Transfer of

A Guide for Strengtheningthe Performance of Health Care Workers

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Project Coordinators:Lucy Harber, Instructional Design Specialist,Intrah/PRIME II

Rick Sullivan, Director of Learning andPerformance Support, JHPIEGO

Core Development Team:Ann Blouse, Director of Information ResourcesOffice, JHPIEGO

Débora Bossemeyer, Clinical Training Advisor,JHPIEGO

Julia Brothers, Clinical Training Advisor,JHPIEGO

Lucy Harber, Instructional Design Specialist,Intrah/PRIME II

Nancy Kiplinger, Instructional DesignSpecialist, Intrah/PRIME II

Cathy Murphy, Acting Director, Training andLearning Unit, Intrah/PRIME II

Swaraj Rajbhandari, Clinical Training Advisor,JHPIEGO

Sharon Rudy, former Associate Project Directorfor Performance Systems, Intrah/PRIME II;currently Director, Population LeadershipProgram

Rick Sullivan, Director of Learning andPerformance Support, JHPIEGO

Reviewers:Mary L. Broad, Distinguished Author andTraining Consultant—a special thanks for yoursupport of this effort

Avinash Ansingkar, Regional Training Manager,Asia/Near East, Intrah/PRIME II

Maj-Britt Dohlie, Supervision Specialist,EngenderHealth/PRIME II

Susheela Engelbrecht, Midwifery Advisor,ACNM/PRIME II

Barbara Felling, Coordinator for TechnicalInitiatives, DELIVER/John Snow Inc.

����������� �Wallace Hannum, Associate Project Director,Performance Systems, Intrah/PRIME II;Associate Professor, School of Education,University of North Carolina at Chapel Hill

Wanda Jaskiewicz, Regional Program Officer,Latin America/Caribbean, Intrah/PRIME II

Marc Luoma, Director of PerformanceImprovement, TRG/PRIME II

Enriquito Lu, Reproductive Health Trainingand Medical Advisor, JHPIEGO/Indonesia

Jim McCaffery, Training Consultant,TRG/PRIME II

Constance Newman, Senior EvaluationManager, Intrah/PRIME II

Robert Rice, Associate Director, Policy andResearch Utilization, Family HealthInternational

Gregory Roche, Performance ImprovementAdvisor, DELIVER/John Snow Inc.

Sylvia Vriesendorp, Organization DevelopmentSpecialist, Management & Leadership Program,Management Sciences for Health

Special thanks to James Griffin, Senior TechnicalAdvisor, Performance Improvement & Training,USAID, for his support of this joint Intrah/PRIME II and JHPIEGO publication.

Editors:David Nelson, Senior Writer/Editor,Intrah/PRIME II

Wendy Dufour, Instructional DesignConsultant, Intrah/PRIME II

Graphic Designer:Molly Windsor, Graphic Designer,Intrah/PRIME II

Introduction 4The Transfer of Learning Matrix 9Action Plan (completed example) 11

SupervisorsBefore Learning 12During Learning 14After Learning 16

TrainersBefore Learning 18During Learning 20After Learning 22

LearnersBefore Learning 24During Learning 26After Learning 28

Co-Workers and OthersBefore Learning 30During Learning 31 After Learning 31

References and Resources 32 Action Plan (blank) 33

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Financial support was provided by the Office of Population, Center for Population, Healthand Nutrition/Global Programs, Field Support and Research Bureau/CMT Division,U.S. Agency for International Development, under the terms of Intrah/PRIME II’s Grant No.HRN-A-00-99-00022-00 and JHPIEGO’s Award No. HRN-A-00-98-00041-00. The opinionsexpressed herein are those of the authors and do not necessarily reflect the views of theU.S. Agency for International Development.

Date of Publication: March 2002

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��� ���� ���actions for supervisors, trainers, learners andtheir co-workers, other stakeholders can also usethis information to gain an appreciation of theprocess and an understanding of the support andresources needed to ensure transfer of learning.

Why does “good training” fail?Many trainers and instructional designers haveexperienced the frustration of designing anddelivering a stellar training intervention only tofind out after training that the learners are notperforming on the job as expected. Supervisorsalso experience frustration when staff membersparticipate in training interventions but then donot use their new knowledge and skills toimprove their work. Upon completion of thetraining intervention, the learners haddemonstrated the skills competently and passedthe knowledge test—so why are they now unableto perform those same skills at their work place?There are many possible reasons.

Historically, training interventions have rarelybeen successful in resolving job performanceproblems caused by factors other than lack ofknowledge and skills. In some situations,learners acquire knowledge and skills duringtraining only to find that they are not supportedin using this new information in their workenvironment.

Before embarking on the design of a learningintervention and making an investment ofresources in training, it’s imperative to makecertain that you are dealing with a performanceissue that can be “fixed” by training. Onceyou’ve invested in training, you must thenensure that your learners are supported onthe job by their organizations, their workenvironment, their supervisors andtheir co-workers.

Performance Improvement (PI) is a systematic approach to solving performanceproblems or creating effective new performance. PI offers a set of easy-to-use toolsdesigned to achieve organizational goals. The PI approach identifies the root causesof performance problems and the interventions needed to close the gaps betweenactual and desired performance.

For information about Performance Improvement and the performance factors,consult www.pihealthcare.org, the website of the USAID Performance ImprovementConsultative Group.

The goal of a health care delivery site is toprovide quality services to a community. Theclinical knowledge and skills of a site’s staff area critical factor in establishing and sustainingquality services. However, there are many otherfactors in the work environment that candirectly or indirectly affect the quality of servicesand influence the ability of providers to applytheir knowledge and skills in the servicesthey offer.

The primary purpose of this guide is to sharestrategies and techniques that can be usedbefore, during, and after training interventionsto ensure support for the transfer of knowledgeand skills to improved performance on the job.The strategies and techniques for transferringlearning are presented in an easy-to-use matrixthat serves as a table of contents for the rest ofthe document. We have also included a briefintroduction to the many performance factorsthat can play important roles in the transfer oflearning. Users of this guide are encouraged toexamine their work environments carefully inorder to fully understand all the factors that maybe affecting worker performance. A case story onpage 7 illustrates several of the performancefactors and demonstrates how to implementsome of the ideas shared in the matrix.

The information in this guide enables all of thestakeholders involved in a training interventionto play their respective roles in ensuring thattransfer of learning occurs. Stakeholders in thetraining and learning process may include policymakers and officials at national, regional andlocal levels, program planners, supervisors,trainers, learners and their co-workers. Forlearning interventions to be successful, stake-holders must work together as partners with acommon goal. While this guide outlines specific

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Possible Interventions

Provide adequate performance standards anddetailed job descriptionsCreate the necessary channels to communicatejob roles and responsibilities effectively

Offer timely, constructive, and comprehensiveinformation about how well performance ismeeting expectations

Develop logistical and maintenance systems toprovide a satisfactory physical environment andmaintain adequate supplies and equipment

Design work space to suit activities

Seek provider input to identify incentives forgood performance

Provide positive consequences for goodperformance and neutral or negativeconsequences for below standard performance

Encourage co-workers to support new skills

Ensure job candidates have prerequisite skills

Provide access to trainers and informationresources

Offer appropriate learning opportunities

The Performance Factors

5. Skills and knowledge required to do the jobDo providers know how to do the job?

4. MotivationDo people have a reason to perform as they areasked to perform? Does anyone notice?

3. Physical environment and toolsWhat is the work environment like, and whatsystems are in place to support it?

2. Performance feedbackDo providers know how well they are doing?

1. Job expectationsDo providers know what they are supposed to do?

The final factor on the list, required knowledgeand skills, is addressed primarily throughtraining and learning interventions.Interventions directly targeting the other fourfactors are not described in detail in this guide.However, supervisors and other stakeholdersoften need to address these factors to help ensurethat the knowledge and skills acquired bylearners result in improved performance onthe job. As you read the strategies proposed inthe matrix for transferring learning, you’llsee many references to these performancefactors and the organizational structures thatsupport performance.

The literature on performance improvementdescribes several primary factors, often inter-related or complementary in their impact, thatsupport good performance in the work place(see table above). When a performance problemis identified in terms of these factors, a solutionor intervention usually becomes clear.

Health care providers can only perform as wellas the systems that support them. Leaders andsupervisors are responsible for building andsustaining organizational structures that enableproviders to work at expected performancelevels. The five performance factors are tools thatcan be used to analyze performance and provideexemplary support.

Transfer of Learning���A Guide for Strengthening the Performance of Health Care Workers

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Transfer of LearningWhen the acquisition of knowledge and skills isidentified as the solution to a performanceproblem or gap at a work site, training or otherlearning interventions will be used to improvethe performance of health care workers. The keyindividuals involved in this process include:

Supervisors: responsible for monitoring andmaintaining the quality of services and ensuringhealth care workers are properly supported inthe work place. In this guide, “supervisor” refersto a learner’s “in-charge” at the healthcare facility.

Trainers: responsible for helping health careworkers acquire the necessary knowledge andskills to perform well on the job.

Health care workers: responsible for the deliveryof quality services (e.g., clinicians, counselors,administrators, cleaners). In this guide,“learners” is used throughout to refer to healthcare workers participating in learninginterventions.

Co-workers: responsible for supporting learnerswhile they are engaged in training and as theyapply new knowledge and skills at the work site.

As the case story on page 7 shows, supervisors,trainers, learners and co-workers all haveresponsibilities before, during and after atraining intervention if practices at a facility areto improve. By working as partners, theseindividuals can help sustain the knowledge andskills gained during training. Many interventionscan be used to enhance the performance ofhealth care workers and the quality of clinicalservices (e.g., focusing on improvedmanagement practices and supervisoryapproaches, adequate equipment and supplies,clear job expectations, performance feedback).As described in the case story, many of thepossible interventions overlap and requirecoordinated implementation.

Learning interventions are the most commonmeans of helping health care workers obtain thenecessary knowledge and skills to perform wellon the job. The most common types include:

Classroom-based, group training courses.

Distance-learning programs in whichinteractions with the trainer and other learnersare facilitated using technology, whether high-tech (e.g., computer applications used over theInternet, interactive videoconferences) or low-tech (e.g., print-based materials sent via thepostal service).

Structured on-the-job training (OJT) coursesthat are facilitated by a trainer or supervisor atthe job site (e.g., whole site training).

Independent self-study programs deliveredusing various media including print, audio/videotapes, CD-ROM, the Internet.

Programs that involve a combination of theabove interventions.

These various learning interventions can be veryeffective in enabling health care workers todevelop essential knowledge and skills.Nevertheless, they are only part of the transfer oflearning process that helps to ensure that suchinterventions result in improved jobperformance.

What is transfer of learning?Transfer of learning is defined as ensuring theknowledge and skills acquired during a learningintervention are applied on the job. The goal is forlearners to transfer 100% of their newknowledge and skills to their jobs, resulting in ahigher level of performance and an improvementin the quality of services at their facilities.

Introduction | Transfer of Learning

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The team is now ready to implement theseinterventions. The supervisor arranges for severalhealth care providers who play key IP roles at thefacility to attend an IP course that combinesclassroom work with self-directed learningactivities that will be completed at the clinic. Inpreparation for the course, the trainer recommendsthat the supervisor:

� share the performance needs assessmentfindings so the trainer can adapt the course tothe identified needs and conduct any additionalassessment of needs required specifically for thetraining intervention

� coordinate the training intervention with inter-ventions that target other performance factors

� work with the site team to select the providerswho can benefit the most from training and tobegin setting expectations for improved IPpractices at the clinic

� meet with the learners to discuss the objectivesof the training and the expected outcomes thatwill be developed into an action plan duringthe training session

� participate in the final session of the course tobecome aware of the knowledge and skills theproviders will be expected to apply at the clinic

� meet with the learners when they returnfrom the classroom portion of the trainingto talk about how best to implement whatthey have learned. The learners will sharean action plan they have developed and refinedduring the course describing specific activitiesto improve IP practices at the clinic, includingsharing their new knowledge with co-workers

� post job aids that list key IP steps on thewall near the instrument processingarea and sink.

The action plan also includes a schedule forcompleting self-directed learning activities. Withassistance from the supervisor, the providers set asidea time and place to complete these exercises. Theyalso inform the supervisor that in the next few weeksthe trainer will be visiting the site to help themaddress any challenges they have encountered whileimplementing the steps in their action plan.

The supervisor and providers continue to monitor thequality of services and within several months thenumber of infections has not only decreased but isthe lowest it has been in years. These improvementstranslate into better health outcomes for clients anda safer environment for health care workers.

Do the issues described in the story belowsound familiar? Consider what actionswere taken in this case to improve thetransfer of learning…

����������������� ���������������The local maternity clinic provides basicreproductive health services and is visited by manymembers of the community. Several health careproviders have complained to the site supervisorthat infections have increased among both staffand clients. In an effort to address the problems,the supervisor chooses a representative group ofthe health care workers at the site to form a teamto conduct a performance needs assessment.

First, the team meets to discuss how to conduct anassessment that will identify the problems andenable them to agree on an outcome that willbenefit the clinic.

Second, the team refers to national service deliverystandards to identify the acceptable level ofinfections among staff and clients. A look at therecords shows that, at present, infection levels are40% higher than the acceptable level.

Next, the team searches out the root causes forthis performance gap. They find several causesrelated to performance factors:

� No infection prevention (IP) standards arein place at the clinic—providers do notknow what is expected of them

� Supervisors are not giving feedbackregarding IP practices—providers do notknow how well they are doing

� Necessary supplies, such as bleach, arelacking—the necessary tools are not in place

� IP practices are inadequate to protect clientsand providers (e.g., hand washing isinconsistent and not done correctly; providersare not wearing gloves at the appropriatetimes)—providers do not know how todo their job

� Incorrect procedures are being used toprocess equipment—providers do notknow how to do their job.

The team identifies and designs severalinterventions that address the root causes for highinfection rates at the clinic: lack of supplies, lack ofperformance standards, and lack of feedback givento clinic workers regarding IP. To improveknowledge and skills, the team decides to offerlearning opportunities for key service providers inIP practices and to post job aids for hand washingand equipment processing at appropriate locations.

Transfer of Learning���A Guide for Strengthening the Performance of Health Care Workers

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What is the transfer oflearning process?The transfer of learning process is an interrelatedseries of tasks performed by supervisors, trainers,learners, co-workers, and sometimes others (e.g.,government regulators, clients, etc.) before,during and after a learning intervention in orderto maximize transfer of knowledge and skills andimprove job performance. The process is usuallyrepresented in a matrix that outlines the specifictasks performed by supervisors, trainers, learnersand co-workers.

Why focus on transferof learning?Transfer of learning is important for supervisors,trainers, learners and co-workers because:

� Transfer of learning is in the best interest ofclients. Health care workers participate in alearning event to acquire new knowledge andskills to better meet the needs of their clients.Improving the transfer of learning enhancesthe quality of services— and may lead toincreased client satisfaction.

� Learning interventions can be expensive—improving the transfer of learning helps toprotect these investments.

� Learners are motivated to perform well attheir jobs when they are able to apply whatthey have learned. The support and guidanceof supervisors, trainers and co-workers canencourage and empower learners to makechanges and improve performance.

� Supervisors and learners are moreaccountable for implementing what islearned if there is early agreement aboutwhat will occur after training (often asoutlined in an action plan).

� Trainers are more likely to prepareinterventions that meet the specific needs oflearners and health care delivery sites whenthey have become invested in the outcomeof training.

�While supervisors may not be proficient inall of the clinical services provided by thehealth workers they supervise, being involvedin the transfer of learning process can helpthem stay up-to-date.

What is the transfer oflearning matrix?A matrix provides a useful means of presentingthe transfer of learning process. The matrixincludes suggestions adapted from the researchliterature and the experiences of supervisors,trainers and learners in the health care field. Thesuggestions can be adapted to fit many sit-uations, including the use of different types oflearning interventions (e.g., classroom, on-the-job, self-directed) and various sorts of super-visory arrangements (e.g., internal on-site,periodic external visits). It may not be possibleto implement all of these suggestions as part ofany one learning intervention. Some of thesuggestions in the matrix may represent a radicalchange from current policies and procedures atyour facility. However, if you can adapt andimplement just a few of the ideas described inthe matrix, you will improve the likelihood thatnew knowledge and skills will be applied on thejob. The more ideas and suggestions you canimplement, the stronger the transfer of learningoperation will be. In the process you will alsohelp to lay the groundwork for changing—and improving—the design of futurelearning interventions.

Introduction | Transfer of Learning

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Transfer of Learning���A Guide for Strengthening the Performance of Health Care Workers

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In addition to the specific suggestions includedin the matrix, the following actions are essentialto the transfer of learning process:

� Exploring and understanding therelationship of knowledge and skills tothe other factors (page 5) that affectperformance at the work site

� Establishing and maintaining structures thatsupport desired performance (e.g., usingnon-training interventions to influence otherfactors that affect performance, such asconstructive feedback, provision of necessaryequipment and supplies, clearprotocols, etc.)

�Working collaboratively with all individualswho can support (or might hinder) desiredon-the-job performance

�Using action plans or similar devices to setand maintain clear performance objectivesand expectations and to document progressand challenges

�Creating a supportive environment in whichall workers appreciate their potential toimprove services by acquiring new skillsand knowledge.

The matrix serves as the organizing mechanismfor the content in this guide. The entries on thegrid summarize specific actions that supervisors,trainers, learners and their co-workers can taketo improve the transfer of learning. Followingthis section are more detailed descriptions ofthese actions. The descriptions correspond withthe cells in the matrix so that you can easilyaccess more information about the areas thatyou find most interesting. In the process ofusing the guide, you may identify additionalactions to support full application of newlearning in your situation. Be open to thesepossibilities in addition to those includedin this document.

What is an action plan?An action plan is a written document thatdescribes the steps that supervisors, trainers,learners and co-workers will complete to helpmaximize the transfer of learning.

An action plan is initiated prior to the trainingintervention so that everyone who can supportthe transfer of learning is involved from thebeginning. The plan is refined during thetraining event and usually is not completed untilafter the event when learners are implementingnew skills on the job. As you will see, actionplans are a recurring topic throughout thisguide. The content and layout of an action planshould support the users of the plan, especiallythe learners. In developing an action plan, keepin mind these important points:

�Write activities as discrete steps that arerealistic, measurable and attainable.

� Identify clear responsibilities for learners,supervisors, co-workers and trainers.

�Develop a specific time schedule forcompleting activities.

� Identify resources necessary to complete theactivities, including plans for acquiringthose resources.

� Instruct learners to use a learning journal tohelp facilitate the development of an actionplan. A learning journal is a notebook inwhich learners document issues, problems,additional needs for skills development, andquestions that arise as new knowledge andskills are applied on the job.

See page 11 for a sample of a completed actionplan that includes several features to consider asyou design a format of your own. A blank actionplan format can be found on page 33. Copy thisfor your use or develop your own format. Theexample used on page 11 is very detailed. Thislevel of detail may not always be necessary,depending on the performance problem and thelearning intervention being undertaken.

Introduction | Transfer of Learning

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plans and manualcomplementary;team’s roles/actions clarified

staff using spaceappropriately

build confidence;ensuresuitability ofspace design

Learner: Mary Danso Training Intervention: Family Planning/Counseling Update Date: April 2001

My Support Team/Network Supervisor: Mrs. Nyako Trainer: Miss Zakari

Co-worker(s): Fatou Abudu (attended training with Mary), Doris Isa , Mercy Nunoo, Awa Koufi

Specific Areas to Improve: (Think about distinct accomplishments and activities to be achieved.)I want to improve my ability to provide appropriate counseling about FP methods

Problems to Overcome: (Describe the barriers that must be eliminated or reduced and how this will be done.)Don’t have a setting for confidential conversations - identify and discuss possible options with clinic supervisor

Participate in post-training meeting to review,revise and endorse my action plan (and Fatou’s);compare with/update procedures manualas needed (follow-up to pre-training meeting)Rearrange furniture in the clinic supervisor’soffice to create small private area for counseling

Participate in action plan review session; reviseand/or update plan depending on progressto date

Orient clients and counsel those interestedin FP; document issues/questions inlearning journal

Discuss journal entries with co-workers(and with supervisor as needed)

Observe counseling session and provide feedback (Fatou to be rated as well)

Assemble box of FP method samples to useduring counseling sessions (store on shelf in

counseling area for all providers to use)

Create poster that encourages clients to asktheir provider about FP; hang in waiting area

Review counseling job aid and notes from trainingactivity; place job aid on table in counseling area

Conduct a practice counseling session withco-worker in counseling area, using FP samplesand job aid

Observe and provide feedback during practicecounseling session (Fatou to practice as well)

Responsibleperson(s)

Resources Date/Time*

Changes ToLook For

Commitment of Support Team/Network:I support the action plan described above and will complete the actions assigned to me. If I am unable tocomplete an activity, I will help make arrangements to modify the plan accordingly.Signature of learner: Mary Danso Date: May 3, 2001Signature of supervisor: Nana Nyako Signature of trainer: Aby ZakariSignatures of co-workers: Fatou Abudu, Doris Isa , Mercy Nunoo, Awa Koufi

Entiresupport team

action plans;proceduresmanual

May 12pm

Mary, Fatou chairs &table

May 22pm

Doris, Mercy box &suppliesfrom stock

May 22pm

samplesalways readyto use

Mary, Fatou posterboard &markers

May 32pm

clients readingposter andaskingquestions

Mary, Awa counselingarea;samples; jobaid

May 42pm

Mary job aidfromtraining

feel ready forpracticesession

Fatou,Mrs. Nyako

counselingskillschecklist

May 42pm

useful feedback(peer/supervisor)

Entire team action plan May 72pm

team agreesthat I’m readyto counselclients

all peers

Mary learningjournal

May 11ongoing*

increase inclients choosingan FP method

Mary,Mrs. Nyako

learningjournal

ongoing* insightsregardingimprovements

May 32pm

skillschecklist

ongoing* ensureproficiencymatchesstandard

Step 1.

Step 2.

Step 3.

Step 4.

Step 5.

Step 6.

Step 7.

Step 8.

Step 9.

Step 10.

Step 11.

Detailed Specific Actions in Sequence(Include regular progress reviews with the supportteam as a part of the specific actions)

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* establish set day and time for ongoing activities

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Understand the performance needConducting a performance needs assessment isan important step in enabling supervisors tofully understand the nature of the performanceneeds at their facilities. Supervisors should askthemselves: “What is the desired performance?Is there a gap between what the staff is actuallydoing and what they should be doing? Do Iunderstand the root causes of this gap? Istraining the right solution to improve jobperformance?” Although training is a popularintervention for improving job performance,other interventions might be more appropriate.Before you embark on a training intervention,be sure that training is the right solutionfor the problem.

Participate in any additionalassessments required for trainingAn additional needs assessment may be con-ducted by trainers to ensure that the goals andobjectives of a learning intervention will meetthe identified performance needs of the learners.In order to design and develop the most effectiveintervention, trainers often require additionalinformation that would not be gathered during aperformance needs assessment (e.g., specificlearner characteristics such as the reading level oflearners or current skill level of each learner on aspecific task).

As a supervisor, you have unique knowledgeof staff members’ on-the-job performanceand can describe the specific gaps in

knowledge and skills that a training interventionneeds to address.

�Communicate with trainers about theresults of the performance needs assessmentand the problems that can be addressedby training.

�Discuss specific measures of success for thelearning intervention. How will the successof the transfer of learning processbe evaluated?

� Involve learners and their co-workers in theprocess. Explain to them the importance ofcooperating with the trainer duringassessment activities such as being observedand answering questionnaires.

� Provide trainers access to your site andto your staff.

By actively participating in additionalassessments, you will help guarantee that theresulting training will have the desired effects.

Influence selection of learnersSelecting the appropriate staff members fortraining is an important part of ensuring theeffectiveness of a training intervention.Participate in staff selection as much as possibleand involve staff by discussing who shouldattend and why. As you think about whom tosend for training, consider the following:

�Who will benefit most from the training?

�Which individuals are most motivatedto learn?

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�Which individuals have the prerequisiteskills required for the course?

�Who is in the best position to share thetraining information with others?

�Who will be implementing the newlyacquired knowledge and skills?

�Which management and support staff willalso be involved in the implementation ofnewly acquired knowledge and skills?Include these staff in the selection process ifyou feel that support will be needed inorder to introduce new services.

�Which two or more individuals wouldmake a good team to introduce a newservice? Sending staff from different cadresmay be helpful. For example, sending aphysician and a nurse to a minilaparotomytraining will provide the site with a teamthat can work effectively together.

Communicate with trainers aboutthe learning interventionSupervisors who are aware of the content of thetraining can model desired behaviors, betterexplain post-training expectations to staff, andreinforce desired behaviors after training.Awareness of the content of training can comefrom reviewing the course materials, receiving anorientation from the trainer, and observing orparticipating in parts of the learning inter-vention. Such interaction between supervisorsand trainers allows learners to see that theirsupervisors are committed to the learningintervention and interested in the entire process.Communicating with the trainers also providesan opportunity for supervisors to make sure thatthe trainers understand the performance need.Working with the trainers, you can determinewhat will maximize the event for the learners.

Help learners create apreliminary action planCommunicate positive messages to learnersabout the importance of training. Identify andshare with them specific expectations aboutperformance. Before the training activity, ask thelearners what they hope to get out of thetraining. Then explain precisely what youanticipate they will be able to do for your facilitywith their new knowledge and skills.

Supervisors can help learners understand howtheir new knowledge and skills contribute to thegoal of improving health care by working with

the learners to develop action plans. Supervisorsand learners can begin preliminary work on anaction plan at their job sites prior to the trainingevent. Discussing the action plan gives bothsupervisors and learners a chance to clarifyexpectations related to the training. Generally,learners will further refine their action planswith the help of a trainer. Supervisors can thencomplete the action plans with the learners afterthe training event. An example of a completedaction plan is found on page 11. See page 33 fora blank plan.

Support and encourage learnersOnce supervisors decide who will attend thetraining, it is important to provide those learnerswith the support they need.

�Assist learners with arrangements for thecourse. Make sure all arrangements are madein a timely manner. Support learners in thisprocess by assigning staff to assist them. Ifthey rely on financial support from yourfacility for travel, lodging or course fees andmaterials, provide funding promptly. Iftraining occurs regularly, create systems toarrange travel, reimburse expenses anddocument the training courses learnershave completed.

�Reassign each learner’s workload during thetraining. Make sure your site functionssmoothly during a learner’s absence bydelegating his or her workload to co-workers.Take care, however, not to make co-workersresentful by overwhelming them withadditional tasks. Make plans to lighten thelearner’s workload for a period after trainingto ensure that he or she will have the timeand energy to share new knowledge andskills with others and to implement changes.

�Reassure learners of your support. Assurelearners that you will give them time tobecome proficient in their new skills.Encourage learners to include post-trainingdebriefings with co-workers on their actionplans so they can share what they learn.Offer to help by organizing staff meetingsand assisting with the distribution oftraining information and job aids. Encourageco-workers to be supportive of learners.

(Note: Unless learners have been trained to trainothers, they should not be expected to train theirco-workers in the skills they will learn, especiallycomplex clinical procedures.)

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Participate in or observe trainingDiscuss with trainers what sessions would bemost helpful or appropriate for you to attend(e.g., sessions that include problem-solvingdiscussions concerning implementation of newknowledge and skills at the work site). Whenpractical, attending the training demonstratesyour support of the trainers as well as thelearners. Training interventions that useon-the-job and self-directed learning com-ponents include activities that occur at the jobsite and therefore provide excellent opportunitiesfor you to be involved in the learning andtransfer of skills.

Protect learners from interruptionsSupervisors have an important role in guardingthe learners’ time by not allowing others tointerrupt or take learners away from trainingactivities. Be prepared to limit your demands onlearners during the training period. Missedsessions create learning gaps that decrease thetraining’s positive impact and affect per-formance. By your actions, you cancommunicate that training is a priority andthat mastering the new knowledge andskills is essential.

Plan post-training debriefingSet aside some of your time to meet withlearners soon after the training to discuss theimplications of what they have learned. Allow afew days for the learners to prepare their notesand organize their thoughts prior to thismeeting. Also schedule some time for thelearners’ co-workers to meet with the learners toshare ideas and discuss implementation.

Provide supplies and space andschedule opportunities forlearners to practiceIf learners will be introducing a new procedureor service at the work site, you may need toprocure additional supplies and possibly somenew instruments or equipment. Someprocedures and services may require a dedicatedspace and equipment within the facility. Youshould arrange for supplies and regularmaintenance of equipment, schedule time forlearners to practice with the instruments andequipment, and help ensure that learners haveopportunities to master the new procedures.

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Good Intentions Gone Bad?Learning interventions that are conducted to fill training quotas or to serve as perksor incentives for workers rather than to meet a specific performance need aregenerally unsuccessful. If you find yourself in a situation where training is occurringbut doesn’t appear to be the best intervention or where you were not involved inselecting those to attend training, make the most of it and explore ways to use thetraining opportunity to improve services. Be creative about how to take advantage ofthe present situation. Suggest to administrators and policy makers that those whobest understand the needs should make decisions regarding who attends futuretraining events.

Did you know…?In the 1980s, several researchers surveyed top executives and trainers about barriers totransfer of learning. Lack of reinforcement on the job and lack of involvement byupper level management (i.e., supervisors) was the number one reason given by bothgroups. Your support and involvement is probably the most effective way to make thetransfer of learning successful. (Kotter JP, 1988; Newstrom JW, 1983)

Feedback Misinterpreted?Feedback that is given (or understood) inappropriately can backfire and result indecreases in desired performance and reductions in worker motivation. Be sure toexplain why and how you are giving feedback and the benefits to be gained.

Here is a personal example from an experienced trainer of trainers. “I was observing anew trainer doing a session from the back of the training room. I was taking care tomake notes about specific examples of things she did well, could improve and shouldstop doing. The trainee was furious because each time I wrote something down sheassumed it was a mistake she made. The irony was that most of my writing referred tothings she did well, but by then she was so angry at me that there was no morecommunication possible. It took a while to heal the relationship.”

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Monitor progress of actionplans with learners andrevise as neededSupervisors, trainers and learners have investedtime and energy in creating action plans. Now isthe time for those efforts to pay off. Meet withthe learners to review together the current actionplan and make sure that you are in agreementregarding expectations and how and when theywill be met. Supervisors and learners can useaction plans as a monitoring tool to gaugeprogress, identify problems, and work onsolutions. Routine supervisory meetings are agreat time to provide constructive feedback andcheck learners’ progress toward mastering andusing their new skills, as well as to ask whatmore you can do as their supervisor to supportthe transfer of learning. When necessary, actionplans should be revised to correspond withchanging needs at the work site. Using actionplans can also help to identify feedback fortrainers or facility administrators aboutproblems and solutions that only theycan address.

Conduct post-training debriefingwith learners and co-workersSupervisors and learners should involve otherstaff at the work site in the transfer of learningprocess by briefing them shortly after thetraining. This is a good time for you to identifyyour expectations regarding implementation ofaction plans and for learners to share what theyhave learned with their co-workers. Supervisors

and learners should set clear objectives fordebriefing meetings to make sure that thediscussion stays focused. Consider using thesemeetings for the following purposes:

� Sharing with co-workers the key conceptslearned during the training

� Providing an opportunity for co-workers toask the learners questions about the training

�Reviewing the needs assessment findings anddiscussing how newly acquired knowledgeand skills can address current needs at thework site and be of value to everyone

�Brainstorming on how to integrate newlyacquired knowledge and skills into presentservices

�Reviewing key activities from the learners’action plans and assigning resources tofacilitate implementation.

Conducting a post-training debriefing providesan excellent opportunity to update all staff anddiscuss how the transfer of learning will improveservice delivery at the work site. It is critical thatyour staff understands the reasons for any newinterventions, services, or changes in proceduresand knows how to implement them. This is anappropriate time for you to voice your supportfor the change process and the newly acquiredknowledge and skills.

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Be a coach and role model—provide encouragementand feedbackEncourage and, when possible, coach learners asthey incorporate new knowledge and skills intotheir work. A coach must be able to demonstratethe skill, observe and give feedback, and evaluatelearner performance against a standard. If youcannot coach the learners, identify someone withappropriate expertise to provide coaching. Eventhough you may not be able to coach learners ina particular skill, you can still provideencouragement to help them build their self-confidence and realize their full potential as theymaster new skills. Encouragement and coachingare very important to the transferof learning. Below are some specificapproaches to consider:

�Give frequent reinforcement and immediateconstructive feedback to learners as they tryout new skills. Voice your support as youobserve learners properly implementingnewly acquired knowledge and skills bygiving immediate positive feedback: “Nicejob Anjou, I’m glad to see you preparingthose instruments for processing accordingto the infection prevention practices thatyou learned.”

�Use mistakes as learning opportunities.When learners make errors while practicing askill, call the mistakes to their attention in atactful and culturally appropriate manner.Your comments should describe the specificbehavior that you observed; include stepsthat the learner performed correctly andthose that need improvement. In most cases,unless a client is in danger, it is best to givefeedback to learners after rather than duringclient-provider interaction.

�Coach learners as they try new skills. Whenlearners begin practicing skills that aredifficult or involve many steps, their skilllevels will likely vary—some learners maystill be novices while others may be closer tomastery. Offer to assist individual learners ina manner that is appropriate to the degree ofprogress they have made toward masteringthe particular skill. When providingguidance, remember to always point outsomething that the learner is doing well

before you offer suggestions forimprovements or ask what the learnerperceives he or she is doing well. Very oftenlearners can make appropriate suggestionsfor self-improvement when given theopportunity to reflect on their performance.

�Model new skills or behaviors in your work.To show that you support the changes thatlearners are implementing, adopt newbehaviors along with the learners and theirco-workers. Don’t expect your staff to makechanges if you don’t model changes as well.

Evaluate learners’ performanceSupervisors can have a significant impact on thetransfer of learning by evaluating performanceand providing feedback. Discuss with learnersthe reasons why evaluation is important,emphasizing that the goal is to provide themwith feedback so they know how they are doing.Assure learners that you will provide ongoingguidance as well as formal periodic evaluations.It may be appropriate to include these periodicevaluations on the learners’ action plan. If youcannot evaluate the learners’ performancebecause you lack the technical expertise, identifysomeone who can.

When you evaluate learners, review with themthe standard for the desired performance that isincluded in their job description or outlined inprocedural guidelines or a skill checklist fromthe training course. Discuss how the standardcompares to their present performance—are theyfailing to meet the standard, meeting thestandard, or exceeding the standard? Involvinglearners in a self-assessment is one way tostimulate this discussion. Remember thatevaluations should always include feedback onwhat learners are doing right.

Stay in contact with trainersMaintain contact with trainers so that you canprovide feedback about which aspects of thetraining were most effective. This allows you toreceive information from trainers about howbest to facilitate transfer of specific knowledgeand skills. The interactions with trainers alsoserve as your direct contact with the trainingsystem, thus providing you with anopportunity to share your ideas regarding othertraining needs.

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Validate and supplement theresults of the performanceneeds assessmentCommunicate with supervisors and, if possible,learners about the identified performance gapsand the desired goals and outcomes of training.Supervisors of learners attending your courses aresome of your most important customers. To helpensure that your course will meet the needsidentified by supervisors and learners you willwant answers to the following questions:

�What is the performance gap that training isexpected to correct?

�Are there other performance gaps that needto be addressed by non-traininginterventions?

�Why do supervisors and learners believe thattraining will improve job performance?

�What will the learners need to be able to doafter the course to improve performance?

�Do the learners selected to attend the coursehave the necessary prerequisite skills?

�Have the supervisors and learners developedpreliminary action plans? If the skill set isnew to both supervisors and learners thepreliminary action plan may be very general.

�Are there resources to support the learnersduring and after training?

With the answers to these questions in mind,share with supervisors and, if possible, learnersthe goals and expected outcomes of your course.You can hold brief orientation sessions withgroups of supervisors to share highlights of the

training content. This can also be anopportunity to pretest key aspects of the courseas the supervisors update their own knowledgeand skills in the content area. Feedback fromsupervisors can be used to link the courseoutcomes to the learners’ specific performanceneeds. Supervisors and learners need tounderstand how attending your course canimprove performance at their facilities. In theevent your course does not meet the needs of thelearners, you may have to modify the courseobjectives and content or help supervisors andlearners select a different course that will bettermeet their needs.

Encourage supervisors and learners to developpreliminary action plans that describe howlearners will apply their new knowledge andskills after training. You will also play animportant role in action planning duringtraining as you help learners consider the bestways to apply their knowledge and skills.

Use instructional design andlearning principles to developor adapt the courseWhether you are adapting an existing course ordeveloping a new one, a systematic process willhelp you prepare a course that will give learnersthe knowledge and skills they need to performwell in their work. Instructional design is aprocess that uses learning theory and principlesto help you develop targeted learningexperiences. Here is a summary of the process:

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� Start by reviewing the performance needsassessment to find out more about therequirements of the organization in whichthe learners work. When feasible, conductadditional assessments. Visit the work siteand talk with the supervisor and several ofthe learners to develop a better under-standing of what they do and why they needthe course you plan to offer. Find out asmuch as you can about the characteristics ofthe learners so you can target content andmaterials appropriately.

�Use what you have discovered about thelearning needs to develop goals for yourcourse. A goal can be broad and general, butit should define the direction of the course.

� From the goals, generate course objectivesthat clearly describe the desired performancein terms of behavior. Well-written objectivesshould be specific and measurable. Oftenthey include the criteria, or standards, formeasuring performance after learning.

� Establish prerequisites so that the learnerswho attend your course are ready to absorbnew knowledge and develop new skills.Because new knowledge and skills build onexisting knowledge and skills, making surelearners have the necessary qualifications willhelp them make a smooth transition to thenew material.

�Develop or adapt the content of your coursebased on the defined objectives and thecharacteristics of the learners (e.g., primarylanguage, reading level). Select instructionalapproaches, techniques, and media based onthe learning need. Design materials andactivities to maintain learner interest andattention. Build in opportunities to practicenew skills and provide feedback on per-formance until learners develop proficiency.

�Design and administer a pretest to assess theexisting knowledge and skills of learners.Plan to give learners a posttest at the endof the course to assess what they have learned.

Send the course syllabus, objectivesand pre-course learning activitiesin advanceA syllabus should be part of the materials foreach training course. Typically a course syllabuswill contain the following information:

� name of the course

� course goals

� course objectives

� length of the course

� target audience

� course prerequisites

� course components (e.g., classroominstruction, clinical practice)

� evaluation methods.

Sending a copy of the syllabus to the supervisorsand learners in advance will help to:

� ensure the course goals and objectives meetthe needs of the learners

� guide supervisors and learners as theydevelop preliminary action plans

� ensure that learners are aware of what theywill be learning and allow them to beginfocusing on the upcoming course content.

Any pre-course activities (e.g., reading assign-ments, refresher modules, learner questionnaires,identification of work site problems and issues)should also be sent in advance. This contactprovides a good opportunity to encouragelearners and supervisors to begin a preliminaryaction plan. You may also want them to identifyspecific problems from their facilities that can beused in case study activities during the course.

Goals and Objectives Should Be SMART

Specific Measurable Attainable Relevant Time-bound

Goal: On completion of the self-directed learning program, the nurse-midwife will counselclients and couples to make reproductive health decisions.

Objectives: After completing module 1, the midwife will be able to describe to a co-worker thebenefits of counseling for RH clients.

After meeting with her learning partners for skills practice sessions, the midwife will beable to demonstrate the counseling process and associated interpersonal communication skills.

During the on-the-job, two-week practice period, the midwife will counsel at least fivecouples to help them make RH decisions. The midwife will perform all the critical skills on thechecklist and score a minimum of 85% overall.

Need help writing good goals and objectives? See Robert F. Mager’s classic,“Preparing Instructional Objectives.” The latest edition was published in 1997.

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Provide work-related exercisesand appropriate job aidsThroughout your course, you should make everyeffort to help learners draw upon what theyalready know and connect what they are learningto what they need to do on the job. The designof your course should include activities andexercises to promote the transfer of learning.Here are some ways to facilitate this processduring your course:

�Design activities that engage learners asparticipants and tap their existing knowledgeand skills.

� Include realistic exercises that address thechallenges being faced by the learners at theirwork sites. Consider brainstorming with theparticipants early in the course to focus onproblems at their facilities and then use thoseproblems as the basis for activitiesthroughout the course.

� Schedule learning topics in shortsegments integrated with practice exercisesand activities.

� Provide frequent opportunities for learnersto reflect on what they are learning and planhow they will use their new knowledge andskills on the job. Give them a notebook touse as a learning journal. Periodically ask thelearners specific questions to answer in theirjournals about how they will apply their newknowledge and skills, what challenges theymay face and how they will overcome thosechallenges. Suggest that learners keep trackof problems and questions they need toresolve and resources they will need to putnew skills into practice. Remind learners torefer to their written reflections as they refinetheir action plans.

� Provide opportunities for learners to supporteach other by giving each other feedback anddiscussing how they will use their newknowledge and skills.

�Help learners identify or develop job aidsthey can use to promote the transfer oflearning (e.g., a poster describing correcthand washing technique to hang on the wallnear the sink). Have learners practice usingjob aids in situations similar to thoseon the job.

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Give immediate andclear feedbackMost workers have a strong need and desire toknow how they are doing on the job. Supervisorsand trainers are encouraged to provideimmediate, individualized, and clear feedback inorder to reinforce learners’ desired behaviors.

There are numerous opportunities during acourse for you to provide feedback to learners:

� during presentations and small-groupactivities when all learners can benefit fromthe shared feedback

� individually during skill practice sessions orwhile marking knowledge tests

� during breaks when you can approachlearners or encourage them to approach you

� during clinical training when learners areworking with clients (though this may be amore challenging opportunity).

Use a variety of techniques to help ensure thatfeedback is timely and meaningful, including:

� verbal feedback, such as positive behaviorreinforcement or constructive correction

� nonverbal feedback, such as smiling andnodding during presentations.

Help learners developrealistic action plansSupervisors and learners are encouraged tocapture training expectations by developingpreliminary action plans prior to beginning acourse. With guidance from trainers, learnersdevelop a more complete action plan during thecourse. As a trainer, you are in a unique positionto help learners decide which skills they needmore practice with and how best to structuretheir practice after the course. If a learner’spreliminary plan was not a formal written plan,you can provide an action plan format that will

help the learner formalize a plan. See pages 10and 11 for information about action plans.

Conduct training evaluationsEach training course should have an evaluationcomponent. During a course you mayadminister several types of evaluations including:

� pre-course knowledge and skills assessmentsto determine whether learners have theprerequisite knowledge and skills

� interim knowledge and skills assessments tomeasure learners’ progress

� post-course knowledge and skills assessmentsto determine whether learners have achievedthe course objectives and are performing tocourse standards

� course evaluations to give learners anopportunity to provide feedback on howwell the course was conducted, whether thecourse materials were appropriate, and howwell the course content met theirperformance needs.

Skills assessments or evaluations are typicallybased on performing a skill to a standard asdetailed in a performance checklist. Aftertraining, these checklists can be used on the jobin a number of different ways. For example:

� learners can use them as a job aid whenapplying the skill

� supervisors can use them to coach learners asthey practice a new skill

� trainers can use them during follow-up visitsto observe and provide feedback to learners.

When used over time, checklists can be helpfulin tracking changes in performance from oneobservation point to the next.

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Conduct follow-up activitiesin a timely mannerIt is important for trainers to follow up withlearners and supervisors to make sure new skillshave become part of the routine back on the jobor to determine why learners are having troubleapplying new skills, if this is the case. Thisfollow-up may include visits to observe, coach,solve problems, gather data (e.g., measuringlearner progress and post-course outcomes) andidentify other possible gaps in performance.

Help strengthensupervisors’ skillsTransferring the responsibility for supportinglearners to their supervisors is a key duty oftrainers. During follow-up visits, discuss thesupervision tools (i.e., performance checklists)developed for the training and how these canbest be used. Conduct practice sessions withlearners and supervisors, if appropriate, and beopen to discussing other performance support

and supervision issues. Helping supervisorsunderstand their important role in the transferof learning process will increase the likelihood oflearner success.

Facilitate review of action planswith supervisors and learnersTo be effective, an action plan has to be more thana piece of paper. When you review action planswith supervisors and learners, you can help themmake sure the activities are described in specificdetail and are consistent with the needs of thework environment. You may be able to suggestways to make better use of time, develop morecreative means for identifying and acquiringresources, or find ways in which learners andsupervisors can work together to reinforcethe learning.

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Staying in touch when funds for maintaining communication are not includedin the budget—a few ideas:

�Have the learners deliver a questionnaire to their supervisors soliciting input on howthe training has improved performance. Include a section that provides anopportunity for suggestions on improving the training based on theperformance outcomes that supervisors are observing.

�Have trainers provide a job aid for supervisors that offers guidance about howto support the learners’ new skills and how to contact the trainer if they havespecific questions.

�Use regional, district, or other scheduled meetings to connect with the supervisorsafter the training intervention.

� Explain to program planners and other decision-makers the importance of providingfunds or opportunities to communicate with supervisors and learners.

Share observations withsupervisors and learnersBe tactful but candid in letting learners andsupervisors know what you believe needsimprovement. You may want to verify yourobservations with co-workers at the site, but becareful about sharing information on skilldeficits. Often people will identify skill deficitsthemselves if provided an opportunity.

Your observations should be aimed at improvingperformance and maintaining your relation-ships with the learners and their supervisors.Remember to share the positive things youobserve and constructively guide any needfor improvement.

Maintain communication withsupervisors and learnersStaying in touch with supervisors and learnerswill help them maintain their commitment toworking on new skills together. You can helpthem find solutions to small problems beforethey become big problems. Staying in touch willalso provide you with ideas that will help youadjust future courses and improve otherelements within the training system.

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Participate in needsassessments and planningYou can make training more beneficial andrelevant to you and your organization byproactively identifying your learning needs,participating in needs assessments and helpingto plan for the training and learning activities.By yourself or together with your supervisor andco-workers, consider what new or upgradedskills you need in order to improve the quality ofservices at your facility. Ask your supervisor whatlearning activities or other types of interventionsare available to address these needs.

Sometimes we don’t know what we need,especially in areas such as communication,leadership, supervision, and management. Theseneeds can be identified through various types ofneeds assessments. If your supervisor isconducting a performance needs assessment, orif trainers are on-site collecting informationrelated to a training intervention, communicatewhat you think are the existing problems at yourwork site. Offer your suggestions for what skillsand training approaches might suit your needs.You can do this by completing questionnaires,participating in discussions with co-workers,

volunteering to have your performanceobserved and assessed, or even offering to helpfield-test or review new training courses.

Once you have been selected for participation ina learning intervention, there are severalimportant things you can do to prepare fortransferring the new knowledge and skills youwill learn back to your job. These activities aredescribed below.

Review course objectivesand expectations and preparepreliminary action plansReview the course objectives and expectationsand then talk with your supervisor about them.Clarify the ways in which the training objectivesare related to your job and how the learningopportunity will improve your work potential,your skills and the services you provide. Discussyour expectations and those of your supervisor.Determine how you will practice and apply yournew skills during and after training. Ask whatsupport you will receive from your supervisor.

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Compile a list of the agreements you make withyour supervisor. These may include:

� you will complete pre-course learningactivities

� you will participate fully in the entiretraining program (no interruptions allowed)

� you will orient co-workers to the newknowledge and skills that will be appliedafter training

� your supervisor will provide opportunitiesfor practicing and strengthening new skillsafter training

� your supervisor and co-workers will activelysupport your efforts to implementimprovements.

This discussion with your supervisor, and a laterdiscussion with co-workers, can help you beginyour preliminary action plan by identifying yourtentative goals and activities. See the sampleaction plan on page 11 for more information.

Begin establishing asupport networkEven before the training starts, you can begin toprepare a support network that will help you toapply your new skills. Tell your co-workersabout your upcoming training and let themknow that you will share key learning points andresources with them afterwards. You may wantto schedule a debriefing session to occur soonafter the training course so that you can sharewith them your final action plan and solicitideas for implementing what you have learned.

Some learning approaches may allow you topractice new skills with co-workers while you arelearning. For example, on-the-job learning, self-directed learning and group-based learning that

take place over several sessions or modulesoften include skill practice or assignments thatlearners must complete between the sessions.

If one or more co-workers are participating inthe same training course, you can complete pre-course learning activities together, then sharewith each other what you hope to gain from thetraining and how you want to work together toapply your new skills. Talking with your co-workers will help you develop a commitmentto support each other to improve yourskills and the quality of health care servicesthat you provide.

Complete pre-courselearning activitiesPrepare yourself to get the most out of thetraining by completing any required pre-courseactivities or learning tasks. In addition to thecourse description and objectives, the trainermay send you some background reading, a self-assessment questionnaire, and case examples orproblems to analyze. Some courses requirelearners to successfully complete a self-directedlearning module before they are eligible to startthe course. The pre-course activities might alsoinclude gathering information or case examplesfrom your own experience or work site to bringfor use in training activities. Completing pre-course activities helps to ensure that you areprepared to learn and apply the new content inthe course and also provides information thattrainers need to make the course more relevantto your experience and working environment.

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Participate actively in the courseThe more actively you participate in coursesessions, exercises and other interactions withtrainers and fellow learners, the more knowledgeyou will acquire. Active participation allows youto draw from the experiences of others, clarifycontent, practice skills, and explore how you willapply the new skills in your job. Activeparticipation includes:

� being on time for and actively engaged in alllearning sessions including discussions,problem-solving exercises, team projects, andskill practice sessions

� asking questions about the course content asit relates to your specific job

� trying out new behaviors where appropriateduring the course, and requesting feedbackto improve your skills

� sharing your ideas and requesting feedbackfrom trainers and other learners

� discussing challenges and questionsindividually with trainers when possible(e.g., after class, during breaks, in betweensessions, during site visits).

Additional mechanisms that can promote youractive involvement in the course include:

� Identifying one or more learners (buddies)with whom you can complete assignments,share ideas, and discuss what you arelearning. It’s helpful to exchange ideas abouthow new skills can best be used in your joband to practice the skills that are applicable.A “buddy” relationship is most effectivebetween co-workers or others with whomyou can make a commitment to have anongoing connection that will permit you tosupport each other after the training event.Linking with a learning buddy who is yourco-worker allows you to identify importantperformance goals as a team and create ajoint action plan for application at yourwork site, including details on how yourplan will be shared with your supervisor andother co-workers. Other post-trainingsupport may come from professionalassociations and formal peer associations.

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�Writing reflections about what you arelearning. Making notes in a learning journalcan help you retain knowledge and skills,share the most relevant information fromtraining with your supervisor, and focus onthe best ways to implement new practices atwork. Your trainer may give youopportunities to write in your learningjournal during the training sessions. In yourjournal, you can also keep track of problemsand questions that you want to pursue withthe trainer or other learners and make notesabout the support and resources you thinkyou will need to put new skills into practice.If you add to your journal throughout thetraining program, you can use it as areference when you complete and implementyour action plan.

Develop realistic action plans fortransferring learningThe preliminary action plan developed withyour supervisor—or the discussions that you andyour supervisor had regarding expectations forthe training—provide the foundation for youraction plan. If your preliminary action plan wasnot a formal document, ask your trainer toprovide you with guidelines and a format fordeveloping a written action plan or refer to thesample plan on page 11. Refer to your learningjournal and use what you have learned from

your participation in the course as a basis forrefining your action plan. Most action plansincorporate areas for improvement (describingmeasurable and achievable goals and objectives),anticipated problems or barriers you willovercome, and specific actions to be taken. Foreach action, identify the person responsible, anyresources needed, a target date for completion,and changes you expect to occur as a result ofthe action. Some of the actions may highlightadditional skills practice or self-developmentactivities to help you reach your goal.

As you prepare to implement your action plan,consider using the following techniques:

� If feasible, make plans to have a trainer visityour work site or be available to consult withyou and your supervisor after training tohelp facilitate implementation of youraction plan.

� Try to anticipate potential areas of resistance(e.g., from supervisors, co-workers oradministrative staff) or barriers at your worksite (e.g., logistical or supply andequipment problems).

�With your trainer or a learning buddy,brainstorm about how these barriers can beovercome and determine what resources andtypes of support are needed to surmount theobstacles.

� Include the steps identified for overcomingbarriers in your action plan.

Transfer of Learning���A Guide for Strengthening the Performance of Health Care Workers

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Meet with supervisor toreview action planThe meeting with your supervisor that youplanned together before training is one of themost effective ways to initiate support fortransfer of learning. Meet with your supervisoras soon as possible after the training ends.Review the goals and objectives and mutualexpectations for improvement that you discussedprior to training. Go over each activity in youraction plan, the resources and support needed,target completion dates, and expected changes.Brainstorm about how your trainer andsupervisor can work together to support thetransfer of your new skills to the job. Makeadjustments to your action plan and establishtimes for regular progress reviews with yoursupervisor.

Apply new skills andimplement action planAfter discussing your action plan with yoursupervisor, share it with your co-workers,especially those you have identified to helpimplement action plan activities. Explain tothem that you will be practicing new skills andcarrying out special activities as your action planis implemented. Orient them to any newprocedures you will be using and share anymaterials that might interest them. (Note:Unless you have been trained to train others,you should not be expected to train your co-workers, especially in complex clinicalprocedures.) Explain the activities that willinvolve your co-workers and ask them to providethe feedback that you need. It is best to haveyour supervisor present during debriefingsessions with your co-workers to reinforce andshow support for your activities.

Post your action plan on the wall or otherprominent place and check off activities whenyou complete them. Be sure to set aside time toreview the training content and practice new

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Introduction | Transfer of Learning

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skills using any job aids provided during training(e.g., flow charts and checklists). If otherco-workers participated in training and youdeveloped a joint action plan, carry out theactivities according to the action planassignments. Meet periodically forprogress reviews with each other andwith your supervisor.

Meet regularly with your supervisor (and withyour trainer if a training follow-up visit isscheduled) to discuss progress and anyconstraints to transferring your learning. Workwith your supervisor to identify any additionalsupport and resources needed to implement thenew skills. Many steps are often necessary toensure transfer of learning occurs—carefullyidentify these actions and then follow each one.Implementing your action plan and applyingyour new skills is a team effort that can onlysucceed with the cooperation and support ofeveryone in your organization.

Use job aidsTraining courses often provide learners with jobaids that are used as memory cues for how andwhen to perform a task. Sometimes learners willdevelop job aids as part of their training course.Use these job aids frequently and, if appropriate,share them with your co-workers. They can helpyou remember what you learned andincorporate your new knowledge and skillsinto your job tasks.

Network with other learners andtrainers for supportA support network of learners or a learningbuddy can increase the likelihood of transferringlearning after training—if there is a commit-ment to maintaining these relationships. Find

ways to continue your contact with otherlearners through regular meetings, telephoneconversations, and visits. You can shareexperiences in implementing action plans,discuss problems encountered and lessonslearned, celebrate successes, and help each otherset new goals or revise action plans.

When trainers contact you for follow-up, usethat opportunity to share successes and problemsand receive feedback. In post-training surveys orinterviews, give concrete and constructivefeedback to the trainer on how the programcould be improved. Also mention additionalskills training and support that you think wouldhelp improve your performance and the qualityof health care services that you provide.

Monitor your own performanceConduct regular progress checks to help ensurecontinued transfer of learning. You can monitoryour own performance by setting aside time toreview your action plan and the feedback orobservation data from your supervisor, trainer,and other learners and co-workers. Considerkeeping a chart of your scores on skillsevaluations. If possible, also chart the healthservice statistics related to your action plan, suchas new services or changes in services. Continueto maintain a learning journal to keep track ofyour experiences, the questions you have andbarriers you face in applying knowledge andperforming skills. Share these notes on a regularbasis with your supervisor and seek help inreviewing and updating your action plan.

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�����������Participate in needs assessmentsand discussions of the training’sintended impactYou and your co-workers can make importantcontributions to the performance improvementand training process even though you may notattend the training event. Try using some ofthe procedures described below to helplearners transfer new knowledge and skills toyour work site.

� Participate in the needs assessments: helpgather information, give honest feedbackabout individual and work site needs as youperceive them and discuss findings with yourco-workers and your supervisor.

� Participate in discussions with yoursupervisor and co-workers about how thetraining is supposed to improve services. Beaware of these training goals and theaction plans of the learners so that you canbe supportive.

Share your thoughts and ideas with others.Training interventions require a supportive,helpful work place in order to be successful.

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Ask learners to bring back keylearning points to share withthe work groupYou and other staff at the work site can benefitfrom the learning experiences of your co-worker(s). In the days prior to the learningevent, make a point of talking with learners toencourage them and let them know that youshare their excitement and are interested in whatthey will be learning. Also let them know thatyou look forward to helping them transfer whatthey have learned when they return to work. Ifyou have specific interest or expertise in thecontent area, you may want to give them a list ofquestions that you would like them to discusswith the trainer or ask them to bring backresource materials to share.

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!�������������Complete learners’reassigned work dutiesWhen co-workers leave for training it is oftenhard to continue to provide good services. Youcan help by taking on some extra duties whilethey are in training. This may mean workingharder for a week or so. Your supervisor mayassign extra duties for you. One way to besupportive is to ask your supervisor if there isanything you can do to help while your co-worker is in training.

Participate in learning exercisesat the request of learnersSome training designs and approaches requirelearners to practice new knowledge and skills onthe job during the course of the learning event.Group-based training that takes place overseveral different sessions often includesassignments that learners must completebetween the sessions. On-the-job and self-directed learning approaches generallyincorporate opportunities for learners to practicenew skills while they are still learning. At therequest of learners or your supervisor, you maybe able to assist with the learning exercises byobserving learners or helping them practice skillsby participating in role-plays.

�� ���������Be supportive oflearners’ accomplishmentsSoon after the learning event, ask the learnerswhat they have learned that is most helpful; askthem about ways to apply knowledge and skillsat your site, and assure them that you will helpthem with the transfer of learning. Although theinitial conversation might be just a friendly chat,make sure that you set aside time to talk abouttheir learning experience in more detail. In mostcases, especially when complex clinicalprocedures are involved, learners will not havethe skills to actually teach you what they havelearned. However, they will be able to share basicprinciples with you that will allow you tosupport their learning efforts. Try using some ofthe following suggestions to support the transferof learning:

�Ask learners to share copies of learningmaterials, then review the materials toupdate your own understanding of the topic.Discuss with the learners things that youfind interesting in the materials and ideasthey have shared.

� If the site supervisor has agreed that newstandards or procedures are to be adopted(e.g., stricter infection prevention practices),ask the supervisor how you can assist in theirapplication. Although you will need trainingto upgrade your own knowledge and skills,learners can provide you with an initialorientation to the new practices.

� If the learners acquired a new skill, watchthem demonstrate the skill or offer toparticipate in role plays with them so thatthey can continue to practice what they havelearned. Find ways to encourage them toapply their new skills.

People are influenced by those around them—you can help your co-workers apply their newknowledge and skills so that everyone canbenefit.

Transfer of Learning���A Guide for Strengthening the Performance of Health Care Workers

32 |

Bertrand JT, Escudero G. Compendium ofindicators for evaluating reproductive healthprograms. Chapel Hill, NC: MEASUREEvaluation, Carolina Population Center,University of North Carolina at Chapel Hill,2002.

Broad ML, Newstrom JW. Transfer of training:action-packed strategies to ensure high payoff fromtraining investments. Reading, MA:Addison-Wesley, 1992.

Broad ML, editor. Transferring learning to theworkplace. Alexandria, VA: American Society forTraining and Development, 1997.

Caiola N et al. Supervising health services:improving the performance of people. Field-testdraft. Baltimore, MD: JHPIEGO, 2002.

Dohlie, MB. Supportive supervision:a performance improvement intervention.PRIME II Better Practices (unpublished draft).Chapel Hill, NC: Intrah,PRIME II Project, 2001.

EngenderHealth. Whole-site training:EngenderHealth’s approach to training.Working Paper No. 11. New York, NY:EngenderHealth, 1998.

Intrah. Making it happen: using distance learningto improve reproductive health providerperformance. Chapel Hill, NC: Intrah, 1999.

Intrah. Reproductive health training for primaryproviders: a sourcebook for curriculumdevelopment. Chapel Hill, NC: Intrah, 1997.

Kotter, JP. The leadership factor. New York, NY:Free Press, 1988.

Newstrom, JW. The management of unlearning:exploding the “clean slate” fallacy. Training andDevelopment Journal 1983; 37(8):36-9.

Sullivan, RL. The transfer of skills training.American Society for Training and DevelopmentInfo-line 1998;9804:1-16.

Sullivan RL, Gaffikin L. Instructional design skillsfor reproductive health professionals. Baltimore,MD: JHPIEGO, 1997.

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Learner: Training Intervention: Date:

My Support Team/Network Supervisor: Trainer: Co-worker(s): Specific Areas to Improve: (Think about distinct accomplishments and activities to be achieved.)

Problems to Overcome: (Describe the barriers that must be eliminated or reduced and how this will be done.)

Responsibleperson(s)

Resources Date/Time*

Changes ToLook For

Commitment of Support Team/Network:

Signature of learner: Date:Signature of supervisor: Signature of trainer:Signatures of co-workers:

Step 1.

Step 2.

Step 3.

Step 4.

Step 5.

Step 6.

Step 7.

Step 8.

Step 9.

Step 10.

Step 11.

Detailed Specific Actions in Sequence(Include regular progress reviews with the supportteam as a part of the specific actions)

�����������

* establish set day and time for ongoing activities

JHPIEGOThrough advocacy, education and performanceimprovement, JHPIEGO helps host-countrypolicymakers, educators and trainers increaseaccess and reduce barriers to quality healthservices, especially family planning and maternaland neonatal care, for all members of theirsociety. JHPIEGO’s work is carried out in anenvironment that recognizes individualcontributions and encourages innovative andpractical solutions to meet identified needs inlow-resource settings throughout Africa, Asiaand Latin America and the Caribbean.Established in 1973, the JHPIEGO Corporationis a nonprofit organization affiliated with JohnsHopkins University.

JHPIEGO

1615 Thames Street, Suite 200

Baltimore, MD 21231

Tel: 410-955-8558

Fax: 410-955-6199

info@jhpiego.org www.jhpiego.org

The PRIME �� ProjectWorking in more than 20 countries, the PRIMEII Project is designed to strengthen theperformance of primary care providers of familyplanning and reproductive health care as theystrive to improve services in their communities.PRIME II is implemented by Intrah inconjunction with project partners AbtAssociates, EngenderHealth, Program forAppropriate Technology in Health (PATH), andTraining Resources Group, and supportinginstitutions, the American College of Nurse-Midwives and Save the Children.

IntrahIntrah is a global health development assistanceorganization based in the School of Medicine atthe University of North Carolina at Chapel Hill.Established in 1979, Intrah focuses on providersof client-centered, primary-level health care inlow-resource settings, and is an establishedleader in the creation of training systems. APAHO/WHO Collaborating Center for theDevelopment of Human Resources in Health,Intrah also assists in building institutionalcapacity and developing and implementingservice delivery policies and standards. Regionaloffices are located in the Dominican Republic,India, Kenya and Senegal.

The PRIME II Project

Intrah

School of Medicine

The University of North Carolina at Chapel Hill

1700 Airport Road, Suite 300 CB 8100

Chapel Hill, NC 27599-8100

Tel: 919-966-5636

Fax: 919-966-6816

intrah@intrah.org www.prime2.org