Trainer Manual

Course purpose
The purpose of this course is to improve the safety and effectiveness of post operative nursing care for
children following cleft surgery. The course forms part of Smiletrains strategy to reduce sentinel events.
There is a strong emphasis on respiratory monitoring and nursing interventions which reflects the high
proportion of sentinel events which are related to aspiration and respiratory problems.

The course is delivered over 3 days to 1 or 2 nurse representatives from active partner hospitals in each
country. The course material is designed around specific learning outcomes and is presented in a variety of
ways; PowerPoint presentations, practical demonstrations, group discussions, and scenario based activities.

Goal
The goal of the training is that upon completion nurses will be confident, competent practitioners who are
able to apply their knowledge and experience to deliver safe and effective nursing care to children undergoing
cleft surgery.

Approach to learning
An important principal underpinning the training is recognition of the need to empower nurses and raise belief
in their capacity to improve nursing care. Poor standards of training, low professional status and poor working
conditions in the countries where Smiletrain works mean that nurses often lack essential nursing skills and
have a poor assessment of their contribution in improving outcomes. This course seeks to improve skills and
understanding and through practical application of learning in the classroom raise confidence to deliver care in
partner hospitals. There is a strong focus on practical participative learning.

Another key element of the training is to equip participants to teach and disseminate their learning on return
to their hospitals. The principles of effective teaching are explored, there is opportunity to practice teaching
others and course trainers are expected to role model good teaching practices.

At the start of the course the emphasis of passing on newly acquired learning and skills is stressed. On the final
day of training each participant is expected to develop an individual action plan for a specific aspect of cleft
nursing care they intend to implement in their hospital.

During the training it is important to review learning to enable participants to recognise and retain new
information. This can be done in several ways:- asking participants to state something new which they have
just learnt for the first time at the end of a session, quick oral quizzes and providing opportunities to use new
learning in practical scenario sessions.

Learning during the training will vary depending on prior knowledge but it is intended that upon completion all
participants will have grasped the Golden Nuggets. These Golden Nuggets are the essential condensed
information which it is hoped as a minimum participants will remember and understand.

Learning outcomes
Following training nurses will be able to:

1. Briefly outline the surgical management of cleft lip palate

2. Outline the nurses role in safe preoperative preparation for cleft surgery
3. Outline the nurses role in safe post operative care following cleft lip palate surgery
4. Describe in detail post operative nursing interventions following cleft surgery
5. Demonstrate understanding of potential complications and nursing interventions
6. Demonstrate competence in BLS
7. Demonstrate understanding of the importance of monitoring vital signs and nursing assessment
8. Demonstrate understanding of the possible causes of changes in vital signs appropriate nursing
interventions
9. Outline the psychological care of the patient and their family
10. Describe appropriate pain assessment and management in children
 11. Explain how nurses can support pre and post operative feeding
12. Outline how a child and their carers can be safely prepared for discharge
13. Outline the importance of and demonstrate appropriate use of nursing documentation
14. Disseminate information amongst colleagues and implement changes in nursing practices to improve
care

Preparation for facilitation

Selection of trainers
Two trainers are required for this course, both should have direct experience of cleft care. Ideally one should
have nursing and one surgical or anaesthesiology expertise. Trainers should be proficient teachers with
experience of participative training. This course has been successfully delivered with translators supporting the
training, however ideally trainers should be able to teach participants directly in their first language.

Selection of participants
A maximum of 25 participants per training is recommended. This number allows for hands-on practical
experience and supervision of basic life support teaching and ensures the involvement of all participants in
other practical activities.

Each partner hospital should send one or two participants. Due to the nature of the course it is most beneficial
for nurses who are directly caring for or responsible for the care of post operative cleft children. This will
include both ward and recovery nurses. This information needs to be emphasised to partner hospitals before
selection of participants, as although the course would be of interest to theatre nurses application of learning
will be limited.

Participants should be asked to bring receipts to cover costs of travel to the training

Selection of a training venue

The venue needs to have a conference facility for 25 participants. Consistent power or efficient generator
back-up is essential. A projector is required. The venue should allow for formal classroom teaching i.e. desks
and chairs and flexibility to rearrange the room for participative training activities. Ideally the training venue
should include accommodation and dining facilities to ensure maximum attendance and prompt start times. A
Smile Train Partner Hospital with training facilities is preferred if available. Otherwise chose a venue close to a
partner hospital in case a theatre visit (recommended) is in plan.

Budget considerations
A budget for the training must be prepared in advance and should include the following:-

Venue hire, accommodation for participants and trainers, meals and tea breaks
Transport for participants and trainers
Training resources
Training resources required

Item Quantity Required Cost

A4 Training Flipcharts 1 per participant
A3 Posters 5 per participant
Nurse Intervention Plan 1 per participant
Spiral bound handouts 1 per participant
Spiral bound handouts for wards 1 per participant
Paper stickers 1 per participant
Pre and post course test 1 each per participant
Audit of partner hospitals 1 per participant
Course timetable 1 per participant
Coloured/ white paper 1 sheet per participant
Course evaluation 1 per participant
Course certificate 1 per participant
Laminated copies of scenarios 5
Flip chart paper 1
Flip chart pens 10
Pens 1 per participant
Name labels/stickers 1 per participant
Infant resuscitation models 4
Junior resuscitation model 1
Paediatric Ambu bags 5
Oxygen saturation monitor 1
Short pieces plastic hose 1 per participant
Plastic straws 1 per participant
Miscellaneous photocopying
Total

Training timetable
The training is designed to be delivered over 3 full days with participants arriving the evening before the
training begins. Local participants can leave at the close on day three, others with longer journeys will require
4 nights of accommodation.

Timekeeping is essential to enable the training to be completed within the allocated 3 days but it is also
important to be available for questions and discussions and this can give the nurses the opportunity to discuss
a possible sentinel event at their hospital how to prevent such an event again.
Preparation for sessions

Day 1

Training Timetable Day 1

Time Resources required Learner activities

8.15 Registration
8.30-9.00 Welcome, introductions & 1 evaluation per participant Identify an expected
expectations, Ice breaker learning outcome
9.00-9.30 Pre-course test 1 pre course test each Test completion
9.30-10.00 Course outline and purpose 1 set course handouts each
Ppt Why the course
10.00-10.15 Role of the nurse in cleft Ppt Role of the nurse
care
10.15-10.45 BREAK
10.45-11.30 Training your team (1) Training your team (1) Ppt Teaching activity
Paper aeroplane materials
11.30-12.15 Overview of clefts and their Ppt Overview of clefts
management
12.15-12.45 Psychological care Ppt Psychological care
12.45-13.00 Audit partner hospitals 1 audit form per partner Complete audit
hospital
13.00-14.00 LUNCH
14.00-14.30 Pre-operative Nursing care Ppt pre-operative nursing care

14.30-15.30 Post-operative Nursing care Ppt Post-operative nursing Group work-problem

care based post-operative
nursing care plan
15.30-16.30 Journey of a child under Journey of a cleft child video
going cleft surgery
16.30-17.00 Pain assessment and Ppt pain assessment and
management management
!7.00-17.15 Preparation for day 2

Welcome, introductions & expectations, Ice breaker (30 minutes)

Resources: Post- it notes, name labels, evaluation forms

Welcome participants and introduce trainers. Explain trainers expectations of participants:- timekeeping,
mobile phones off, participation, learning by doing, freedom to ask questions, supporting on another, listening
to others, sharing learning with nurses on return to partner hospitals. Explain that all participants will be asked
to be perform practical activities in front of the group, emphasise that this is a safe environment to practice
and learn from mistakes. Explain that nurses are life- long learners and that the training is an opportunity to
learn from one another.

Participants are asked to write one personal learning objective they have which they expect to be met during
the training, these are written on post it notes and displayed.

Give each participant an evaluation form and ask that it is completed after each session, forms will be
collected on day 3.

Pre-course test (30 minutes)

Resources: 1 pre course test per participant

Pre and post course multiple choice tests are included in the resource pack. Trainers must emphasise that the
purpose of the test is not to highlight areas of weakness but to enable participants to see their progress during
the training. The tests are completed under test conditions. The pre course test is marked by trainers and
returned by lunchtime on day 1.

After completion of the pre course test give each participant a spiral bound set of hand outs.

Course outline and purpose (30 minutes)

Resources: Why the course power-point presentation

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain the meaning of the term sentinel event

List the most common sentinel events

Explain the intended purpose of this training

Emphasize:

Nature and timing of common sentinel events

Role of the nurse in cleft care (15 minutes)

Resources: Role of the nurse PowerPoint presentation

Intended learning outcomes:-

By the end of the session participants will be able to:

Understand the role nurses play in the care of a child undergoing surgery for cleft lip/palate surgery

Be able to explain why nurses are best placed to save lives

Emphasize:

Expect the unexpected- always be ready to act.

Assessing, Deciding, Reacting are 3 vital nursing skills that save lives

Training your team (1) (45 minutes)

Resources: Training Trainers (1) PowerPoint presentation, printed Instruction for paper aeroplane folding
activity, paper for folding, 1 per participant, 1 sheet flip chart paper.

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain the purpose of training

Explain problems faced when training adults

Describe how adults learn best

 Describe traits of an effective trainer

Describe how we learn

Identify learner styles

This is the first of 3 sessions that are intertwined in the training. This first session introduces teaching concepts
and includes an activity making paper aeroplanes (this can be substituted by any simple paper folding exercise)
(slide 7).

The purpose of the activity is to enable participants experience the difficulties of trying to learn a new skill
using only verbal instructions and the advantages of using a combination of verbal, written, demonstration and
practical approaches.

Participants are divided into 3 groups. Group 1 is given verbal instructions (lecture style) of how to make a
paper aeroplane. No repetition is allowed, when instructions have finished participants are told to follow
them, they are not told what they are making. Next group 2 is given the same instruction repetition is allowed
but not clarification. Finally group three is taught to make the same aeroplane using demonstration, verbal
instruction clarification and coaching. The results of each group are shared and the experiences of the learners
in each group.

At Slide 11 divide participants into 2 groups. One group is to the identify from their experience the
traits/characteristics of a poor teacher, the second to identify the traits/characteristics of an effective teacher
(3 minutes). Both groups feed back to the whole group and findings are recorded on a flip chart.

Emphasize:

The purpose of the course is to pass on learning.

Teaching using multiple styles and learning by doing increase the success of training

Overview of clefts and their management (45 minutes)

Resources: Overview of clefts PowerPoint presentation

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain what a cleft is

Explain how clefts occur

Give examples of different clefts and syndromes

Explain what problems are associated with clefts

This session has often been helpful to answer a variety of general questions about feeding, hearing, timing of
surgery, genetics etc.. and remove some of the myths that still linger around clefts even within the nursing
profession. It is helpful to introduce the idea that some hospitals may have different protocols and that we can
learn from each others experience.

Psychological care (30 minutes)

Resources: Psychological care PowerPoint presentation

Intended learning outcomes:-

By the end of the session participants will be able to:

 Discuss commonly held beliefs related to the causes of cleft lip/palate

Discuss possible ways a family may react to the birth of a child with cleft lip/palate

Discuss how these reactions may affect the care of a child with cleft lip/palate

Audit of partner hospitals (15 minutes)

Resources: 1 audit sheet per participant

The purpose of the audit is to identify what basic equipment is available at SmileTrain partner hospitals. This
includes the availability of oxygen saturation monitoring, oxygen and paediatric Ambu bag in theatre, recovery
and the post-operative ward. Participants are also asked to state any particular challenges they face when
caring for children following cleft surgery. It is important to stress to participants that this information is useful
for Smiletrain in their aim to improve the quality of care it will not be used in any way to judge an
establishment.

Preoperative nursing care (30 minutes)

Resources: Preoperative nursing care PowerPoint

Intended learning outcomes:-

By the end of the session participants will be able to:

Discuss the importance of physical and psychological preparation of a child and their carer for cleft
lip/palate surgery

Describe in detail pre operative nursing interventions and rationale

Emphasize:

Safe preoperative care is an important element of surgical care.

Introduce the nursing process as one way to organise and deliver nursing care.

Post-operative care (1 hour)

Resources: Post operative nursing care Powerpoint, 8 flip chart pages and pens

Intended learning outcomes:-

By the end of the session participants will be able to:

Discuss the importance of safely retrieving a patient from recovery

Describe the initial nursing priorities when a child returns to the ward

Describe in detail post operative nursing interventions and rationale following cleft surgery

Emphasize:

The essential equipment which should be available on the ward before a child return following cleft surgery.

The 7 criteria which must be checked before it is safe to take a child from recovery to the ward.

After presenting the PowerPoint presentation divide participants in 8 groups. Give each group one potential
problem/need which a child following cleft surgery may experience. Each group is to use a piece of flip chart
paper and write the goal of care and nursing interventions which are specific to the problem/need. It may be
helpful to draw the format on the flip chart paper as shown on slide 14 before giving to each group. After 15
minutes to complete the task each group feeds their findings back to the main group for discussion. This is an
opportunity to sensitively correct misconceptions and inappropriate care suggestions.

Journey of a child undergoing cleft surgery (1 hour)

Resources: SmileTrain Video A childs journey through cleft surgery

Show the 23 minute video. Pause if necessary to explain aspects of the care and summary stills. After showing
the video ask for questions/comments raised by the video. Ask participants to mention if any care on the video
is different to what they have seen in their hospital.

Pain assessment and management (30 minutes)

Resources: Pain assessment and management PowerPoint (30 minutes)

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain how infants respond to pain

Describe how to assess pain in children

Discuss non-pharmacological pain management

Discuss pharmacological pain management

Day 2
Preparation for day 2 (15 minutes)

Any housekeeping information and reminder to review sessions from day 1 in the hand-outs.

Training Timetable Day 2

Time Resources required Learner activities

8.30-8.40 Quick quiz (1) 10 quiz questions based on day Quick Individual verbal
1 quiz
8.40-9.30 Nursing Assessment (1) Ppt Nursing assessment and
observations

9.30-10.30 Nursing assessment (2) Drinking straws/tube pieces Straw/tube game

Ppt Nursing assessment and
observations

10.30-11.00 BREAK
11.00-11.45 Post-operative Ppt Post-operative
complications (1) complications

11.45-13.00 Post-operative Complication scenarios Group work scenario

complications (2) laminated activities
13.00-14.00 LUNCH Resources required Learner activities
14.00-14.45 Paediatric Basic Life Ppt Paediatric basic life support Experience using
Practical Resuscitation models, Ambu resuscitation models
bags
14.45-15.45 Paediatric Basic Life Support Resuscitation models Ambu Resuscitation role play
scenarios bags
15.45-16.00 BREAK
16.00-16.45 Feeding children with clefts Feeding cleft children Ppt
16.45-17.00 Preparation for discharge Discharge Ppt
17.00-17.15 Preparation for day 3

Quick quiz (10 minutes)

Ask 10 quick verbal questions based on any topics which were covered in day 1. Anyone can answer give small
prizes if possible for correct answers.

Nursing Assessment (1) (50 minutes) & (2) (1hour)

Resources: Monitoring vital signs and nursing assessment in children PowerPoint. 1 short piece of plastic hose
and one plastic straw per participant, bin or receptacle, oxygen saturation monitor.

Intended learning outcomes:-

By the end of the session participants will be able to:

Understand the importance of patient assessment

State normal ranges of vital signs for different ages

Describe changes which may be observed in vital signs following surgery

 Describe essentials of respiratory assessment

Understand concepts of oxygen saturation monitoring

Briefly explain the importance of AVPU assessment of responsiveness

This is a key session within the training. The presentation contains a lot of information and is divided into 2
parts with an activity in the middle. The activity can be at any point during or after the respiratory assessment
section of the presentation when trainers feel that participants need an energiser. For the activity ask the
group to stand in a circle, give each participant a straw and ask them make a small paper bullet to blow
through the straw attempting to get their bullet in a central waste paper basket. Next give everyone the tubing
and again make a bullet with the same aim. This activity can be performed as a team activity if preferred.

The purpose of the activity is to give participants insight into the diameter of an infant and an adult airway and
to consider how easily an infants airway can be obstructed.

Emphasize:

The difference between simply recording vital signs and thorough nursing assessment.

The need to ask questions when performing nursing assessment to try to identify a cause for changes.

Key slide:31 differentiate between signs of a child in respiratory distress and respiratory failure.

Oxygen saturation should be 94% or above. The monitor is a lag monitor and does measure respiratory
efficiency (demonstrate with breath holding etc..)

Post-operative complications (1) (45minutes) and 2 Post operative scenarios (1hour 15 minutes)

Resources: Post operative complications and post operative complication scenarios, laminated scenarios.

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain the purpose of the recovery ward

Describe the common respiratory postoperative complications and their management

Demonstrate appropriate decision making in response to changes in a childs condition

This session has two parts, firstly a PowerPoint presentation followed by scenarios to enable participants to
apply learning from this and earlier sessions to practical situations. For the scenarios divide participants into 5
groups. Give each group a copy of a scenario slide (laminated if possible) and ask them to consider the
information provided (10 minutes). After consideration and discussion the group should decide:-

1. What has happened to the vital signs?

2. What other information would you like?

3. What is the problem?

4. What will you do?

Each group should present to remaining groups.

Emphasize:

The management of airway obstruction and the ability to act to save a life even if you are not entirely sure of
the diagnosis.
Paediatric Basic Life Support (45 minutes) & Paediatric Basic life Support Scenarios (1 Hour)

Resources:

Paediatric Basic Life Support and BLS scenario PowerPoint presentations, Infant and junior resuscitation
models, Ambu bags

Intended learning outcomes:-

By the end of the session participants will be able to:

Define the term 'Basic Life Support BLS

Identify signs of impending cardiorespiratory arrest in a child

Understand the nurses role in BLS

Describe how to assess and recognise an infant or child who requires BLS

Demonstrate how to perform BLS on an infant and a child

Demonstrate appropriate decision making and action in response to changes in a childs condition

After the BLS presentation all participants are to practice the BLS sequence using resuscitation models and
Ambu bags ( 4 groups) working at the same time. For the remainder of the session use the BLS scenario slides.
Ask for 3 participants to demonstrate their responses to the information given in each slide by using the
resuscitation models in front of the rest of the group. Do not show the diagnosis until the group has
responded. Repeat with 3 more groups of 3 participants. The purpose of the activity is to apply newly learnt
skills into real life situations.

Emphasize: Seconds count and the need to always be prepared for and expect the unexpected.

Feeding children with clefts (45 minutes)

Resources: Feeding cleft lip and palate Powerpoint presentation, 1 infant resuscitation model

Intended learning outcomes:-

By the end of the session participants will be able to:

Describe feeding difficulties which cleft children may encounter

Describe pre-operative nursing goals and specific interventions related to feeding

Describe post-operative feeding care and advice for carers

While one trainer presents the other trainer can use the resuscitation infant to demonstrate possible feeding
positions.

Emphasize:

Post operative feeding must not commence until the child is awake, responsive and protecting their airway
and that should be nurse supervised.
Preparation for discharge (15 minutes)

Resources: Discharge preparation PowerPoint Presentation

Intended learning outcomes:-

By the end of the session participants will be able to:

Describe the importance of preparing carers for discharge

Describe the important elements of discharge preparation

Day 3
Preparation for Day 3

Remind participants to revise all sessions to date using the hand outs and group discussions in the evening etc
in preparation for the post test on day 3

Training Timetable Day 3

Time Teaching resources Learner activities

8.00-8.30 Quick quiz Ten quick questions from day 1 Group quiz
&2
08.30-9.00 Documentation and nursing Ppt Documentation
care pathway Nursing care pathway 1 per
participant
09.00-9.45 Nurse Intervention Plan Ppt Scenarios Practical experience
scenarios using nurse intervention
plan
9.45-10.15 Post course test and 1 Post course test per
marking participant
10.15-10.45 Training your team (2) Ppt Training your team (2)
10.45-11.15 BREAK
11.15-12.15 Training your team (3) 4 A4 Flip charts Practical experience
training using the A4 flip
charts
12.15-13.00 What next? Ppt What next
13.00-14.00 LUNCH (collect evaluations)
14.00-14.30 What next? (cont) Flip chart Developing nursing
action plans
14.30-15.00 Summing up, questions,
feedback, certificates
15.00 Close

Quick quiz

Divide participants into 2 teams. Ask each team 5 quick response questions based on day 1& 2. Each
participant can answer once only, if possible give a group prize to the wining team

Nursing documentation (30 minutes) Nurse Intervention plan scenarios (45 minutes)

Resources: Nursing documentation and Nurse Intervention Plan scenario PowerPoints, 1 Nurse Intervention
Plan per participant.

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain the importance of nursing documentation

Describe what a Nursing Care pathway is

Explain the benefits of using a Nursing Care Pathway to guide nursing care

Demonstrate appropriate use of the Nurse Intervention Plan

Following the nursing documentation presentation ask for 5 volunteers to come forward individually and
demonstrate utilising the Nurse Intervention Plan in response to scenario questions. This provides a final
opportunity to link theory and practice.

Emphasize: Timely, appropriate nursing interventions saves lives

Post course test and marking (45 minutes)

Resources: 1 post course test per participant

All participants complete a post course multiple choice test. 2 post course tests are available. Participants can
be given a repeat of the pre course test or preferably the alternative post course test. The alternative test,
tests the participants ability to apply new learning rather than just repeat learnt facts. After completion of the
30 minute test, papers are swapped and the test is marked as a group. Marks are recorded before returning
papers.

Training your team 2 (30 minutes) & 3 (1 hour minutes)

Resources: Training your team 2 PowerPoint presentation, 4 flip charts.

Intended learning outcomes:-

By the end of the session participants will be able to:

Explain how to plan a training session

Demonstrate leading a training session using the SmileTrain presentation flip chart

Following the presentation divide participants into 4 groups. One group is to use each of the 4 presentations in
the flip chart as a resource to plan and present a 10 minute training session. 1 person from each group is
chosen to be the trainer and the remainder are the trainees, other participants will observe the teaching.
Encourage groups to consider the attributes of an effective trainer, different ways to present information and
test understanding. Remind groups to plan how they will use a portion of the presentation for their session (15
minutes planning). After the break each group presents to the other participants (10 minutes), followed by an
evaluation and feedback to the trainer.

What next (1 hour 15 minutes)

Resources: 'What next? 1 and 2 PowerPoint presentations, flip chart and pens

Intended learning outcomes:-

By the end of the session participants will be able to:

Identify aspects of cleft nursing care that could improve in their hospital

Understand the principles of managing change

Explain how they could initiate a change in nursing practice in their workplace

What next ?1 presentation includes steps to assist participants as they consider and plan to implement one
aspect from this training in their workplace. Ask participants to turn to the action plan template in their
handouts and think through a change they wish to introduce. For example a participant may choose to teach
BLS to their colleagues or how to use the Nurse Intervention Plan or the importance of vital sign monitoring.

Emphasise that they must choose an intervention which is achievable by nurses (i.e. not recruiting more staff
or building a recovery department). Ask each participant to state the what, why, how and when of the change
which is recorded by a trainer on the flip chart. The other trainer needs to record the participants proposal on
the bottom of the audit form from day 1. Explain to participant that they are committing to undertake this
implementation on return to their hospital and SmileTrain is taking note of their intentions.

Present What next? 2

Collect evaluation forms

Summing up, questions, feedback, certificates

Remind participants of the vital role nurses play in caring for cleft children and the fact that good nursing care
saves lives. Recognise that nurses do and will face challenges in their work place but encourage them to strive
to provide safe, quality care and to be a drop that creates a ripple of change. Reiterate SmileTrains
expectation that all participants will share their learning with others, use the training resources they have been
given and implement a change in their work place.

Present each participant with an attendance certificate, flip chart, sticker, ward copy of handouts and set of
A3 posters.

Evaluating the training

Trainers can use different methods to evaluate the training. Completion of the evaluation form will provide a
gauge of satisfaction and how useful participants have found elements of the training. The pre and post course
test will provide insight into prior and acquired levels of understanding. The practical scenario based sessions
provide the opportunity for trainers to observe participants demonstrating their leaning. Subjectively trainers
can assess the engagement, interest, and responsiveness of participants during the training.

It is important to follow up with partner hospitals to ensure that participants implement their action plans and
this can be used as another evaluation tool to assess the lasting impact of the training.