TRAINING STAFF FOR NEW SERVICES
It is important to plan for training current staff and onboarding new staff to help ensure consistency. You can plan for staff training needs in various areas below.
1. Helping alert patients about reproductive services
Patients may not know or assume that their provider offers abortion care. Studies exploring if, when, and how patients wish to be informed of available abortion services at their primary care clinics showed participants were most open to provider-initiated discussion of available abortion services during wellness exams or contraception visits (Dianat 2020, Hatcher 2018). Appropriate communication of abortion services included: 1) using sensitive language, 2) respect for and assessment of patient beliefs, and 3) contextualizing abortion services within reproductive health. Routine inclusion of description of abortion services may help educate patients about available services, strengthen the patient-provider relationship, and reduce abortion stigma.
2. Scheduling Appointments
Make every effort to minimize the wait time for an appointment, as well as the number of calls and visits required to complete the process. In states where laws mandate waiting periods, expediting care can be more difficult.
Consider incorporating telehealth for aspects of screening and counseling. Utilize other members of the care team for elements such as information provision, counseling and follow up, as appropriate.
All staff interact with patients about their reproductive health needs, including front desk personnel, medical assistants, nurses, and providers. So it is important that all staff are trained in using non-judgemental and gender neutral language while speaking with patients in order to create an inclusive environment.
A sample Abortion Scheduling Template (TEACH) is available for use.
3. Patient-Centered Counseling and Consent
In many primary care settings, the provider does most of the counseling, but occasionally a counselor may take on this role. Unlicensed staff can provide information and investigate patient concerns, which can be followed up by the provider, who usually undertakes formal consenting. In addition to having staff members review Chapter 2 of this Workbook, consider having them visit a high-volume abortion site to observe counseling styles and get an understanding of workflows. Counseling around early pregnancy loss (EPL) can differ substantially from options counseling for an abortion visit (see Chapter 8 and providecare.org).
4. Ultrasound (US) Training
There are many ways to increase staff ultrasound skills. Consider starting staff training with dating ultrasounds using online ultrasound training videos available through the University of Washington, AUIM, or NAF (for members). If you work with Planned Parenthood, you may have access to their interactive online curriculum. If US is available on site, it is also helpful to receive training on US guidance to assist with challenging procedures.
There are an increasing number of options for point-of-care ultrasound machines available for purchase for a practice setting. Consider consulting with individual colleagues, on reproductive health listservs, or reviews.
5. Assisting in the Procedure Room
Just as you went through your individual training, your support staff will need training in many of the same techniques and language and Chapter 6 of this Workbook is a good resource for them. A Training Checklist for Staff Assisting in the Procedure Room (TEACH) may be a useful training tool.
6. Working With Interpreters
For your patients who speak other languages, use the resources for interpretation that you already use in your practice. Utilizing certified bilingual staff or professional interpreters is essential. This can be done with in person or telephone interpreter services. These resources should provide comprehensive language skills, neutrality and confidentiality. Document the use of interpreter services, interpreter name and identification number if applicable. For patients who are deaf or hard of hearing and use sign language, ensure you have sign language interpreters available or on site video platforms for sign language interpretation. The AAFP provides resources for incorporating medical interpreters into your practice.
7. Preparing for Medical Emergencies
Medical complications may arise in any clinical setting and preparedness is the key to managing any medical emergency effectively. Simulation and drills build communication, improve staff readiness during a crisis, and decrease risk to patients. Many medical emergency simulation drills (TEACH, Abortion Clinic Toolkit) are available and can be carried out on a quarterly or recurrent basis.
8. Preparing for Security Emergencies
Security is also an issue for any medical setting. Security drills help prepare staff to handle critical situations. They also help staff understand their role in keeping their workplace safe, express concerns, and know their fears are taken seriously. When working with your staff, it may be helpful to put security into a larger framework (e.g. all clinics need to be prepared to handle fires or disruptive patient behavior, not just those that offer abortion services). We have linked to five different security drills that may be useful to practice.
New providers should consider personal and online security precautions before beginning to provide services. See Chapter 9: Personal Security Section.
9. Sterilization and Disinfection
We have included easy-to-follow training posters on the following techniques:
- Wrapping Instruments and Trays for Sterilization (TEACH)
- Unwrapping Sterile Packages, Using Aseptic Technique (TEACH)
- Decontaminating, Cleaning & Disinfecting the IPAS Syringe (Ipas)
- Reprocessing Vaginal Ultrasound Probe (TEACH)
10. Fetal Tissue Questions and Disposal
Patients often have questions about fetal development and want to see or know what happens to the tissue. See Chapter 2 for how to answer these questions. All removed tissue is considered biohazard and must be handled, stored, and disposed of in a manner that minimizes the risk of exposure. (NAF 2022). A protocol for tissue handling, storage, and disposal must be in place (Stanford EHS 2017). Some patients may request to take tissue home for a variety of reasons. This however, is regulated in several states due to public health concerns. Contact your local Department of Health to determine current regulations.
11. Medications, supplies, and storage
It may take some time and up-front cost to order necessary medications and supplies. A comprehensive list of medications, supplies, and vendors necessary to provide medical and aspiration management of EPL and / or abortion can be found here and a sample budget here.
If your site is already doing IUD insertions, adding a set of dilators and manual vacuum aspirators to an IUD set up may be all that you need for aspiration procedures.
Additional medications that should be stocked include medications for pain control and for complication management. For pain control, sites should have ibuprofen and lidocaine available. For complication management, it is important to have misoprostol and/or methergine readily available in case of hemorrhage. Additionally, sites should consider having medications available for unlikely allergic reactions and a foley catheter with a large balloon for intrauterine tamponade.
For medication abortions, a step-by-step guide for ordering mifepristone is available at Mifepristone Ordering Guide (RHAP). UW Access Delivered Provider Toolkit is another resource for this process. Misoprostol only regimens are also available and effective. If you have mifepristone on site, store it in a secure location. Dispensing requirements and updates to the REMs criteria are also available. Please see Chapter 4.
12. After Hours Calls
For patients undertaking EPL management or abortion care, provide a 24-hour contact number to triage any concerns that arise. Counseling patients thoroughly on what to expect will help decrease the number of calls, but often a phone call can save your patients an ED visit. Print after-hours number on your written aftercare instructions. (See Chapter 7 Abortion Aftercare for sample aftercare instructions.)
- All members of the call pool should be familiar with triage algorithms and informed that these additional services are being provided.
- Leadership buy-in is critical so that all providers in the call pool understand they are expected to appropriately triage patients.
13. Telemedicine Medication Abortion
Medication abortions can be performed safely and effectively in office or via telemedicine, however it is important to know your local state-based laws and regulations (KFF 2022). Medications can be sent by mail, via a mail order pharmacy in certain states, or prepared for drive-by pick up. Staff should be trained to offer this service to patients, as appropriate. Please see Chapter 4 for detailed protocols for telemedicine medication abortion.
In late 2021, the FDA modified the REMS criteria, removing the “in-person dispensing requirement.” However, providers must contract with specific mail order pharmacies for home delivery of mifepristone. The UW Access Delivered Provider Toolkit is an excellent resource for specifics on setting up mail order pharmacy services.