.7 Evaluating the curriculum

The students should be assessed to see whether they have learned the necessary skills and facts. In the same way, the curriculum should also be examined to find out whether any changes are needed. This process is called curriculum evaluation.

The aim of curriculum evaluation is to find out how successful the curriculum is and to find out ways in which it can be made better. The basis for the evaluation is to see whether the students learn how to do their job satisfactorily.

The curriculum can be evaluated by testing the students at the end of the course. If they complete their examinations satisfactorily, this suggests that the course has been good enough. However, the examinations must be relevant and based on the job that the students are being trained to do. Also, the course may help the students to reach a satisfactory standard, but it may take much more time than necessary.

The curriculum can also be evaluated by finding out how well the students are doing after they have left the school or college and started work.

Example - On-the-job evaluation

In one district a group of health workers were trained to do a number of tasks. One of the tasks was to conduct an immunization programme. After a few months it was found that a lot of the mothers brought their children for the first vaccination. Only a few came back for the necessary second injection

Comments

Clearly this part of the training programme had not been successful.

There are many reasons why the programme may not have succeeded, for example:

· the health workers may have had too many other responsibilities and so did not have enough time to talk to the mothers about the need for the second injection.

· the programme may not have trained the workers how to communicate.

· the programme may have failed to teach them suitable attitudes.

5.8 Methods of evaluating the curriculum

Analysis of health needs

In the example above, the weakness of the training programme - or the curriculum - was shown by an analysis of the health statistics for the district. This is the best way to evaluate a curriculum, although it may not always be possible. It is the best way because the purpose of the curriculum is to train people to solve health problems. If the health workers can solve the problems, the curriculum is probably satisfactory. If not, it may need to be improved.

Health statistics are usually available for details such as:

- the number of children immunized,
- the number of live births,
- the number of infant deaths, and
- the number of cases of disease.

If the statistics are available, they can help the teacher to decide which parts of the curriculum need improvement.

But remember that some of the things health workers are trained to do cannot be easily shown in statistics. Also, in many areas the information collected may not be very reliable or complete. For example, the number of reported cases of diphtheria may go up because the system of reporting the disease has improved - not because more people are suffering from diphtheria.

Critical incident studies

Critical incident studies are a fairly simple method of finding out from the health workers themselves how successful a curriculum is. The teacher asks an experienced health worker to describe five or six recent events that he or she has not felt able to handle. These situations are the critical incidents. This kind of questioning is then repeated among a sample of recently trained health workers. Using this approach, the teacher can build up a picture of the situations that have caused problems for health workers.

Some of the critical incidents may be very unusual or rare. In some cases it may not be necessary to change the curriculum. Again, if only one worker finds that a particular situation causes problems, while all the others report that they can deal with it, then probably no action needs to be taken. However, if several workers report difficulty with similar situations, then clearly the curriculum should be looked at.

Supervisors' reports

In many countries the work done by the health workers is supervised. In some cases this supervision is carried out almost continuously - as in hospital wards. In other cases the supervision is very restricted - for example when health workers work alone in remote villages. Therefore the value of supervisors' reports will vary from one situation to another.

However, all of these reports can be more useful if the supervisors are asked to comment on specific points. For example, you may have tried teaching part of the curriculum differently, so ask the supervisors whether they notice any differences in the way the new health workers do that particular job. Supervisors can also help if they identify the tasks that the students do well or badly at the end of the course.

They may also be able to point out the tasks that are taught wrongly. For example, students may not have been taught about local traditions or how to cooperate with village councils.

If the teacher asks for advice from supervisors and acts on that advice, the curriculum will be made more effective.

5 9 Evaluating lessons

Lessons can and should be evaluated. This is just as important as evaluating the curriculum.

Broadly the same methods should be used. After a lesson (or possibly a group of lessons), the teacher should find out how much the students have learned. This evaluation should be based on performance testing. The teacher should find out whether the students can do the tasks that they have been taught to do.

If the students cannot do the tasks, then the teacher must change the content of the lessons or the teaching methods.

5.10 Summary

1. The aim of a curriculum or a lesson should be to give the students the skills and the knowledge needed to do the job.

2. The content should be organized on a "task" basis.

3. The curriculum must include a high proportion of time for practicing the skills of communication, thinking, and using equipment.

4. Evaluation may lead to changes in the content or the teaching methods.