Enhancing preparedness: Assessing the impact of an online Training of Trainers program for nurses in Indian COVID-19 hospitals

Abstract

Background:

Several studies have shown that frontline health-care personnel have experienced overwhelming stress and mental health problems since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic. To address the psychological impact of the COVID-19 crisis on nurses working in COVID-19 hospitals across India, a series of Training of Trainers (ToT) programs were conducted. This study examined the effectiveness of these programs in reducing stress and improving coping self-efficacy of nurses.

Aim:

To examine the effectiveness of online Training of Trainers Program for Nurses working in Covid-19 Hospitals in India.

Materials and Methods:

A cross-sectional survey with a convenient sampling method was adopted. The tools consisted of Knowledge, Practice, and Attitude Survey Schedule; Perceived Stress Scale; and Coping Self-Efficacy Scale. A total of 89 participants in the ToT group and 31 participants in the control group, working in COVID-19 hospitals across India, participated in the study. Data were collected through an online google survey. The study sample was sent the survey link through email and WhatsApp messages. Frequencies, means, standard deviations, and Chi squares were calculated to analyze sociodemographic variables. Pearson correlation coefficient and Student’s t-test were used for analysis.

Results:

There was a significant difference between the two groups, with the ToT group scoring higher on knowledge, practice, coping self-efficacy, and positive attitude and lower on perceived stress than the control group.

Conclusion:

Our findings indicate support for the online mode of training programs for health care professionals, particularly significant in crisis situations.

On January 30, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a public health emergency of international concern.[1] COVID-19 challenged the capacity of healthcare resources and significantly altered the roles and responsibilities of healthcare workers in the workplace.[2] Natividad et al. (2021) reported that healthcare systems are grappling with increasing numbers of infected healthcare workers who are also experiencing an emotional impact.

Factors such as increased workload, staff shortages, risk of redeployment, and insufficient resources were seriously affecting the physical and mental health of healthcare workers, placing a heavy burden on the system health.[2] Extremely stressful environments and chronic fatigue affected all aspects of their personal and professional lives. Due to the increased workload, healthcare workers did not have enough time to care for themselves, relax, or even meet their basic needs.[3] Social interaction was also limited, and social distancing in the workplace is out of the question. Pervasive states of isolation and self-neglect led to irritability, anger, and emotional instability.

According to Schwarzer, effective coping in stressful and difficult situations is associated with self-efficacy.[4] Low self-efficacy is thought to lead to anxiety and helplessness, while high self-efficacy tends to encourage people to accept challenges, set goals, and achieve them successfully.[5,6] Previous studies have observed significant correlations between self-efficacy and mental health[7] and well-being.[8]

In India, during the early stages of the COVID-19 pandemic, healthcare workers, especially doctors and nurses, worked under overwhelming stress and suffered from burnout, anxiety, irritability, depression, and insomnia.[9,10] To study and address the psychological impact of the COVID-19 crisis on nurses in India, the Department of Nursing, National Institute of Mental Health and Neuroscience (NIMHANS), India, in collaboration with the Department of Clinical Psychology, NIMHANS India, Department of Health and Family Welfare, Government of India (GoI), developed self-made training materials and conducted a series of training of trainers (ToT) programs with 463 nurses working in COVID-19 hospitals in India. Due to the shortage of mental health professionals in India[11] and the urgency of the COVID-19 pandemic, the broader objectives of the above project were (1) to understand the stressors of nurses working in different parts of the country when caring for COVID-19-positive patients and (2) to establish a pool of master trainers (MTs) who can train nurses in their respective states in stress management and resilience building and mentally prepare them for future crises.

The training intervention unfolded in three phases. Phase 1 included an online survey to explore stressors among nursing professionals caring for COVID-19 patients in India, guiding the tentative development of the TOT program. Phase 2 involved expert discourse to refine and finalize the TOT program. Phase 3 encompassed the implementation of the TOT program, including pre- and postassessments of knowledge, attitude, and skills. Feedback was taken immediately after the program and again after a month, with 463 participants attending and 410 completing both assessments.

The training program comprised three sessions: The first focused on managing emotions and stress; the second on self-care, work–life balance, and physical health; and the third on managing interpersonal relationships and seeking support. Delivered online, the program utilized various interactive methods such as didactics, videos, case scenarios, and role plays. Sessions were conducted in groups of at least 30 participants over three consecutive sessions lasting 2 hours each, facilitated by experts from NIMHANS.

Subsequent to this project, a WHO-funded initiative evaluated the effectiveness of the TOT program. This article discusses the study’s findings, examining how master trainers delivered the program to second-generation nurses and its impact on both first- and second-generation groups. The study aims to shed light on the program’s efficacy in reducing stress and enhancing self-efficacy. Positive results hold promise for the widespread adoption of the online TOT program in healthcare settings, offering valuable support amid ongoing and future health crises.

MATERIAL AND METHODS

Study design and participants

A cross-sectional survey with a convenient sampling method was used. A total of 82 participants who received trained in ToT programs from two large central institutes offering mental health and related services in the first-generation group and 39 participants (second-generation group) drawn from the group of participants trained by the first-generation group participants were recruited. The control group comprised 31 participants. The informed consent was obtained from the study participants, and the ethical clearance was obtained from the institute ethics committee (No. NIMHANS/EC (BEH.SC.DIV.) Meeting 2021; 09/9/2021).

Procedure

The study comprised two phases.

Phase 1:

Development and validation of the Knowledge, Practice, and Attitude (KPA) scale by three experts. Permission to use the Coping Self-efficacy Scale (CSES) was obtained.

Phase 2:

An online survey was conducted, involving both experimental and control groups.

• Experimental Group: Received a ToT program, consisting of Master Trainers (MT) and Non-Master Trainers (Non-MT) from the first- and second-generation groups. MTs were defined as those who trained a minimum of 5 nurses after completing the ToT program. The first-generation group comprised nurses trained by Institute A or B, while the second-generation group included nurses trained by MTs from the first-generation group.

• Control Group: Consisted of nurses who did not undergo the ToT program or any other stress management intervention during the COVID-19 pandemic, working in settings similar to the treatment group participants.

Participants:

Institute A trained 463 nurses in the ToT program, with 200 MTs and 263 non-MTs. Institute B trained 156 nurses. From Institute A, 200 MTs trained 2000 nurses (second-generation group). From Institute B, 156 first-generation nurses (MTs) and 1225 second-generation nurses were trained.

Recruitment:

MTs trained by both institutes were contacted via email, WhatsApp, and telephone.

• First-Generation Participants: 46 nurses from Institute A (MT = 37, non-MT = 09) and 36 nurses (MT) from Institute B, first-generation groups, responded to the survey.

• Second-Generation Participants: MTs from Institute A provided contact details for 225 second-generation participants, of which 39 responded. MTs from Institute B provided details for 23 participants, none of whom responded.

• Control Group Selection: First- and second-generation participants from Institute A were asked to recommend nursing professionals for the control group. Contact details of 47 nurses were received, with 31 participating in the survey.

Survey Distribution:

The study sample received survey links via email and WhatsApp messages.

Measures

A demographic data sheet was used to obtain demographic information, namely, participants’ age, education, marital status, whether they were staying with the family or away, nature of work, designation, and years of work experience.

A Knowledge, Practice, and Attitude Survey Questionnaire (KPA) was developed for this study to assess the participants’ knowledge, skills, and attitude related to the ToT program. This measure was developed based on a review of research literature and existing measures. The knowledge questionnaire has nine multiple-choice questions, and higher scores indicated greater awareness about stress and coping. The practice measure is 10 items scale and assesses practice of coping skills. All items were measured as a 7-point Likert scale (0 = never, 1 = rarely, 4 = always). The attitude scale is a 4-point Likert scale (0 = strongly disagree, 4 = strongly agree) and consists of 6 items that assess participants’ attitude toward the ToT program.

Perceived Stress Scale (PSS-10): The scale measures, over the past month, the degree to which life has been experienced as unpredictable, uncontrollable, and overloaded.[12]

The Coping Self-Efficacy Scale – Short Form (CSES-SF): This is a 13-item measure of perceived self-efficacy for coping with challenges and threats.[13] The instrument yields three subscale scores: “problem-focused coping” (α = 0.91), “stop unpleasant emotions and thoughts” (α = 0.91), and “support” (α = 0.80). Anchor points on the scale are 0 (“cannot do at all”), 5 (“moderately certain can do”), and 10 (“certain can do”).

Data analysis

Data were coded for Statistical Package for Social Sciences (SPSS) software (version 24). Frequencies, means, standard deviations, and Chi squares were calculated to analyze sociodemographic variables. To examine the relationship among variables, the Pearson correlation coefficient was used and differences between the groups were calculated using Student’s t-test.

RESULTS

The three groups were comparable on all demographic characteristics, except for age and designation [Table 1]. The majority of the participants were females, working in private institutes, and were educated up to Masters. There was a significant age difference between the three groups (P = 0.001). The participants in the first-generation group were older (x̄ = 37.90, SD = 8.02) than second-generation (x̄ = 34.10, SD = 7.82) and control groups (x̄ = 32.36, SD = 6.70). Similarly, the three groups also differed significantly in their designation, with most participants in the first-generation group (59%) being teaching faculties and those in the second-generation group being nursing officers (39%) and students in the control group (42%).

Table 1.

Demographic characteristics of the participants

Variables		Mean S.D			F	Sig (2-Sided)
		First Generation n=82	Second Generation n=39	Control Group n=31
Age		37.90±8.02	34.10±7.52	32.36±6.70	7.38	0.001***
		n (%)	n (%)	n (%)	Chi-square Value	Sig (2-Sided)
Gender	Male	25 (31)	5 (13)	11 (36)	5.620	0.060
	Female	57 (69)	34 (87)	20 (65)
Types of Institutes	Central	28 (34)	6 (15)	7 (23)	5.470	0.242
	State	18 (22)	13 (33)	9 (29)
	Private	36 (44)	20 (51)	15 (48)
Professional Qualification	GNM	2 (2)	3 (8)	0 (0)	10.871	0.092
	BSc Nursing	10 (12)	9 (23)	2 (7)
	MSc Nursing	59 (72)	25 (64)	27 (87)
	Ph. D Nursing	11 (14)	2 (5)	2 (7)
Designation	Student	11 (13)	10 (26)	13 (42)	22.230	0.001***
	Nursing Officer	20 (24)	15 (39)	12 (39)
	Teaching Faculty	48 (59)	12 (31)	6 (19)
	Nursing Administrator	3 (4)	2 (5)	0 (0)

***P<0.001

The correlation between knowledge, practice, and attitude variables was calculated for the first-generation group, second-generation group, and control group. As shown in Table 2, for the first-generation group, knowledge variable scores were positively correlated with practice (P = 0.01), suggesting that more knowledge was associated with more practice. However, for the first-generation ToT program participants, there were no significant correlations between knowledge and attitudes, and practices and attitudes. There were no significant correlations between the knowledge, practice, and attitude variables of the second-generation participants and those of the control group.

Table 2.

Correlations among knowledge, practice, and attitude

Variables	First-Generation Group			Second-Generation Group			Control Group
	Knowledge	Practice	Attitude	Knowledge	Practice	Attitude	Knowledge	Practice	Attitude
Knowledge	-	0.31**	- 0.06 (NS)	-	0.04 (NS)	-0.03 (NS)	-	0.35 (NS)	0.01 (NS)
Practice	0.31**	-	-0.01 (NS)	0.04 (NS)	-	-0.14	0.35 (NS)	-	0.01 (NS)
Attitude	-0.06 (NS)	-0.01 (NS)	-	- 0.03 (NS)	-0.14	-	0.01 (NS)	0.01 (NS)	-

**P<0.01, NS: Not significant at 0.05 level

The distribution and scores on knowledge, practice, attitude, PSS-10, and CSES between the first-generation and second-generation ToT groups, first-generation and control groups, and second-generation and control groups post ToT program were studied [Table 3]. The results showed no significant difference on any outcome measure between the first- and second-generation groups. The mean scores obtained suggest moderate knowledge, high level of practice, positive attitude, moderate stress level, and high level of coping self-efficacy in both groups. However, there was a significant difference between the first-generation and control groups on knowledge (P = 0.001), practice, PSS-10 (P = 0.01), and CSES (P = 0.001). But these groups did not differ significantly on attitude. Mean scores for the control group indicated inadequate knowledge, moderate practice, positive attitude, moderate stress, and moderate degree of coping self-efficacy. Similarly, the comparison between the second-generation group and control groups also showed significant differences in knowledge (P = 0.001), practice (P = 0.001), PSS-10 (P = 0.01), and CSES (P = 0.001). However, there was no significant difference in attitude between the two groups.

Table 3.

Between group analysis on the KPA questionnaire, PSS-10, and CSES at post-ToT Program

Variable	Mean±S.D		t	Mean±S.D		t	Mean±S.D		t
	First (n=82)	Second (n=39)		First (n=82)	Control (n=31)		Second (n=39)	Control (n=31)
Knowledge Questionnaire	5.87±1.85	6.10±1.82	-0.63	5.87±1.85	3.29±1.69	6.72***	6.10±1.82	3.29±1.69	6.57***
Practice	28.32±5.65	26.47±4.98	1.72	28.32±5.65	21.03±6.81	5.73***	26.47±4.98	21.03±6.81	3.82***
Attitude	17.57±3.06	17.56±2.06	0.01	17.57±3.06	16.38±3.00	1.84	17.56±2.06	16.38±3.00	1.93
PSS-10	16.13±5.27	16.07±4.72	0.05	16.13±5.27	19.61±4.92	-3.28**	16.07±4.72	19.61±4.92	- 3.03**
CSES	207.43±32.41	192.13±30.24	2.44	207.43±32.41	150.16±60.98	6.38***	192.13±30.24	150.16±60.98	3.72***

PSS-10=Perceived Stress Scale -10, CSES=Coping Self-efficacy Scale; **P<0.01, ***P<0.001

DISCUSSION

The study examined the effectiveness of an online ToT program in improving knowledge, practice, and attitude; reducing stress; and enhancing the coping self-efficacy among nurses across India.

Improvement in knowledge, practice, and attitude

Results indicated that participants in the first-generation and second-generation groups had moderate knowledge about stress and coping in the post ToT program, as compared to control group participants who were found to have poor knowledge. Furthermore, significant differences between knowledge and practice variables were observed between first-generation and control group participants and between the second-generation and control group participants, demonstrating the effectiveness of the ToT program in increasing stress and coping awareness and increased participation in practicing the coping strategies among participants in the ToT program. These results support the claim that effective training in a health care setting will improve the knowledge and skills of professionals.[3,10] However, all the three groups showed similar positive attitude toward the ToT program, suggesting that the nurses who did not participate in the ToT program (the control group) also recognized the need for the ToT program to improve their handling of difficult situations such as the COVID-19 pandemic. There was a significant positive correlation between knowledge and practice variables in the first-generation group, suggesting that increased knowledge is associated with increased practice of coping strategies. However, there was no correlation between knowledge, practice, and attitude variables of the second-generation and control groups. This finding is consistent with previous research showing that the nurses’ attitude toward evidence-based practice are more positive than their knowledge and skills.[14]

Decrease in the level of stress

All the three groups reported experiencing moderate levels of stress. ToT program participants may have experienced moderate stress while working under unusually difficult and stressful conditions related to the COVID-19 pandemic, in which case moderate stress was expected. Some research suggests that minimal levels of stress can be beneficial as they facilitate deeper focus, decision-making, and effective learning,[15] whereas higher stress levels can have negative effects on a person’s physical and mental health.[13] However, all three groups reported a moderate level of stress; the first- and second-generation groups showed significantly greater improvements in measures of perceived stress, suggesting the effectiveness of the ToT program in reducing stress levels.

Increase in coping self-efficacy

Both first- and second-generation participants reported higher levels of coping self-efficacy, indicating that ToT program participants believed strongly in themselves and the ability to cope with stressors. The participants in the control group reported moderate levels of coping self-efficacy. The results for the control group are consistent with previous studies that investigated the self-efficacy levels of nurses interacting with patients during COVID-19 and reported moderate levels of self-efficacy.[16] A significant difference was also observed between the first-generation group and control group and between the second-generation group and control group, suggesting that the knowledge and skills/strategies acquired and practiced by first- and second-generation ToT program participants improved their perception of their ability to handle similar stressful situations in the future. Furthermore, first- and second-generation ToT participants did not differ significantly in measures of coping self-efficacy, suggesting that the ToT program was effectively taught to second-generation participants by the master trainers of the first-generation group.

It is suggested that the effectiveness of the training program depends on the transfer of training.[17,18] We can conclude that in this study, compared to the control group, ToT participants had lower stress levels and higher coping self-efficacy, suggesting that participants who received the program of ToT could transfer their knowledge, skills, and attitude to their work place. Additionally, as the evaluation was conducted 6 months after participation in the ToT program, the results also indicated long-term maintenance of training benefits. Studies suggest that self-efficacy is associated with better mental health, resilience, and reduced burnout.[8,9] It is also an important predictor of a nurse’s willingness to care for patients with infectious diseases.[15] To our knowledge, this is the first study in India conducted during the period of COVID-19 pandemic to investigate the effectiveness of an online ToT program among nurses working in Indian COVID-19 hospitals. The results of this study have important implications for the development and usefulness of using an online model to train nurses in emergencies. This is especially important in situations such as that of the COVID-19 pandemic, when accessing training programs through an in-person mode is difficult or when the training program needs to be delivered to a large population across the country and globally. Some of the strengths of the studies include the following: (1) The study compared first-generation and second-generation groups to determine whether training programs delivered by first-generation groups to second-generation groups produced the same effects as expert-led programs delivered to the first generation group; (2) a control group was included in the study to compare ToT participants with a similar group that did not receive the ToT program, so that differences between the two groups could be attributed to the ToT program; and (3) despite the sample was small, the study participants represented the major parts of the country.

Limitations

The study has some notable limitations. First, the sample size was relatively small, especially the second-generation group and control groups. A large sample size would have justified the generalization of the study findings. Second, the ToT program participants were not assessed on perceived stress and self-efficacy measures prior the delivery of the ToT program. However, due to this limitation, a control group was included in the study. Third, participants in the three groups were not comparable on age and profession, where the participants in the first-generation group were older than participants in other two groups and belonged to teaching profession, while participants in the second-generation group were nursing professionals, and control group students, which may have affected the results. Fourth, the participants belonged to different professional groups, work experiences, and ages, which may have affected the training outcome. Due to the small sample size, we could not compare them. Finally, the ToT program participants were assessed almost nearly 6 months after the training program was implemented, when COVID-19 cases and associated stress were low. It is possible that an investigation of the effectiveness of the training program immediately after the training program may have provided different findings.

CONCLUSION

The study demonstrates the effectiveness of the ToT program in improving knowledge, practice, and attitude; reducing stress levels; and improving coping self-efficacy among the nursing professionals working in COVID-19 hospitals in India. The study offers valuable implications in terms of the suitability of an online mode of training program for health care professionals in crisis emergency circumstances.

Ethical Clearance no and date

No. NIMHANS/EC (BEH.SC.DIV.) Meeting 2021; 09/9/2021.

Declaration regarding the use of generative AI

AI tool Chat GPT 3.5 version was used to grammatically organise the introduction and discussion content in a better way. I assume full responsibility for the entire content of the manuscript, including the parts generated by the AI tool.

Authors contribution

All authors contributed to conceptualization, literature review, data collection and analysis, writing and editing the manuscript. All authors approved the final draft.

Data availability

Data will be made available on reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was funded by the World Health Organisation, India.