Objectives

Training frontline providers to effectively:

  • Learn a simple model for effective referral-making
  • Recognize the emotional importance of honoring clients’ right to make their own decisions
  • Explain their professional responsibility to honor clients’ decisions and privacy
  • Recognize how their own feelings and attitudes might conflict with providing care
  • Identify referral behaviors that respect clients’ confidentiality and right to make their own decisions
  • Increase their sense of comfort and professional pride about referring even when they feel personally ambivalent

Duration

70 minutes, including:

  • 20 minutes: Introduction to the Module
  • 20 minutes: Activity: Providers Have Feelings, Too
  • 20 minutes: Activity: Separating Personal Views from Professional Responsibility
  • 10 minutes: Wrap-up: Power Point and Closing Discussion

Materials Needed

Introduction to the Module

(20 minutes)

After welcoming the group:

  1. Introduce yourself, your co-trainers, and the work of Provide.
  2. Be clear with your audience that this training will teach trainees how to make effective abortion referrals for women facing an unintended pregnancy who elect to end the pregnancy. The training will not focus on adoption referrals or on referrals for prenatal care or parenting help. Trainers can make suggestions about organizations to contact for more information on those referrals. Remind the audience that there are many excellent trainings on full options pregnancy counseling; however, the focus of this training is referring for abortion care.
  3. Share the aims of the workshop: Recognize that to make effective referrals for various kinds of client needs, staff must manage a considerable amount of knowledge and skill. Acknowledge that sometimes we’re not sure how to deal with a situation, and that this series of training sessions will provide tools to help them make the referrals that clients need.
  4. Share the aims of this module: Exploring professional responsibility to honor clients’ decisions and privacy (or the core values that bring trainees to their line of work) as well as recognizing how individual feelings may conflict with providing care.

Note

With some audiences, it may be useful to note that the aim of the training is not to change their minds about abortion, but to teach them how to do effective referrals for people seeking abortion care.

  1. Introductions: Ask the group to introduce themselves. (If the group is very large, this may need to be abbreviated or cut entirely.)
  2. Community Agreements: Suggest community agreements to set rules for how the group will interact with each other.
  1. Suggest that instead of creating a safe space for the training, we would like participants to create a brave space. [Use flipchart and put Brave Space at the top of the flipchart paper.]
  2. Explain to participants that trainers report back to site supervisors about the training and offer technical assistance to sites to incorporate high-quality abortion referrals into the site. Therefore, we do not want to set the expectation that the training is confidential.
  3. Instead, we want to create a Brave Space: A Brave Space is a space where participants can be open, vulnerable, and honest about their experience making abortion referrals for patients/clients. Participants are active listeners who ask questions to increase their understanding of the concepts presented and other participants point of view.
  4. Establish some ground rules in the Brave Space. These could include (but are not limited to):
  1. Validate and support the ideas, feelings or experiences of others.
  2. Be open to people sharing difficult experiences.
  3. Ask questions to learn more about other participants experiences.
  • If appropriate, suggest a parking lot for questions that arise during the training. [Use flipchart for parking lot.]
  1. Shift gears: Explain that the session starts in an unusual place: thinking about our experience not as providers but as patients or clients.
  1. Ask participants to recall a time that they sought help from a health care provider, and received care that made them feel listened to and understood. [Allow them a few moments to remember.]
  2. Check to see if there are at least a few people who have recollections.
  3. Ask them—without necessarily disclosing what happened—to say how it felt, using emotion words. Write the words on a flipchart.
  4. Ask participants to recall a time that they sought help from a health care provider, and felt judged or got unwanted advice—or feared being judged. [Allow them a few moments to remember.]
  5. Check to see if there are at least a few people who have recollections.
  6. Ask them—without necessarily disclosing what happened—to say how it felt, using emotion words. Write the words on a flipchart.
  7. After a few responses, process by reminding participants that—even if it was not related to our health care—we’ve all experienced these positive and negative feelings, and understanding our clients’ feelings and needs is paramount for serving them well and for making proper referrals.

Providers Have Feelings, Too

(20 minutes)

Note

Abortion should be an example throughout this activity. Be sure that you include it in your examples in Steps 1 and 2. If participants do not raise it in Steps 5 and 7, probe for situations related to unintended pregnancy.

  1. Acknowledge that as providers, the participants encounter patients/clients in various situations, and are asked to respond to a wide range of requests for help, including requests for help accessing women’s reproductive health care services. Ask what kinds of women’s reproductive health services patients/clients ask about. [Use flipchart to list responses. Make sure they mention abortion.]
  2. Acknowledge that some situations can cause discomfort for providers and that is normal. For example, studies show that some providers are not comfortable helping a woman requesting an abortion referral, or providing full referral support to clients from marginalized groups, or referring adolescents for contraceptive services. Ask whether certain situations or requests are more likely to cause provider discomfort or resistance, etc., at their workplace. A woman experiencing violence? A sex worker needing an HIV test? Someone requesting prenatal care? Abortion? Infertility services?
  3. Ask for a show of hands if a patient/client has ever inquired about a problem that made them feel uncomfortable or ambivalent—either because they do not know how to help, or have personal feelings about the type of service requested, about the client, and/or about the nature of the situation. [Allow them time to reflect; check that at least some recall such a situation.]
  4. Put them in pairs and allow a few minutes to talk about the following: (put the following bulleted items on a flipchart or use the Module 1 Presentation, Slide 2)
  • the situation;
  • the feelings it caused;
  • how they handled the situation (what they did);
  • the underlying principles or values that guided how they handled it

Note

Asking participants to jot down a few notes about their story may increase their willingness to share later in the activity.

  1. Then ask about the factors underlying people’s hesitations. Probe for: ‘Protectiveness’ toward client; Protecting one’s own emotional comfort zone; Personal values (e.g., about abortion); Lack of information; Lack of skills; etc. Write all responses on the flipchart.

Note

Asking participants to publicly declare that they are not making certain types of referrals can cause embarrassment, or can divert the conversation to the legitimacy/illegitimacy of certain services. Instead, focus on what the provider felt in the face of the request, e.g., lack of information, lack of skill, personal anxiety, moral objection, lack of time, a sense that the client did not realize what was best for him/her.

  1. Ask about any situations [types of services/referrals] in which they went ahead and provided thorough referrals or other care despite their own discomfort or ambivalence.
  • Ask about the specific situation. [Allow responses as time allows; probe for abortion].
  • Ask about the principles underlying their actions. Probe for: Confidentiality; Respect; Client rights; Professional standards; Autonomy.
  1. Write AUTONOMY on the flipchart; ask what autonomy means. Probe for (and write on flipchart): moral independence; self-directing freedom. Acknowledge that respecting every single client’s autonomy can be a challenging part of maintaining professional competence. Remind participants that honoring client autonomy is a core principle of care-giving, emphasized in virtually every professional code of ethics. Segue to next activity.

Note

Note: Trainers may wish to keep the flipchart paper with AUTONOMY on the wall throughout the training and refer to it repeatedly.

Separating Personal Views from Professional Responsibility

(20 minutes)

Note

Depending on the audience you are training, you may need to adapt this activity. Some in the audience may be governed by professional code of ethics whereas others are not.

Note

Trainers should familiarize themselves with the code of ethics relevant for each audience.

  1. 1. Ask the trainees what kinds of professional codes inform the work they do. [Professional codes could be degree/profession-based (i.e. nursing/social work) whereas others could be job-based (i.e. domestic violence advocates).]
  • In situations where many in the audience do not adhere to a degree/profession-based professional code, trainers may consider exploring the core values that bring trainees to the work they do such as compassion, dignity, worth of the individual, empowerment, etc.
  1. Demonstrate a negative role-play for referral, asking participants to think about their code of ethics/core values while watching the role-play. This can be for abortion or for another service that providers sometimes stigmatize. If you are training alone, take the role of the “bad referral-maker” ask for a volunteer to play the role of the client.
  2. Ask participants to identify all the ways that the provider failed in her/his professional responsibility/core values. Probe for: What did this client need? What did she get? How do you think she felt? What do you think happened after she left? What do you think was going on in the provider’s mind/heart? [Note: The aim is to help participants recognize and devalue behavior that is judgmental and/or does not respect client autonomy. It is not about counseling techniques such as open-ended questioning, etc.]
  3. Acknowledge that living up to our professional responsibilities can sometimes cause discomfort. Using PowerPoint and/or Handouts: Introduce the STAR model as a user-friendly way to ensure quality referral-making. Explain that they will have opportunities in later sessions to practice with this model but for now use the STAR model to briefly identify what the provider might have said/done.

Wrap-up: Power Point and Closing Discussion

(10 minutes)

  1. Show PowerPoint slide reinforcing 3-4 key ethical principles for client-provider interactions [Mention: Autonomy; Confidentiality; Informed Consent].
  2. Mention that professional codes also address these issues. Clarify, for example, that in the case of actual abortion provision, physicians’ codes allow individuals to abstain from performing abortion under the conscientious objection clause; however, the code specifies that they must then refer the client for abortion.
  3. Close by reinforcing: Even when it is hard, you can perform at a professional level and make proper referrals for your clients. Explain that the next session will give them practice at making referrals in different challenging situations.