Overview and Background of Learning for Performance

This section introduces the Learning For Performance process and explains its benefits. It also contains descriptions of three areas of work that are fundamental to the process: performance improvement, instructional design and human resources for health.

Introduction

Health workers¹ are among the most valuable resources of any health system. Developing a strong workforce requires training health workers to perform their jobs, updating their skills and knowledge to match evolving health needs and helping health workers advance along appropriate and satisfying career paths.

Learning interventions² are critical components of offering good quality health care services, ensuring that health workers perform to standard and addressing the human resources for health crisis facing many countries.

Learning For Performance

Learning For Performance is an instructional design process that is targeted to fix a performance problem or gap when workers lack the essential skills and knowledge for a specific job responsibility, competency or task. The Learning For Performance process combines experience in two key areas: performance improvement and instructional design. This process can be used to develop learning interventions of any scale.

Learning for Performace steps

Learning for Performance uses a step-by-step process with practical tools. The steps of Learning for Performance appear in this document in the order they are typically performed. As the development team follows the process, it is often appropriate to go back to an earlier step and refine the outputs to make the education or training program focused, efficient and effective. The Learning for Performance process is flexible and, depending on the situation, it may be possible to use only portions of the process, or enter the process at steps other than the first step. Experience shows that the first few steps usually occur in tandem.

Box 1: The steps to Learning for Performance

Specify the learning goal related to the gap in skills and knowledge Learn about the learners and their work setting Identify existing resources and requirements for training and learning Determine job responsibilities (or competencies) and major job tasks related to the gap in skills and knowledge Specify essential skills and knowledge Write learning objectives Decide how to assess learning objectives Select the learning activities, materials and approaches and create the instructional strategy Develop, pretest and revise lessons, learning activities and materials, and learning assessment instruments Prepare for implementation Implement and monitor learning and logistics Assess effectiveness of the learning intervention and revise

Benefits of the Learning for Performance process

Using the Learning for Performance process can:

• Improve performance of the workforce. Learning interventions developed with the Learning for Performance process prepare workers for specific job tasks where there is a performance problem or gap and a priority health need.
• Improve the quality of services. Learning interventions that are delivered within a performance improvement context, addressing the five key performance factors, can improve the overall quality of services.
• Contribute to worker satisfaction. When learning interventions are relevant to specific job responsibilities and tasks, health workers may be more engaged and involved in learning and more motivated to perform well on the job.
• Increase the effectiveness of learning. When learning interventions focus on what is most important, learning can improve. Learners do not have to guess what they are expected to learn. Trainers, teachers and preceptors know what they are expected to teach.
• Increase the efficiency of training. Learning interventions will use the time efficiently by focusing on essential content, skills and knowledge, while delivering specific outcomes. The time required for training is generally shorter than when the intervention is developed without following the Learning for Performance process. This may be especially beneficial for efforts to address human resources for health issues.
• Improve decision making. Decisions about learning interventions are based on specific, practical, relevant criteria when the Learning for Performance process is used.

Key Companion Resources for Learning for Performance
Transfer of Learning: A guide for stregthening the performance of health workers. Available Here Preservice Implementation Guide: a process for strengthening preservice education. Available Here Effective Teaching: a guide for education healthcare providers. Available Here

Performance Improvement

Learning for Performance places learning interventions in the context of performance improvement, a method of analyzing performance problems, determining the missing factors that lead to these problems and setting up systems to improve and support worker performance. Performance improvement is based on addressing the factors that need to be in place for workers to perform their jobs to standard. There is some evidence that attention to the performance factors can also improve job satisfaction and staff retention.³

Box 2: Factors that support health worker performance
Performance Factors	Question to identify which factors are missing
Clear job expectations	Do workers know what they are supposed to do?
Clear and immediate performance feedback	Do workers know how well they are doing?
Adequate physical environment, including proper tools, supplies and workspace	What is the work environment like and what systems are in place to support it?
Motivation and incentives to perform as expected	Do workers have a reason to perform to standard? Does anyone notice? Do they believe the task is important or that they can perform successfully?
Skills and knowledge required to do the job	Do workers know how to do the job?

When a performance gap is identified in terms of these performance factors, a solution or set of interventions can be matched to the root cause of the gap.

For example, if health workers do not know HOW to do the job, the performance gap is likely caused by a lack of skills and knowledge, and a learning intervention is an appropriate solution.

Performance gaps may be identified at different levels. For example:

• At the health facility level, e.g., workers on the job are not performing up to an established standard
• At a district or regional level, e.g., there are not enough workers who are prepared to address a priority health problem
• At the system level, e.g., an entire cadre or a new cadre has been assigned a new area of responsibility but has not yet been prepared to perform the work.

When multiple performance factors are missing

Often, more than one performance factor is responsible for a performance gap. For best results, interventions to close a performance gap must be carefully coordinated. When managers, supervisors and administrators ensure that all of the performance factors are in place, they are providing the organizational support that health care workers need to perform to expected levels. For example:

• If workers do not know how to process surgical instruments correctly (factor 5) and the autoclave is broken (factor 3) then at least two interventions are needed to improve infection prevention practices at the facility. If training is not coordinated with an equipment upgrade, performance may not improve.
• If supervisors do not understand how surgical instruments should be processed, and if they do not require and encourage proper practice (factor 2), performance still may not improve even if the autoclave is fixed and the learning intervention succeeds at closing a gap in skills and knowledge.

Box 3: Is a learning intervention the only intervention needed?
When more than one performance factor is responsible for an overall performance gap, coordinating all related interventions helps ensure that, together, the interventions will result in better performance. For the above example where clinic-based health workers are not performing appropriate infection prevention practices to standard, the missing performance factors and related interventions are listed below.
Missing performance factors	Planned interventions
lack of sterilization equipment and consumable supplies for infection	provide sterilization equipment and ongoing supply of consumables to improve the physical environment in the clinic
health workers do not know how to perform appropriate infection prevention	provide training in skills and knowledge for infection prevention tailored to the health characteristics and infection prevention responsibilities, worksite requirements and protocols
lack of clear job expectations and performance feedback about infection prevention	develop and disseminate infection prevention service standards and protocols develop job descriptions that clearly describe responsibilities in infection prevention train staff to use supportive supervision to convey and reinforce job expectations about infection prevention

Key Companion Resources for Performance Improvement
Stages, steps and tools: a practical guide to facilitate improved performance of health care providers worldwide. Available Here

Instruction Design

Instructional design is a systematic five-phase process used worldwide in health, education, business and industry to develop training and educational programs. The five phases of the instructional design process are: analyze, design, develop, implement and evaluate.

Learning for Performance applies the five phases of instructional design and strengthens the relevance and efficiency of the learning by systematically linking the curriculum content and learning methods to the job tasks, the specific learners and specific work contexts. This results in better transfer of learning to improved performance on the job. (See References and Resources for more information on instructional design.)

Box 4: The instructional design process and Learning for Performance steps
Analyze	Design	Develop	Implement	Evaluate
Skills and knowledge gaps and learning goals Learners and their work setting Resources and requirements Job responsibilities and tasks Essential skills and knowledge	Learning objectives Learning assessment methods Learning activities, materials and approaches, and the instructional strategy	Lessons, learning activities and material, and learning assesment instruments (develop, pretest and revise)	Preparation Implementation and logistics monitoring	Effectiveness (assess and revise)

Learning for Performance: The Importance of Understanding the Human Resources for Health Context

Many countries are taking bold steps to identify human resources for health issues and to meet the goal of getting adequate numbers of "the right health workers with the right skills in the right place doing the right things."⁴ Wherever human resources issues are identified, a multisectoral approach to planning, developing and supporting the health workforce is recommended. Within the framework of this multisectoral approach,⁵ addressing the performance of health workers is a key strategy. The Learning for Performance approach can play an important role in enhancing health worker performance.

Box 5: Selected situations where Learning for Performance supports efforts to address human resources for health issues

Learning for Performance enhances and increases the efficiency of education and training efforts required to support the following processes: Aligning training with national health goals and priorities Accelerating the training of health workers Upgrading the skills of an entire health worker cadre Creating and deploying a new health worker cadre Shifting tasks among existing cadres (e.g., from doctors to nurses, or from nurses to community health workers) Improving the density of health workers in a specific area Upgrading skills and knowledge of newly recruited health workers for the settings in which they will work Developing fast-track bridging programs to assist existing health workers to gain the skills and knowledge needed to advance to positions in higher priority health worker cadres Training community workers, who may have no prior education in health, to address uneven rural/urban distribution of health care services

The Learning for Performance approach offers several key benefits within the context of human resources programming because it:

• Ties learning to specific, identified job responsibilities and competencies, which is especially beneficial in task shifting
• Eliminates unnecessary topics from training, which reduces "curriculum bloat"
• Identifies the most appropriate ways to develop health workers (approaches, methods, assessments, etc.)
• Incorporates skills practice and application of skills and knowledge that are directly linked to the worker's job situation
• Addresses the performance factors that determine whether new skills and knowledge can be applied on the job (transfer of learning).

The structured process of Learning for Performance can be used to develop professional skills, behaviors and attitudes that may be lacking in the traditional education for health professionals. Examples of such skills are: management skills for nurses, supportive supervision, lifelong learning skills, sensitivity to gender issues, treating all clients or patients with respect and empathy (e.g., destigmatization and elimination of discrimination toward persons living with HIV and women seeking postabortion care).

Key Companion Resources for Human Resources for Health

In some settings comprehensive human resources for health (HRH) assessments are available. However this is often not the case. An optional worksheet is included to help training developers understand and take into account the human resources context in which the Learning for Performance process will be applied and the specific linkages between a learning intervention and other HRH strategies and approaches. Additional companion resources for human resources for health are listed below: Management for Health. HRM [Human Resources Management] Resource Kit. Available Here The Capacity Project. Human Resources for Health Global Resource Center. Available Here Global Health Workforce Alliance. HRH Action Framework. Available Here Tool 2 (Optional): Human Reources for Health Context Worksheet (See Step 1) World Health Organization. HRH Tools and Methodologies. Available Here

Maximizing the Success of Learning Interventions

Training is often proposed as a stand-alone intervention to fix a service delivery problem. This approach often fails to bring about desired changes in health care or in worker performance, not because the training has failed, but because of a failure to support training with interventions that address other root causes of poor performance.

Every effort should be made to ensure that other potential root causes of performance gaps are identified and addressed to better ensure the success of learning interventions. For example:

• When health workers are being trained to provide antiretroviral therapy, other interventions may be needed to strengthen the supply and logistics system to avoid stock-outs of antiretrovirals.
• When workers are trained to take on additional tasks, it may be important to adjust compensation or provide non-financial incentives for taking on additional work.

Stakeholder support and involvement are critical to the development of learning interventions of any scale. Especially when the learning intervention involves multiple groups, it is essential to convene a stakeholder group or to involve stakeholders at the beginning of the development of a learning intervention and to involve them when key decisions are made. Stakeholder groups may include representatives from:

• Ministries of health, education, finance
• Professional associations and councils (e.g., nurses, midwives, doctors, lab technicians)
• Schools of nursing, midwifery, medicine, allied health and others
• Community leaders
• Health education professionals
• Specific groups that will benefit from improvements in services (e.g., persons living with HIV, women, mothers, adolescents).

1. Health worker is used in this document to refer to all people primarily engaged in actions with the principal intent of enhancing health (e.g., doctors, nurses, midwives, lab assistants, managers and supervisors and health managers) as well as informal, community or family care providers.
2. Learning Intervention is used in this document to refer to any type of education or training program. These include any educational course or program (e.g., pre-service or basic education, in-service training, continuing education, continuing professional programs or courses), as well as all learning approaches (e.g., classroom-based courses, distance learning, on-the-job learning, independent self-study, clinical practicum and blended learning approaches).
3. Yumkella F. Retention of health workers in low-resource settings: challenges and responses. Capacity Project Technical Brief No. 1. Chapel Hill, NC, IntraHealth International, 2006. Available Here
4. World Health Organization. Working together for health: the World Health Report 2006. Geneva, WHO, 2006. Available Here
5. An international working group has developed a framework with the following elements: policy, finance, education, partnership, leadership and human resources for health management systems. This framework is becoming a common reference point for stakeholders, policymakers and others addressing human resources for health issues. Available Here