A representative, cross-sectional clinical skills assessment of 163 mid-level, rural-based, government health care workers was conducted in four districts of Nepal in June 2007. All Health Assistants and Auxiliary Healthcare Workers within the target districts were scored using checklists of standardized key skills in clinical encounters with model patients or clinical models. Participant scores were reported as a mean percentage in adult medicine 28(%), pediatric medicine 56(%), maternity medicine 35(%), orthopedic medicine 45(%), clinical procedures 59(%), and management 46(%). This was measured against the government’s 60(%) standard on clinical skills. There was little significant difference between categories of health workers by district of posting or years of experience. There was a minor difference in skills by level of facility - workers in higher level facilities scored better across the domains. Reasons for poor performance in clinical skills were attributed to a lack of clinical in-service training programs, training only focusing on prevention and public health, and poor on-sight supervision. Poor pre-service schooling factors included heavy theory concentration in pathophysiology and inadequate clinical exposure opportunities. Recommendations for the improvement of clinical skills and decision-making include the institution of in-service competency-based training with a high emphasis on real patient exposure. Pre-service recommendations include implementation of a national certification program and an expansion of the current government clinical training sites and clinical teacher development programs.





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