Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide

1Integrating female genital mutilation content into nursing and midwifery curricula: A PR ACTICAL GUIDE

Integrating female genital mutilation content into nursing and midwifery curricula: A PR ACTICAL GUIDE Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide ISBN 978-92-4-004202-5 (electronic version) ISBN 978-92-4-004203-2 (print version) © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. iii CONTENTS Acknowledgements iv i. Introduction 1 ii. FGM learning outcomes 3 STEP 1. PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 8 Provides guidance on the preparatory steps, such as conducting a context assessment regarding FGM and identifying relevant stakeholders to be involved in the curriculum development or update. STEP 2. DEVELOP FGM CURRICULUM CONTENT 12 Details how the responsible Curriculum Review Committee (CRC) or equivalent body applies the findings of the context assessment and review of existing FGM training content already in the curriculum to develop FGM content aligned with the six learning outcomes. STEP 3. PILOT TESTING, IMPLEMENTING AND EVALUATING CONTENT 18 Describes how to pilot test the FGM content and scale-up and evaluate the implementation process. ANNEX 1: Checklist for integrating FGM content 20 ANNEX 2: Terms of Reference of the Curriculum Review Committee 24 ANNEX 3: FGM stand-alone training timetable 25 iv Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide ACKNOWLEDGEMENTS This practical guide was developed by the World Health Organization (WHO) in collaboration with experts in midwifery and nursing curricula and training materials on female genital mutilation (FGM) from low-, middle- and high-income countries. Christina Pallitto, Wisal Ahmed and Karin Stein of the WHO Department of Sexual and Reproductive Health and Research managed the development of the guide and accompanying tools. Gillian Barber developed an earlier draft of the guide with input from the following external and WHO experts: Teresita Abeno (Nursing Council of Kenya); Jama Ali Egal (Somaliland Nursing and Midwifery Association); Pandora Hardtman ( Jhpeigo); Caroline Homer (Burnet Institute, Australia); Stella Masala Mpanda (Tanzania Midwives Association); Naeema El-Gasseer (World Health Organization Egypt) and Vernon Mochache Oyaro (WHO Consultant). This document was developed with the financial support of the Government of Norway and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) – a co-sponsored programme executed by WHO. 1 Female genital mutilation (FGM) is a harmful practice and has no health benefits. The World Health Organization (WHO) opposes this practice and supports the health sector to provide high-quality FGM prevention and care services, including by building knowledge and skills of health workers. Despite the numerous and often severe physical and psychosocial health consequences associated with FGM, evidence shows that health-care providers often lack the knowledge and skills to provide FGM prevention and care services. A preliminary review of the existent pre-service midwifery and nursing curricula from countries with high FGM prevalence and countries that are home to diaspora populations from these areas revealed gaps in content. It was noted that trainings on FGM content are often ad hoc and stand-alone, and they target licensed health workers as opposed to those in the pre-qualification stage of training. To respond to the gaps in FGM training content and to address an increasing demand from countries for guidance on integrating FGM content into midwifery or nursing curricula in a systematic manner, this document explains how to develop context specific FGM training content in a step-by-step approach. PURPOSE OF THE GUIDE This guide is intended to promote a global health sector response to FGM for the provision of high-quality prevention and care services to women and girls at risk of FGM or living with the consequences of FGM. It also aims to support the systematic development of pre-service and in-service FGM content for midwifery and nursing education curricula which are relevant to context and need. This document could also be used for training materials of other cadres of health-care providers. Curriculum planners can use this document to update an existing curriculum to include FGM prevention and care, or to develop a new one if a suitable curriculum does not exist. The process described here will follow the same steps in both cases; however, some adaptations would be made depending on whether it is an initial curriculum development process or an update. It is intended that this document be used as appropriate for a particular context to ensure midwives and nurses are able to provide the care that women and girls need. Though it is recommended that FGM training content be integrated throughout curriculum content, this may not be feasible for all countries. Different approaches that could be considered as interim solutions are also described. In cases where a more immediate teaching tool is needed, a content guide that can be adapted for developing and conducting a two-day training is provided in Annex 3. i. Introduction 2 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide MIDWIFERY AND NURSING COMPETENCIES Midwifery and nursing practice and education benefit from international standardized competencies established by the International Confederation of Midwives (ICM) (1) and International Council of Nurses (ICN) (2). However, ICM and ICN competencies are not specific to FGM prevention and care services. The FGM learning outcomes in this guide will enable curriculum developers to align the specific knowledge and skills to these competencies. Similarly, in curricula where ICM and ICN competencies are not covered in midwifery and nursing education, the FGM learning outcomes will need to be aligned to the most relevant or appropriate training module/s. TARGET AUDIENCE This document is aimed at curriculum planners and educators who have been commissioned to develop, review and update existing national and subnational nursing and midwifery pre-service and in-service curricula with relevant FGM content. 3 The overall aim of the FGM training content is to equip health workers with the necessary knowledge and skills to help them provide quality prevention and care services to girls and women at risk of FGM or who have already undergone FGM, regardless of whether these services are being provided at a health facility or during community health outreach. The training content aims to achieve the following learning outcomes by improving knowledge and skills related to FGM: 1. Knowledge on FGM that is relevant to the contextual setting: FGM definition FGM types Guiding principles that FGM is a human rights violation and has no health benefit National/subnational rates of FGM by type National/subnational rates of FGM medicalization 2. Understanding one’s own and the community’s values and attitudes around FGM and the drivers of FGM and FGM medicalization: One’s own values and attitudes towards FGM and FGM medicalization Drivers of FGM and FGM medicalization 3. Legal and accountability measures on FGM and FGM medicalization: FGM violates medical ethics and no health-care provider should perform it National/subnational codes of conduct on FGM National laws on FGM, where relevant Documenting and reporting on FGM and FGM medicalization ii. FGM learning outcomes 4 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide 4. Roles and responsibilities in providing FGM prevention and care services: FGM prevention and care responsibilities at facility level and during community outreach activities based on professional competencies Promoting the role of midwives as advocates for FGM abandonment 5. Management of FGM complications as per professional competencies: General knowledge on FGM complications In-depth knowledge on FGM complications based on FGM types Clinical management steps for health complications based on professional competencies Documenting FGM-related services in managing complications 6. How to offer person-centred communication for FGM prevention: Person-centred communication principles and skills Applying the person-centred communication technique for FGM prevention How to refuse requests to perform FGM Documenting FGM-related services in promoting prevention. NOTE: The overall objective of the FGM training and the six learning outcomes can be applied in both pre- and in-service training material. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 5STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 THE THREE STEPS Provides guidance on the preparatory steps, such as conducting a context assessment regarding FGM and identifying relevant stakeholders to be involved in the curriculum development or update. Details how the responsible Curriculum Review Committee (CRC) or equivalent body applies the findings of the context assessment and review of existing FGM training content already in the curriculum to develop FGM content aligned with the six learning outcomes. Describes how to pilot test the FGM content and scale-up and evaluate the implementation process. This document for planning, developing, implementing and evaluating FGM training content within midwifery and nursing curricula is structured around three steps. A checklist for tracking your status in completing each step in this process can be found in Annex 1. 6 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide Responsible entity: Midwifery and nursing professional authority or organization Responsible entity: The Curriculum Review Committee PREPARE FOR CURRICULUM UPDATE/ DEVELOPMENT IDENTIFY & INVOLVE key stakeholders 1 CREATE / CONVENE Curriculum Review Committee (CRC) Identify professional, academic and community stakeholders to consult during context assessment and who can participate in the Curriculum Review Committee (CRC). Agree on terms of reference of CRC (Table 1 and Annex 2). Convene selected professional, academic and community stakeholders who can provide relevant information on current and expected knowledge and skills on FGM prevention and care. Select Chair, midwifery and/or nursing advisors, facilitator/coordinator, training content lead writer and reviewers. Compile information on the following indicators from relevant sources (Table 2): – FGM knowledge, attitudes, practices (KAP) of nurses and midwives – Service users’ expectations/attitudes on FGM – Evaluation results of FGM training – Drivers of FGM and FGM medicalization – FGM prevalence by types and by practitioner – FGM laws and health policies. Using Worksheet 1: – Indicate where FGM training content features in the curriculum – Identify training content alignment gaps with situational analysis findings – Identify training content gaps based on the six FGM learning outcomes. Decide what FGM learning content midwives and nurses need (Worksheet 1) based on: – Situational assessment (Table 2) – FGM learning outcomes – Decision on the approach to be used for including FGM content (modular, integrated or hybrid) (Table 3) – Draft detailed FGM content – Feedback from stakeholders on the draft curriculum – Update draft FGM content. REVIEW national/subnational FGM profile (situational analysis) DEVELOP FGM CURRICULUM CONTENT 2 DETERMINE & DEVELOP the training content into curriculum 1 2 2 3 REVIEW all FGM content within curricula 1.1 1.2 1.3 2.1 1 1 2.2 PILOT TEST THE FGM CONTENT IMPLEMENT & EVALUATE 3 Responsible entity: – The Curriculum Review Committee – Midwifery and nursing professional authority or organization PILOT TEST TOOLS Table 1: Members of the CRC and their roles Table 2: FGM indicators informing FGM training focus Table 3: Curriculum integra- tion approaches: strengths and weaknesses Worksheet 1: Identifying and addressing FGM training gaps 2 3 Table 4: Guide to pilot testing and evaluating training content 4 1 4 ADJUST AND VALIDATE curriculum based on pilot test 3.1 3.2 Develop pilot test plan and select a group of students and teachers from one or two institutions (Table 4). Train selected teachers on implementation. Evaluate over a defined period, analyse and report to CRC and stakeholders. Adjust curriculum based on results of pilot test. Seek endorsement of adjusted curriculum from CRC. Submit to the midwifery and nursing professional body for validation. SCALE UP trainings3.3 Develop scale-up plan and provide briefing workshops to stakeholders. Implement as appropriate. REGULARLY REVIEW curriculum and update at predetermined intervals 3.4 Regularly conduct evaluations against FGM learning outcomes (Table 4). Review experiences of clinical and classroom learning with students and teachers. Update the curriculum as per findings, including any contextual changes (Tables 2, 3 and 4). 4 2 3 4 1 OVERVIEW OF THE 3 STEPS A checklist for tracking your status in completing each step in this process can be found in Annex 1. 7Responsible entity: Midwifery and nursing professional authority or organization Responsible entity: The Curriculum Review Committee PREPARE FOR CURRICULUM UPDATE/ DEVELOPMENT IDENTIFY & INVOLVE key stakeholders 1 CREATE / CONVENE Curriculum Review Committee (CRC) Identify professional, academic and community stakeholders to consult during context assessment and who can participate in the Curriculum Review Committee (CRC). Agree on terms of reference of CRC (Table 1 and Annex 2). Convene selected professional, academic and community stakeholders who can provide relevant information on current and expected knowledge and skills on FGM prevention and care. Select Chair, midwifery and/or nursing advisors, facilitator/coordinator, training content lead writer and reviewers. Compile information on the following indicators from relevant sources (Table 2): – FGM knowledge, attitudes, practices (KAP) of nurses and midwives – Service users’ expectations/attitudes on FGM – Evaluation results of FGM training – Drivers of FGM and FGM medicalization – FGM prevalence by types and by practitioner – FGM laws and health policies. Using Worksheet 1: – Indicate where FGM training content features in the curriculum – Identify training content alignment gaps with situational analysis findings – Identify training content gaps based on the six FGM learning outcomes. Decide what FGM learning content midwives and nurses need (Worksheet 1) based on: – Situational assessment (Table 2) – FGM learning outcomes – Decision on the approach to be used for including FGM content (modular, integrated or hybrid) (Table 3) – Draft detailed FGM content – Feedback from stakeholders on the draft curriculum – Update draft FGM content. REVIEW national/subnational FGM profile (situational analysis) DEVELOP FGM CURRICULUM CONTENT 2 DETERMINE & DEVELOP the training content into curriculum 1 2 2 3 REVIEW all FGM content within curricula 1.1 1.2 1.3 2.1 1 1 2.2 PILOT TEST THE FGM CONTENT IMPLEMENT & EVALUATE 3 Responsible entity: – The Curriculum Review Committee – Midwifery and nursing professional authority or organization PILOT TEST TOOLS Table 1: Members of the CRC and their roles Table 2: FGM indicators informing FGM training focus Table 3: Curriculum integra- tion approaches: strengths and weaknesses Worksheet 1: Identifying and addressing FGM training gaps 2 3 Table 4: Guide to pilot testing and evaluating training content 4 1 4 ADJUST AND VALIDATE curriculum based on pilot test 3.1 3.2 Develop pilot test plan and select a group of students and teachers from one or two institutions (Table 4). Train selected teachers on implementation. Evaluate over a defined period, analyse and report to CRC and stakeholders. Adjust curriculum based on results of pilot test. Seek endorsement of adjusted curriculum from CRC. Submit to the midwifery and nursing professional body for validation. SCALE UP trainings3.3 Develop scale-up plan and provide briefing workshops to stakeholders. Implement as appropriate. REGULARLY REVIEW curriculum and update at predetermined intervals 3.4 Regularly conduct evaluations against FGM learning outcomes (Table 4). Review experiences of clinical and classroom learning with students and teachers. Update the curriculum as per findings, including any contextual changes (Tables 2, 3 and 4). 4 2 3 4 1 8 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide Preparing for curriculum development or update involves identifying and convening relevant stakeholders as part of a Curriculum Review Committee. STEP 1 PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT WHAT IS A CURRICULUM REVIEW COMMITTEE (CRC)? A CRC consists of a group of people who take responsibility for the curriculum development process and steer the work by members and recruited specialists. Generally, the CRC plays a central role in ensuring that curricula and training content is fit for purpose by: • reviewing current curricula and establishing necessary changes • enabling the achievement of required learning outcomes or competencies • meeting national/local responsible midwifery and nursing professional authority standards • complying with institutional policies and standards, both for health institutions and academic settings • ensuring prerequisites and assessment requirements are clearly described • being accessible to teachers and, where appropriate, to students • providing for expert input (curriculum development/education, midwifery, nursing and other health professionals) • providing for user input (users of the curriculum, and of the service) • developing and reviewing draft documents for final submission to the appropriate body. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Provides guidance on the preparatory steps, such as conducting a context assessment regarding FGM and identifying relevant stakeholders to be involved in the curriculum development or update. 9Ensure that members of the CRC include: • practising midwives, nurses and nursing/midwifery managers • specialist FGM advisors (medical, psychosocial) • teachers (classroom, clinical) who will use the curriculum • members of professional associations • representatives of midwifery and nursing professional authorities (i.e. national midwifery/nursing councils) • faculty and administrators of national academic institution(s) • members of women’s organizations and community-based organizations representing women, girls and communities they represent • ministry of health (MoH) reproductive, maternal, newborn, child and adolescent health (RMNCAH) programme officers • technical officers of international organizations (e.g. WHO, United Nations Population Fund). The Curriculum Review Committee can lead the situation and context analysis that will inform the priority areas of the curriculum. The relevant indicators to consider in defining the scope and priorities of the curriculum are described in Table 2. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 COMPOSITION OF CRC Step 1: Prepare for curriculum update/development 10 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide Sample terms of reference for the CRC can be found in Annex 2. TABLE 1 Members of the CRC and their roles MEMBER ROLES AND RESPONSIBILITIES Committee Chair Responsible for organizing and conducting meetings, ensuring adequate resources, staying informed on standards, monitoring progress of working groups, reporting to academic and clinical authorities. Midwifery/nursing advisors and representatives Responsible for providing the most updated clinical input. Midwifery/nursing education advisors and teachers Responsible for ensuring best educational practice. Information technology/library science specialists Responsible for identifying and advising on relevant and appropriate information resources. Coordinator Responsible for ensuring smooth progress, briefing participants, problem solving, facilitating meetings. Lead writer Responsible for drafting the content of the curriculum, working closely with the Coordinator and Chair to gather information and produce materials aligned with learning outcomes. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 11 TABLE 2 FGM indicators informing FGM training focus RELEVANT INDICATORS FGM TRAINING FOCUS FGM prevalence • Where prevalence is <10%: Training content should emphasize FGM prevention and referral mechanisms to specialized centres for clinical management. • Where prevalence is ≥10%: Training content should focus equally on FGM prevention and FGM care. FGM drivers and types • Ensure that training content on FGM prevention considers the drivers of FGM in that context. • Ensure that clinical management content relates to FGM types present. • If FGM medicalization is present address its drivers and how health- care providers can play a role in stopping this practice. FGM legislation and health policies on FGM • Describe existent legislation and health policy on FGM if present. • If no legislation or policies against FGM exist in the setting, training emphasis should focus on medical ethics of “do no harm” and professional code-of-conduct principles or other relevant accountability mechanisms. Knowledge, attitudes and practice (KAP) related to FGM among health professionals (nurses/midwives) • Where possible, allow the data to determine the key knowledge and skills that need to be strengthened. • Data on FGM-related attitudes of health-care providers can highlight areas to be addressed during training. Data on service users’ expectations/attitudes on FGM • These data can highlight areas to be addressed during clinical encounters and other FGM prevention sessions. Evaluation results for FGM training • Include an evaluation with pre- and post-training assessment using the WHO questionnaire or other KAP questionnaire. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Step 1: Prepare for curriculum update/development 12 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide The curriculum content should be aligned with the six learning outcomes. Worksheet 1 should be used to identify the FGM training content gaps in relation to these learning outcomes while also considering contextual needs (Table 2). The worksheet can also be used to document where the new FGM training content will be integrated within the existent curriculum if an integrated or hybrid approach will be used as described in Table 3. Three approaches can be applied when integrating FGM training content into a curriculum: 1. MODUL AR: FGM content is contained in one module, which covers all FGM training content. 2. INTEGR ATED: FGM content is integrated throughout the curriculum. 3. HYBRID: FGM content is included using a combination of modular and integrated approaches. Each approach has strengths and weaknesses as summarized in Table 3. The integration of FGM training content throughout the curriculum is a recommended approach as it applies FGM knowledge and skills to all midwifery/nursing practice. Some countries may prefer a hybrid approach and have modules dedicated to harmful practices, including FGM, while also integrating FGM prevention and care skills-building within midwifery/nursing clinical care competency modules. The decision on which approach to use will depend on how often the curriculum review process occurs in a particular setting and the current content and structure of the curriculum. For instance, if FGM training content does not coincide with the overall midwifery/nursing curriculum review timeline, a modular approach can be used and FGM training content can be inserted as an addendum to the existing curriculum until the review process occurs. STEP 2: DEVELOP FGM CURRICULUM CONTENT STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Details how the responsible Curriculum Review Committee (CRC) or equivalent body applies the findings of the context assessment and review of existing FGM training content already in the curriculum to develop FGM content aligned with the six learning outcomes. 13 TABLE 3 Curriculum integration approaches: strengths and weaknesses APPROACH STRENGTHS WEAKNESSES SINGLE MODULE that covers all FGM training content. • More straightforward to draft and make future updates • Easy to identify in the curriculum • Can be used as stand-alone content (e.g. for in-service training). • Risk of knowledge and skills gained during this session being overshadowed by other modules because of limited exposure to content during the training period • May be difficult to cross-reference or apply knowledge and skills gained in this component to other components • Not efficient use of curriculum space and time in an already stretched curriculum. INTEGRATED FGM training content throughout the curriculum. • Encourages broad thinking about FGM issues in relation to all midwifery/nursing practice • Highlights relevance of most learning, including less obvious content (e.g. interpersonal communication and advocacy) • Distributed within training content and will not require much adjustment in time allocation. • Can be difficult to identify FGM content in the curriculum during review and update process. HYBRID combines both approaches • Has some similar advantages as first two approaches, such as ease in development while enabling broad thinking about FGM issues in relation to multiple aspects of midwifery/ nursing practice. • Has similar disadvantages to first two approaches, such as being a less efficient approach compared to one that is fully integrated. NOTE: It is important to be aware that FGM curriculum development may take three to six months and even longer if all midwifery/nursing curricula are under review. As an interim measure, countries can adapt the two-day training agenda in Annex 3 for interim in-service trainings. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Step 2: Develop FGM curriculum content 14 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide Si x le ar ni ng o ut co m es t o gu id e tr ai ni ng c on te nt G ap s id en ti fi ed in cu rr en t cu rr ic ul um G ap s in F G M t ra in in g fo cu s pe r co n te xt u al a ss es sm en t fi n d in gs (T ab le 2 ) W he re th e tr ai ni ng co nt en t w ill b e in se rt ed in r ev is ed c ur ri cu lu m 1. Kn ow le dg e on F G M • FG M d efi ni tio n • FG M ty pe s • G ui di ng p rin ci pl es th at F G M is a h um an rig ht s vi ol at io n an d ha s no h ea lth b en efi t • N at io na l/s ub na tio na l F G M p re va le nc e ra te s by ty pe • N at io na l/s ub na tio na l F G M m ed ic al iz at io n ra te s. 2. U nd er st an di ng o ne ’s o w n an d th e co m m un it y’ s va lu es a nd a tt it ud es ar ou nd F G M a nd t he d ri ve rs o f F G M an d FG M m ed ic al iz at io n • O ne ’s o w n an d th e co m m un ity ’s v al ue s an d at tit ud es to w ar ds F G M a nd F G M m ed ic al iz at io n • D riv er s fo r F G M a nd F G M m ed ic al iz at io n. 3. Le ga l a nd a cc ou nt ab ili ty m ea su re s on F G M a nd F G M m ed ic al iz at io n • FG M v io la te s m ed ic al e th ic s an d no he al th -c ar e pr ov id er s ho ul d pe rf or m it • N at io na l/s ub na tio na l c od e- of -c on du ct pe na lti es fo r FG M • N at io na l l aw o n FG M w he re r el ev an t • D oc um en tin g an d re po rt in g on F G M an d FG M m ed ic al iz at io n. W O R K SH EE T 1 Id en ti fy in g an d ad dr es si ng F G M t ra in in g ga ps STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 15 Si x le ar ni ng o ut co m es t o gu id e tr ai ni ng c on te nt G ap s id en ti fi ed in cu rr en t cu rr ic ul um G ap s in F G M t ra in in g fo cu s pe r co n te xt u al a ss es sm en t fi n d in gs (T ab le 2 ) W he re th e tr ai ni ng co nt en t w ill b e in se rt ed in r ev is ed c ur ri cu lu m 4. Ro le s an d re sp on si bi lit ie s in p ro vi di ng FG M p re ve nt io n an d ca re s er vi ce s • FG M p re ve nt io n an d ca re re sp on si bi lit ie s at fa ci lit y le ve l a nd du rin g co m m un ity o ut re ac h ac tiv iti es ba se d on p ro fe ss io na l c om pe te nc ie s • Pr om ot in g ro le o f m id w iv es a s ad vo ca te s fo r F G M a ba nd on m en t. 5. M an ag em en t o f F G M co m pl ic at io ns a s pe r pr of es si on al co m pe te nc ie s • G en er al k no w le dg e on F G M co m pl ic at io ns • In -d ep th k no w le dg e on F G M co m pl ic at io ns b as ed o n FG M ty pe • Cl in ic al m an ag em en t s te ps fo r e ac h co m pl ic at io n ba se d on p ro fe ss io na l co m pe te nc ie s • D oc um en tin g an d re po rt in g FG M c ar e se rv ic es . 6. H ow t o off er p er so n -c en tr ed c om m u - ni ca ti on fo r FG M p re ve nt io n • Pe rs on -c en tr ed c om m un ic at io n pr in ci pl es a nd s ki lls • Ap pl yi ng th e pe rs on -c en tr ed c om m un i- ca tio n te ch ni qu e fo r F G M p re ve nt io n • H ow to re fu se re qu es t t o pe rf or m F G M (w he re F G M m ed ic al iz at io n is p re se nt ) • D oc um en tin g FG M p re ve nt io n se rv ic es . STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Step 2: Develop FGM curriculum content 16 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide PLANNING THE PATHWAY FOR FGM WITHIN THE CURRICULUM The curriculum pathway is how FGM content is distributed within the curriculum. It is important that curriculum developers ensure that FGM training content follows a logical learning experience for students, with each new topic building on what they have learned earlier. For example, female anatomy and physiology will need to be established prior to introduction of FGM definitions and typology. How FGM affects structure and function can follow. Similarly, FGM epidemiology and its drivers as well as legal issues related to this practice should be covered before progressing to FGM prevention counselling skills-building. It might be evident that FGM content needs to be included in some learning modules, such as women’s health and gynaecology as well as care of women during childbirth. However, including FGM in other sections of the curriculum – such as those related to professional codes of conduct – can encourage students to understand the experiences and needs of women and girls who have undergone the practice or are at risk of experiencing it. It is important to keep a record of where FGM features in the curriculum for future updating. NOTE: A comprehensive curriculum will focus not only on the knowledge, skills and practices expected of students, but will also include a section on guidance for teachers; for example, on appropriate learning and teaching methods than can be used, and guidance on assessment. Refer to the training timetable in Annex 3 for a stand-alone training addressing the six learning outcomes. STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 17Step 2: Develop FGM curriculum content 18 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide Assessments before and after implementing new content will ensure the content is accessible, adequate, feasible and effective. A pilot test of proposed content is recommended prior to implementation to ensure that any changes can be incorporated before scaling up. A process or final evaluation will ensure that the learning outcomes are achieved. CONSIDERATIONS WHEN PLANNING FOR AND CONDUCTING PILOT TESTS OR EVALUATIONS Piloting (or pre-testing) and evaluating FGM training content helps to identify sections of the curriculum that work well and those that need adjustment to achieve the required FGM learning outcomes. Some considerations are listed in Table 4. Once the data are analysed and results compiled in a report, the CRC and other relevant stakeholders can review and decide which areas will require revisions and what steps should be taken before roll-out of revised FGM content. STEP 3: PILOT TESTING, IMPLEMENTING AND EVALUATING CONTENT STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Describes how to pilot test the FGM content and scale-up and evaluate the implementation process. PILOT TEST describes how the new or revised curriculum is pilot tested to ensure it is fit for purpose with students and teachers before being adopted and rolled out. SCALE-UP AND EVALUATE details how the new/updated curriculum is put into general use and how it is evaluated at predetermined intervals. 19 TABLE 4 Guide to pilot testing and evaluating training content APPROACH PILOT-TEST EVALUATION Areas to be tested or assessed • FGM content (select content expected to contribute to key skills/learning outcomes in FGM prevention and care) • Clinical and classroom teaching methods attained by students • Assessment strategies and how well they work • Six FGM learning outcomes. • FGM content (select content expected to contribute to key skills/learning outcomes in FGM prevention and care) • Clinical and classroom teaching methods attained by students • Assessment strategies and how well they work • Six FGM learning outcomes. Evaluation method Qualitative: • In-depth interviews/focus groups • Observation of clinical or classroom teaching. Quantitative: • Special test forms, questionnaires (e.g. WHO KAP questionnaire), clinical skills assessment sheets, checklists, clinical scenarios Qualitative: • In-depth interviews/focus groups • Observation of clinical or classroom teaching. Quantitative: • Special test forms, questionnaires (e.g. WHO KAP questionnaire), clinical skills assessment sheets, checklists, clinical scenarios Who will conduct it • Representatives of clinical midwifery/ nursing schools; teachers, professors or external consultant • Representatives of clinical midwifery/ nursing schools; teachers, professors or external consultant Who will be assessed • Teachers/Professors • Students NOTE: Students and professors who participate in the assessments need to understand that their feedback is confidential and will not affect their employment or educational status. • Teachers/Professors • Students NOTE: Students and professors who participate in the assessments need to understand that their feedback is confidential and will not affect their employment or educational status. Where • A sample from a class of students and their teachers in two different geographical regions with varying FGM prevalence. • 1–2 classes of students and their teachers in 3-5 training institutions in different geographical regions with varying FGM prevalence. Frequency and timeline • 4–6 weeks (start to finish) • Every 3–5 years Domains for data analysis and reporting • Content relevance, accuracy, suitability and comprehensibility • Knowledge, skills and behaviour change with regards to the six FGM learning outcomes • Content relevance, accuracy, suitability and comprehensibility • Knowledge, skills and behaviour change with regards to the six FGM learning outcomes STEP 3: PILOT TEST & EVALUATE THE FGM CONTENT 3 STEP 1: PREPARE FOR CURRICULUM UPDATE/DEVELOPMENT 1 STEP 2: DEVELOP FGM CURRICULUM CONTENT 2 Step 3: Pilot testing, implementing and evaluating content 20 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide ANNEX 1 CHECKLIST FOR INTEGRATING FGM CONTENT KEY TASKS SPECIFIC ACTIVITIES STATUS Identify and involve key stakeholders Identify professional, academic and community stakeholders to consult during context assessment and who can participate in the Curriculum Review Committee (CRC). NOTES Create/convene Curriculum Review Committee (CRC) Agree on terms of reference of CRC (Table 1 and Annex 2). Convene selected professional, academic and community stakeholders who can provide relevant information on current and expected knowledge and skills on FGM prevention and care. Select Chair, midwifery and/or nursing advisors, facilitator/coordinator, training content lead writer and reviewers. NOTES Conduct situational analysis Compile information on the following indicators from relevant sources (Table 2): • FGM knowledge, attitudes, practices (KAP) of nurses and midwives • Service users’ expectations/attitudes on FGM • Evaluation results of FGM training • Drivers of FGM and FGM medicalization • FGM prevalence by types and by practitioner • FGM laws and health policies. NOTES STEP 1: Prepare for curriculum update/development 21 KEY TASKS SPECIFIC ACTIVITIES STATUS Review all FGM content within curricula Using Worksheet 1: Indicate where FGM training content features in the curriculum Identify training content alignment gaps with situational analysis findings Identify training content gaps based on the six FGM learning outcomes. NOTES Determine and develop the training content into curriculum Decide what FGM learning content midwives and nurses need (Worksheet 1) based on: • Situational assessment (Table 2) • FGM learning outcomes • Decision on the approach to be used for including FGM content (modular, integrated or hybrid) (Table 3) • Draft detailed FGM content • Feedback from stakeholders on the draft curriculum • Update draft FGM content. NOTES STEP 2: Develop FGM curriculum content 22 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide KEY TASKS SPECIFIC ACTIVITIES STATUS Pilot test Develop pilot test plan and select a group of students and teachers from one or two institutions (Table 4). Train selected teachers on implementation. Evaluate over a defined period, analyse and report to CRC and stakeholders. NOTES STEP 3: Pilot test the FGM content 23 STEP 3: Pilot test the FGM content KEY TASKS SPECIFIC ACTIVITIES STATUS Adjust and validate curriculum based on pilot test Adjust curriculum based on results of pilot test. Seek endorsement of adjusted curriculum from CRC. Submit to the midwifery and nursing professional body for validation. NOTES Scale up trainings Develop scale-up plan and provide briefing workshops to stakeholders. Implement as appropriate. NOTES Regularly review curricu- lum and update at prede- termined intervals Regularly conduct evaluations against FGM learning outcomes (Table 4). Review experiences of clinical and classroom learning with students and teachers. Update the curriculum as per findings, including any contextual changes (Tables 2, 3 and 4). NOTES STEP 3 (cont.): Implement and evaluate 24 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide ANNEX 2 TERMS OF REFERENCE OF THE CURRICULUM REVIEW COMMITTEE Terms of reference that describe the CRC’s purpose, authority and scope should be developed and should include the following content, which can be adapted for a particular setting: • Clear description of the purpose of the CRC; for example, development of a curriculum with updated FGM content • Outline of what needs to be achieved; for example, review of current curricula to analyse necessary changes and development of an updated version • Process for selecting the Chair • Arrangements for briefing CRC members, including individual and collective roles and responsibilities and their limits, reporting guidelines and structure, confidentiality boundaries • Roles and responsibilities of key actors • Qualifications of individual members • Time frame for membership and time frame for the committee • Suggested arrangements for release from other responsibilities • Arrangements for recruiting new and terminating non-performing members • Communication strategies and feedback structures. 25 ANNEX 3 FGM STAND-ALONE TRAINING TIMETABLE The overall aim is to equip health-care providers with the necessary knowledge and skills to help them provide quality prevention and care services at health facility or community health outreach level to girls and women at risk of FGM or who have undergone FGM. Session Title Content Emphasis Training Material Training Method Duration Introduction to FGM • FGM definition • FGM types • Guiding principles that FGM is a human rights violation and has no health benefit • National/subnational FGM rates by types • Rates of FGM and FGM medicalization (national/ subnational • Slide presentation including key indicators on FGM prevalence and response at national/ subnational levels • Sessions 4.1, 4.2, 4.3, 4.5, 4.6 from WHO’s Person- centred Communication for FGM Prevention: A facilitator’s guide for training health-care providers • Presentation • Group exercise 60 mins Values and attitudes towards FGM; drivers of FGM and FGM medicalization • Examine one’s own and community’s values and attitudes towards FGM and FGM medicalization • Drivers of FGM and FGM medicalization • Session 3 in WHO’s Person- centred Communication for FGM Prevention: A facilitator’s guide for training health-care providers • Group exercise 60 mins Introduction to role of health- care providers in addressing FGM • FGM prevention and care at facility and during community outreach activities • Promoting role of midwives as advocates for FGM abandonment • Sessions 5.1 and 6.1 in WHO’s Person-centred Communication for FGM Prevention: A facilitator’s guide for training health- care providers • Animated video • Presentation • Group exercise 120 mins Legal aspects • FGM violates medical ethics and no health-care provider should perform it • National/subnational code-of-conduct penalties • National law on FGM • Documentation and reporting of FGM and FGM medicalization • Sessions 9.3, 9.4 and 9.5 in WHO’s Person-centred Communication for FGM Prevention: A facilitator’s guide for training health- care providers • Session 9.2 slide presentation templates (five slides) • If available, MoH reporting or referral forms on FGM for legal measures • Presentation • Group exercises • Exercise on completing MoH form 60 mins 26 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide Session Title Content Emphasis Training Material Training Method Duration 1. FGM prevention • Person-centred communication principles and skills • Sessions 6.2–6.6 in WHO’s Person-centred Communication for FGM Prevention: A facilitator’s guide for training health- care providers • Presentation • Role plays 40 mins • Applying the person- centred communication technique for FGM prevention • Sessions 8.2 and 8.3 in WHO’s Person-centred Communication for FGM Prevention: A facilitator’s guide for training health- care providers • Participatory exercise 120 mins • How to refuse an FGM request • Sessions 9.6 and 9.7 in WHO’s Person-centred Communication for FGM Prevention: A facilitator’s guide for training health- care providers • Participatory exercise 90 mins • Documenting and reporting FGM prevention services • Sample forms for MoH clinical recording and monthly reporting • Practice session • Handouts 30 mins 2. Care for FGM complications • General information on FGM complications • Focus on FGM complications related to FGM types at national/ subnational level • Session 4.4 from WHO’s Person-centred Communication for FGM Prevention: A facilitator’s guide for training health- care providers • Slides on common FGM types and associated complications • Presentation 45 mins • Clinical management steps for each complication based on the skill set and competencies as defined by the MoH • Presentation • Handouts from WHO’s Clinical Handbook on Care of Girls and Women Living with FGM, including any nationally adapted versions • Practice session • Handouts 60 mins • Documenting and reporting FGM care services • Sample form for MoH clinical recording and reporting • Practice session • Handouts 30 mins 27 References 1. International Confederation of Midwives. Essential competencies for midwifery practice: 2018 update. The Hague: ICM; 2019 (https://www.internationalmidwives.org/assets/files/general-files/2019/02/icm-competencies_english_final_jan-2019-update_ final-web_v1.0.pdf, accessed 7 September 2021). 2. International Council of Nurses. Nursing care continuum framework and competencies. Geneva: ICN; 2011 (https://siga-fsia.ch/ files/user_upload/07_ICN_Nursing_Care_Continuum_Framework_and_Competencies.pdf, accessed 7 September 2021). Useful Resources International Confederation of Midwives (2013). ICM Global Standards for Midwifery Education. The Hague: ICM (https://www. internationalmidwives.org/assets/files/general-files/2018/04/icm-standards-guidelines_ammended2013.pdf, accessed 7 September 2021). International Confederation of Midwives (2013). ICM Global Standards for Midwifery Education – Companion Guidelines. The Hague: ICM (https://www.internationalmidwives.org/assets/files/general-files/2018/04/companion-guidelines-for-ed-standards-2011--- amended-web-edition-june-2013.pdf, accessed 7 September 2021). International Confederation of Midwives (2014). International Code of Ethics for Midwives. The Hague: ICM (https://www. internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf, accessed 7 September 2021). International Confederation of Midwives (2017). Female genital mutilation. Position statement. The Hague: ICM (https://www. internationalmidwives.org/assets/files/statement-files/2018/04/eng-fgm.pdf, accessed 7 September 2021). International Confederation of Midwives (2017). Heritage and culture in childbearing. Position statement. The Hague: ICM (https:// www.internationalmidwives.org/assets/files/statement-files/2018/04/eng-heritage-and-culture-in-childbearing.pdf, accessed 7 September 2021). International Confederation of Midwives (2017). Midwives, women and human rights. Position statement. The Hague: ICM (https:// www.internationalmidwives.org/assets/files/statement-files/2018/04/eng-midwives-women-and-human-rights1.pdf, accessed 7 September 2021). International Confederation of Midwives (2017). Professional accountability of the midwife. Position statement. The Hague: ICM (https://www.internationalmidwives.org/assets/files/statement-files/2018/04/professional-accountability-of-the-midwife-eng.pdf, accessed 7 September 2021). International Council of Nurses (2011). Nurses and human rights. Position statement. Geneva: ICN (https://www.icn.ch/sites/default/ files/inline-files/E10_Nurses_Human_Rights%281%29.pdf, accessed 7 September 2021). International Council of Nurses (2011). Women’s health. Position statement. Geneva: ICN (https://www.icn.ch/sites/default/files/inline- files/A19_Womens_Health.pdf, accessed 7 September 2021). International Council of Nurses (2012). The ICN Code of Ethics for Nurses, Revised 2012. Geneva: ICN (https://www.icn.ch/sites/ default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf, accessed 7 September 2020). International Council of Nurses (2018). Health of migrants, refugees and displaced persons. Position statement. Geneva: ICN (https:// www.icn.ch/sites/default/files/inline-files/PS_A_Health_migrants_refugees_displaced%20persons_0.pdf, accessed 7 September 2021). UNAIDS, UNDP, UNFPA, UNHCR, UNICEF, UNIFEM, WHO, FIGO, ICN, IOM, MWIA, WCPT, WMA (2010). Global strategy to stop health care providers from performing female genital mutilation. Geneva: WHO (https://apps.who.int/iris/bitstream/handle/10665/70264/ WHO_RHR_10.9_eng.pdf, accessed 7 September 2021). References 28 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide United Nations Population Fund (2018). Calling for the end of the medicalization of female genital mutilation. New York: UNFPA (https://www.unfpa.org/sites/default/files/resource-pdf/FGM_Policy_Brief_On_Medicalization_Brochure_-_PDF_June_18.pdf, 7 September 2021). World Health Organization (2001). Female genital mutilation: Integrating the prevention and management of the health complications into the curricula of nursing and midwifery – a teacher’s guide. Geneva: WHO (https://www.who.int/gender/other_health/ teachersguide.pdf, accessed 7 September 2021). World Health Organization (2008). Resolution WHA61.16. Female genital mutilation. In: Sixty-first World Health Assembly, Geneva, 24 May 2008. Geneva: WHO (https://apps.who.int/iris/bitstream/handle/10665/23532/A61_R16-en.pdf, accessed 7 September 2021). World Health Organization (2013). Midwifery educator core competencies. Geneva: WHO (https://www.who.int/hrh/nursing_ midwifery/13012WHO_Midwifery_educator_core_competencies.pdf, accessed 7 September 2021). World Health Organization (2016). WHO guidelines on the management of the health complications from female genital mutilation. Geneva: WHO (https://apps.who.int/iris/bitstream/handle/10665/206437/9789241549646_eng.pdf, accessed 7 September 2021). World Health Organization (2018). Care of girls & women living with female genital mutilation: a clinical handbook. Geneva: WHO (https://apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf, accessed 7 September 2021). World Health Organization (2019). Strengthening quality midwifery education for Universal Health Coverage 2030: framework for action. Geneva: WHO (https://apps.who.int/iris/bitstream/handle/10665/324738/9789241515849-eng.pdf, accessed 7 September 2021). 29 30 Integrating female genital mutilation content into nursing and midwifery curricula: a practical guide