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Train the Trainer: A Comprehensive Approach to working with Healthcare Professionals Caring for Aging Holocaust Survivors:


 Paula David, MSW, CSW, Melissa Tafler, MSW, CSW Jodeme Goldhar, MSW, CSW May 2000


Rationale for the Model:
As fiscal resources become exceedingly strained and as workloads become increasingly more difficult, social workers need to respond in innovative, efficient and cost effective ways in order to provide and share education to multidisciplinary staff both within institutional and community care programs. Moreover, as the demographics increase for older adults and as service requirements become more complex, the available health care delivery tends to become fragmented. As such, it is crucial to develop collaborative working relationships with health care professionals in diverse settings in order to develop best practice guidelines and integrative models of care.

Today's Health Care system is a complex one that requires professionals and para-professionals to maintain and sustain an equally complex knowledge base. This paper will outline a model for staff education and development that is flexible enough to be discipline specific, suitable for lrge or small groups and cost effective. The package was initially developed and designed by the Baycrest Centre's Holocaust Resource Project to use as an in-house training tool supporting a multidisciplinary staff working with a high percentage of survivors of the Holocaust. With exposure and experience the Training Tool evolved, and requests from community health care settings increased. While the material was originally intended for Holocaust survivors and now is currently geared to healthcare professionals caring for aging survivors of genocide, the model itself can be extrapolated and applied to other topics.

The Training Tool is unique in that it was designed as a one hour presentation that would not only accommodate various disciplines, but could readily be presented by different trainers. With careful selection and ongoing mutual support of a group of six trained facilitators, the Train-the-Trainer Project has to date reached over 1800 health care workers. While it utilizes an interactive lecture format with audio-visual support, the model considers the discussion and processing period as critical to its effectiveness. It is the participants' discussion and input that personalizes and customizes the content.

Utilizing both Baycrest's resources and the caring community's expertise, an extensive outreach to service providers, educators, nursing homes, homecare services and health care facilities has been initiated. The Holocaust Resource Project developed and maintains the program, adapting and changing it as required. Participants' evaluations and data are maintained, so that the training and learning remains both relevant and useful. The success of the model is based on a 'train the trainer' approach, so as the need and requests for training increase, we will be able to respond appropriately. Since the issues are multidimensional, the response must be as well, and this model allows the co-ordinators to individualize the various sessions and continue to customize the educational material. It also maintains vital partnerships throughout the community, so that all participants can work together and be aware of all available resources.


The Training Outline:
Individualized training modules were developed to meet the needs of multidisciplinary health care professionals, para-professionals and students working with survivors of the Holocaust and their families. Three specific training modalities were developed in order to respond to specific need assessments ascertained during the development and research stage of this initiative. The training modules include an in-service training package for multidisciplinary providers of care within the Baycrest setting. The second program responds to the varied aspects of multidisciplinary professionals and paraprofessionals providing care within a community context. Finally, the third package targets students, in an academic setting, learning to care for the personal and health care needs of aging individuals. Each of these programs can be further defined and refined to accommodate either a more intensive clinical or educational session if required.

Each module works to offer an effective one-hour session aimed at discerning the complications of providing care to aging survivors. This service aims to respond to the manner in which care plans are initiated and the varied ways in which these decisions and implementations may effect the way individual survivors respond to the natural processes of aging. The goal of the training is to promote optimum level of care within an environment of awareness so that both providers and receivers of care can develop helpful, trusting and effective relationships.

There were many factors that came into play in designing the content and format of these training sessions. Clearly, the first consideration was that of the orientation of the group, and the type of role they play in the lives of their patients or clients. Social workers discuss clinical implications for clients and family members and use the information in the Manual to discuss their cases in the context of case management and individual and family counselling. Nursing staff often focus on client care needs and the impact the Holocaust may have on individual patients and their respective illness. The flexibility of the training manual allowed the content to be adapted to meaningfully reach the many professionals and para-professionals who participated in a wide variety of settings. By doing this, participants gained information and examples that were concrete and most relevant to their work environment. It also gave individual facilitators control and autonomy in molding the material to a structure and format that would be most effective to meet their needs, and the needs of the group. The result was an enhanced experience for that particular group and for the individual facilitator.

In addition to adapting the content of the material to the various groups of professionals, the format of the presentation fell on a continuum from "lecture" style to interactive/informal discussion. This depended on the degree to which the group had a professional/academic background and a more or less advanced command of the English language. For example, a small group style presentation proved to be much more effective for a group of Personal Support Workers at a home care agency, as their levels of English comprehension varied greatly. The facilitator could then use the group conversation as a reliable predictor of the vocabulary that would be most effective in facilitating the group discussion.

The goal of each presentation and discussion is to foster a safe environment to share knowledge, provide support and allow for optimum levels of learning to occur within a supportive environment. The trauma inflicted by the Holocaust is a difficult area to discuss and a more challenging area in responding to the tragic realities. It is important to bring this awareness into the one-hour session. Participants have the opportunity to learn new ways to practice effectively and feel safe in discussing where they may have provided care more optimally prior to specialized professional development.


Host Institution:
The physical space provided by the host institutions for these presentations also plays a role in the format of its delivery. Physical spaces have ranged from a large auditorium with audio/visual equipment and a podium, to a vacant resident's room in a nursing home where the group was offered sitting space on two beds. The former space prompted a more focused learning environment where the group was comfortable and able to focus on the material at hand.

An important issue to consider is the endorsement an individual agency gives the presentation and how it is introduced to staff. A nursing home staff were asked to attend this workshop in between their shifts or when they had a moment to sneak away from their floor. As a result, these staff where exhausted the moment they sat down, and preoccupied with getting back to work throughout the presentation.

In contrast, those groups whose presentation was structured with an allotted time space were able to plan for the upcoming presentation, and relax and participate throughout. We have learned through experience to carefully clarify the host institution's commitment before finalizing the presentation. When senior staff endorses and facilitates attendance, it is a worthwhile learning experience for everyone involved.

Each training module evokes difficult reactions from it participants. It has become obvious that bringing the provision of care into the context of individual and personal histories of the clients evokes emotional reactions. It has become crucial to process these responses with the participants in order to share ways that we can work with survivors of genocide when we too are emotionally distraught by the knowledge we learn. Focus is generally on care for the providers of care as well as care to the consumers.

One Facilitator's Perspective:
As a model, the "train the trainer" approach allows a rich and multi-faceted experience for both the facilitators and the participants. The role of the "trainer" in this project is a unique opportunity to offer a learning experience to peers, while simultaneously gaining valuable facilitation and teaching skills. Through debriefing, regular meetings and "team facilitating" with the other trainers, facilitators have a chance to reflect back on each training session and use one another for ongoing evaluation and analysis of the learning process. Using the training manual as a guideline, the six facilitators involved in the project thus far have approached facilitation in unique ways, depending on one's personal style of presentation, and the specific needs and learning goals of the audience at hand. The flexibility of this training tool, allows each facilitator to create a safe environment for dealing with subject matter that is emotionally charged and can trigger unconscious reactions in participants. Carefully capturing these reactions and examining the thought process and life experiences behind them through effective group facilitation has allowed successful and lasting learning experiences.

As one goal of this project is to allow health care professionals, teachers and educators to extrapolate basic approaches of this training model and apply it to other subject matter, it continues to be critical that we gather feedback and evaluate the successes and challenges of each training workshop. With the hopes of sharing this knowledge to others interested in adopting this model, the following recounts some of the key factors identified in contributing to the success of the training.


Dealing with Emotional Reactions:
As the content of this presentation can trigger intense emotions, the facilitator needed to be prepared for a multitude of reactions and responses from individuals, as well as be aware of her own emotional state. The general consensus from the group of six facilitators was that the material could become emotionally exhausting to present, and peer debriefing or presenting in teams was helpful and necessary to combat this. This group meets regularly to discuss ongoing issues, seek support and identify areas of potential expansion for this project through the sharing of experiences and reporting of observations. As training in the area of working with elderly survivors is relatively new terrain, the discussion of case presentations was extremely important to keeping this material based in the experiences of the client population, and applicable to survivors in the present.

Emotionally charged responses from group participants were not uncommon, as many can relate some of the survivor experience to a personal life experience of immigration, loss or family history. Through interactive discussion and processing of emotional responses, staff not only gained some in-depth knowledge about working with survivors of childhood trauma, they also left the training session with a greater awareness of how their own life experiences may come into play when working in a setting with elderly survivors.


Implications for the Model:
Working with aging survivors of the Holocaust and their families is both a challenging and rewarding journey. It is important to learn about the survivor's losses while at the same time never forgetting to celebrate their lives. Working with survivors of the Holocaust allows us to witness the indefinable potential of the human spirit, its resilient nature and pushes everyone a little further and a little closer to conceiving the inconceivable and persevering to endure the unendurable.

As this Project has evolved, we have become more aware of the connections between the needs of aging survivors of the Holocaust and other groups of elderly individuals suffering from post-traumatic stress disorder related to cultural genocide. In approaching other agencies and community groups, these similarities are discussed and the training adapted to accommodate other needs. While nothing can be done to reverse the many injustices that survivors of the Holocaust faced both during and after the war, we can perhaps use what we have learned from this group to better support others. This effort also provides an opportunity for survivors and their families to make a positive contribution stem from a horrific life experience.

It is incumbent on all caregivers working with Holocaust survivors to share the knowledge base and understanding as it grows and develops. The needs are changing and the service delivery systems must be cognisant of both of these needs and appropriate responses. Baycrest has been serving the community's elders for over eighty years and has developed a broad base of expertise, research, outreach and services. Now that the survivor population has joined the ranks of the elderly population; Baycrest has formed partnerships with those agencies and organizations working with survivors. We all recognize the need to work together and rally as many resources as possible.

As the survivors age and their issues evolve with their respective mental and physical maturation so do the needs for innovative and resourceful responses. So too does the available research, literature and knowledge. Current literature and practice modalities do not represent the changing needs of those survivors eighty-five years and older and their families. As such, professional responses demand the creative use of theory and practice on a continuum. Practitioners and policy makers must keep up with these demographic changes in order to provide quality services for these individuals and their families.


Customizing the Training:
As of December 1999, the six Trainers involved in the pilot Project represent a collaborative initiative amongst community and residential services for the elderly. All are social workers with masters degrees. Two staff come from community agencies that provide home care, group services, meals on wheels, counselling and home visits, one staff is from the private nursing home sector and the remaining three staff represent both the Social Work Department and the Holocaust Resource Project at Baycrest; a multi-service residential and community agency.

The Training Manual was designed by the Holocaust Project to be fluid. Each Trainer receives one and the contents are to be copied and re-distributed as needed. Each Manual contains specific resources for the Trainers as well as a range of material for handouts for participants. It is an important component of the sessions that every participant receives the handout for future reference. Thus, while the basic content remains the same, the Trainers have the option which articles to add or delete to customize the Manual for a particular group. The staff of the Holocaust Project assumes the responsibility to maintain and update the selection of articles and the content of the Handouts for the Trainers. The basic Table of Contents is as follows with a range of reprinted profession articles supplied by the Project for Trainers to choose.

The following chart gives an indicator of how the material would be presented and re-presented in order to adapt to different groups. It is the adaptability of both the material and the trainers to the individual disciplines that is critical to the success of the program.

 

Subject Matter Nurses Social Workers
 Homemakers
Chronology Historical context raising potential medical outcomes of war, deprivation, trauma Historical context raising potential psychosocial outcomes on survivors and impact on family members Historical context raising issues of potential reactions to personal care and matters of privacy for survivors
Triggers Overview of circumstances that may trigger difficult memories emphasizing impact of medical experimentation, murder by 'caretakers', and specific examples related to living/dying in concentration camps Overview of circumstances that may trigger difficult memories emphasizing impact of instituitonalized or professional care on both survivors and their family members -impact of loss of independence Overview of circumstances that may trigger difficult memories emphasizing impact of 'strangers' in the home, failing health, fear of dependency,
Terms/Words Vocabulary to better understand patients 'stories', and enable communications Vocabulary to better understand and initiate therapeutic conversation Vocabulary to better understand and enable communications
Other Languages A list of basic communication words, emphasizing socialization and comfort in Yiddish, Russian and Hungarian.
Relevant articles Articles emphasizing medical or nursing issues Articles discussing the role of the social worker with survivors and families General articles expanding on available community services


The Trainers are responsible for returning both their own and the participants' evaluations to the Project co-ordinators for evaluative and research purposes and to maintain the relevance of the Handouts. As the Project reaches more disciplines and more individuals, we continually update and adapt the Manual to maintain it's relevance and reflect the expanding body of knowledge.

As we respond to the ever-changing needs of the survivors of the Holocaust we are also learning of relevant connections to the needs of all survivors of genocide. Tragically, other cultures and countries have also been victims of genocide since the Nazi Holocaust. It is imperative that those individuals working with aging Jewish survivors share both the knowledge and resources with these other communities, so that while we cannot prevent the fact of genocide, we can participate in the support and healing of all survivors. Fifty-four years since Liberation has allowed the survivors of the Holocaust, their families and caregivers time to rebuild, regroup and reassess the care needs of their various life stages. The educational model described in this paper refers to the needs of aging survivors of the Holocaust, with the recognition that this work will also provide insight into the needs of other groups and communities.

Recognizing the uniqueness of this clientele, their extreme age and extreme exposure to violence emphasizes the needs for an individualized response to individuals' needs. Employing creative responses with this population is not an option but a necessity, and all personnel must be aware of not only individual needs but of the historical perspective which impacts on most of this group's ideas, beliefs and interactions. All personnel must be supported in order to actualize this training and put it into practice. To date, the Project has trained over sixteen hundred healthcare providers. This has been a unique opportunity to blend theory with practice for the benefit of service providers, the community and ultimately the survivors of the Holocaust.