attitudes of health professionals. Contents that were delivered focused on communication skills, culturally sensitive care approaches, and health outcomes improvements for patients. Educational techniques were the means or methods by which these contents were delivered, such as case studies, didactic lectures, interactive teaching and learning approach, problem-based learning, and team-based learning. The use of these various teaching and learning approaches enhanced the acquisition of the required knowledge, skills, and attitudes by the healthcare professionals although some of these approaches were observed to be more successful than others.

According to the evidence obtained from the RCTs, it was suggested that the integration of in-service training programs within clinical setting is useful in changing the behaviors of health professionals positively (14, 19, 21, 24). The use of in-service training has been successful in the improvement of client-provider communication, provider-provider communication, knowledge, skills, and attitudes of health professionals towards patients and clinical behaviors in general (15, 19, 22, 23).

Various teaching techniques were used in the interventions. Teaching technique refers to the means by which knowledge, skills, attitudes, and behaviors are transferred by the instructor to the learner (14). Accordingly, 8 articles were identified to focus on the techniques, and
their obtained are presented in Appendix 3. Educational methods that were used include lectures and interactive methods, such as case studies/problem-based learning, role play, and simulation/demonstration.

Lecture

This is a technique by which knowledge content is presented, and the facilitator determines content, organization, and pace (14). The lecture method was used in some studies (15, 20); it was observed that lecture methods were effective in the transfer of knowledge, compared to other methods. A comparison of simulation-based training with didactic lecture and printed visuals demonstrated a significant increase in the mean post-test score and overall higher learner satisfaction with simulation-based training (20). In a systematic review, a comparison of classroom teaching with clinically integrated teaching for evidence-based medicine showed that classroom teaching improved mostly knowledge, compare to attitudes, behaviors, and skills; on the other hand, clinical teaching improved skills, knowledge, behaviors, and attitudes (24).

Interactive methods

This is the use of various teaching methods, such as case study/problem-based learning, simulation, demonstration, and role play. These methods were used by researchers who declare interactive teaching methods to be very useful
in teaching knowledge, skills, attitudes, and behaviors. The same researchers observed interactive methods that are useful in teaching the adult learner (14, 15). These teaching and learning methods were concluded to be more successful in adult learning due to being interactive. They were also useful when multiple methods were used together (14).

Case study/problem-based learning

This is an interactive teaching method that requires the use of created or actual cases
that present materials and questions (14).
These methods were used in training health professionals with positive outcomes (13, 14).

Role play

This is also an interactive teaching method where roles are assigned to participants to depict a situation, which is then discussed. This method was observed to be useful in the teaching of knowledge, skills, attitudes, and behaviors (14).

Simulation-based training and demonstration

This is where educational training occurs in settings that are provided to mimic real situations. The comparison of simulation-based training and interactive teaching showed that both approaches were useful in the transfer of knowledge, skills, attitudes, and behaviors (16).

Setting and frequency of interventions

The setting is the place in which the training takes place. Two articles were identified that considered the place where the training occurs. A comparison between the effects of in-service emergency care training and usual care revealed that the type of training did not make any difference, as there was an improvement in health professionals' treatment of patients (23). These intervention programs were presented in settings, such as the clinical settings and simulation laboratories for 1 to 3 days.

Outcomes of interventions

The outcomes were the consequences of training intervention and changes in knowledge, skills, and attitudes that were positively affected and then influenced the clinical behaviors of health professionals. These consequences were reported in the studied articles through post-test assessment of participants that received various forms of interventions during in-service training sessions. According to the reviewed studies, there was an indication that in-service training could effectively address knowledge particularly if various teaching methodologies are applied (13, 17, 19, 22, 23); as there was an improvement in staff’s knowledge, skills, and attitudes after in-service training programs.

Feasibility of in-service training programs

Based on the review, it is evident that in-service training programs were feasible. The programs did not bring about the large budget cost if participants were nonresidential, and therefore there was no accommodation cost, the programs were held in hospital premises and conference halls within the hospitals. The main incurred costs were given to the expenses of facilitators and snacks, as well as lunch for participants (17, 18, 22). On the other hand, if participants are accommodated, the costs will be higher. The in-service training programs are also organized in cohorts for the health professionals since all the staff cannot be trained and work at the same time. However, based on the evidence, it is strongly suggested that in-service training programs are feasible
for the acquisition of knowledge, skills, and attitudes among health professionals to ultimately improve patient health outcomes (13, 17, 19, 21).

Discussion

According to the review of articles identified for the present study, there are similar discussions regarding in-service education for health professionals as a format to improve knowledge, skills, and attitudes with the aim of improving clinical behaviors and health outcomes for patients (13, 14, 17). In-service training is a form of education given to people while they are formally employed and is a preferred technique for health professionals because it does not take the professionals off the duty for a long time as in a formal educational program (25). Moreover, in-service training programs enhance the knowledge, skills, and attitudes of health professionals to improve patient outcomes (14).

In order to improve midwifery clients’ satisfaction with childbirth care, in-service training programs for midwives are considered expedient to change the clinical behaviors of midwives towards client care. Abundant evidence was obtained in the present review to support the use of in-service training that is frequently delivered in various modules useful for health professionals’ improvement in client care (13, 17, 19, 21). The educational techniques support the positive transfer of knowledge, skills, or attitudes (13, 14, 17, 19, 21). These educational techniques are also supported according to the literature regarding education (25).

Furthermore, in the present review, it was noticed that delivering modules, such as communication skills and patient-centered care, through the use of various teaching and learning methods are helpful (14, 21). This finding is supported by some systematic reviews that focused on the development of communication skills and reported that the use of techniques, including feedback and practice, behavior modeling, more practice opportunities or longer duration, were more efficient with simulations and feedback to address attitudinal issues of health professionals.

In order to train the learner, she/he should play an active role in the teaching-learning process (25). Therefore, teaching and learning that actively involves the learner enable learning. In addition, the training methods that allow for immediate practice or the application of knowledge after learning is useful in the enhancement of learning that is supported by adult learning principles (13, 25).

Strengths and Limitations

The strength of the present study was the identification of in-service training as an effective technique in addressing the knowledge, attitudes, and skills of health team to achieve the best maternal outcomes. Various databases were searched and scientific processes were followed. However, the limitation of this study was the presence of few articles that directly addressed midwives' knowledge, skills, and attitudes.

Conclusion

In-service training is important in the improving and safeguarding competencies for optimal performance of health professionals to provide patient-centered care service. There were no identified interventions for midwives that aimed to improve patient-centered care. However, there is evidence of interventions for health professionals (including midwives) that aimed at improving clinical behaviors to enhance client health outcomes. Therefore, the use of multiple interactive educational techniques and application of adult learning principles can be helpful in the acquisition of attitudes and clinical behaviors.

Considering the nature of competencies acquired by the learner and choosing the appropriate techniques to enhance its transfer are important in the success of designing and implementing in-service training programs. Furthermore, it is useful to be conscious of and apply adult learning principles in planning and implementing the curriculum. The following key points were obtained according to the present review:

1. Educational techniques that provide a passive transfer of information, such as reading and lecture, should not be exclusively used as a teaching method but in combination with other interactive methods. The techniques should be used that engage the learner in mental processing, such as simulation, case studies, and other interactive strategies (14, 15). This finding is also echoed by educational psychologists (25).
2. The use of simulation is a preferred educational technique notably for the transfer of psychomotor skill (22).
3. For adult learners, self-directed learning was also observed to be an effective strategy; however, it requires the use of interactive techniques that engage the learner. Self-directed learning has additional benefit as it permits the learners to study at their own speed (14).
4. Adult learners would like to be engaged in problem-centered learning experiences and to perform tasks while learning. Therefore, the use of problem-based learning is recommended in teaching adults (25).
5. Repeated exposure to desired competencies or behaviors is also supported in the literature. It is recommended to run frequent in-service training programs, which then serve as reinforcement.
6. It is also important to direct reinforcement programs toward important targets or exclusively information to avoid what educational psychologists refer to as cognitive overload.
7. The setting should be selected based on its conduciveness for the use of the chosen educational techniques. Furthermore, the setting should be similar to the work environment of health professionals and permit hands-on practice for feedback. 
8. The availability of appropriate staffing in the units, involvement of staff in identifying the need for in-service training, having an explicit philosophy for the unit and continuous review, and evaluation are important to ensure the success and implementation of learning outcomes (18).
9. In-service training programs can positively affect desired learning outcomes among midwives and increase the provision of patient-centered care services if effective teaching techniques are used.

Acknowledgements

The authors acknowledge the support of Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, Social Innovation in Public Health Impulse, and University of Western Cape in Cape Town, South Africa. They also would like to appreciate the efforts of research assistants, namely David Ameyaw, Thomas Hinni, and Precious Duodu.

Conflicts of interest

The authors declare no conflicts of interest.