Abstract
Competency-based education that relies on nurses’ and healthcare professionals’ needs assessment is crucial to tackling healthcare crises such as COVID-19. Strengthening the capacities of human resources by implementing customized infection control training programs is therefore mandatory. This study aims to measure the effectiveness and satisfaction of the Competency Outcomes and Performance Assessment (COPA)-based training program. The study implemented a single group pretest-posttest experimental design. A single-stage cluster sampling technique was used. All field hospitals in Jordan were listed, and one hospital was randomly selected. A total of 87 personnel from different disciplines agreed to participate after reading the letter of information and signing the informed consent. A panel of experts representing different disciplines and hospital units initially met and agreed upon a list of competencies required for the training program, and the program was accordingly developed. The study measured the healthcare professionals’ competencies in infection control and prevention before and after the administration of the competency-based training program. The results revealed significant differences between participants’ pretest and posttest scores in all infection control domains and the total scores. For example, the increase in participants’ total competency scores after the training was statistically significant (P < 0.007). The mean total satisfaction score was 61.18 + 7.00 reflecting that the participants were highly satisfied with the provided training. In conclusion, it is imperative to provide healthcare professionals with adequate clinical training to ensure that healthcare services are going to be delivered in the highest possible quality and minimize the possible adverse events.
Keywords: Competencies, COVID-19, Healthcare professionals, Infection control, Nurses, Training
Introduction
The world has changed since the appearance of the coronavirus in 2019 (COVID-19). The novel COVID-19 created a worldwide crisis that has tremendously affected all aspects of life. What adds to the crisis is the appearance of multiple variants of the virus globally (CDC, 2021). As of March 5, 2022, more than 400 million persons were diagnosed with COVID-19, with around 6 million deaths (Worldometers, 2022). Among those, about 1.5 million persons in Jordan were infected with COVID-19, 80 thousand active cases, and around 14 thousand total deaths (Worldometers, 2022). In Jordan, four field hospitals were established by the ministry of health; each with a 300-bed capacity and about 300-400 working healthcare professionals.
While managers were trying to handle financial, logistic, and infrastructural resources to handle the crisis, ensuring the clinical competencies of healthcare workers remained the foremost urging need required to achieve the purpose for which field hospitals were developed (Hodgetts, 2020). Therefore, strengthening the capacities of human resources is mandatory. Because there are few pre-established infection-control specialized programs to train healthcare professionals before starting work at field hospitals, providing competency-based training can be the administrators’ best means to overcome such challenges. Training newly hired staff resembles administrative support to them. Such kind of employees’ support is proven to improve employees’ satisfaction and retention (Cockerham et al., 2011; McKillop et al., 2016).
Background
Competencies need rapid assessment and advancement to tackle the immediate COVID-19 related healthcare crisis (Shinners & Africa, 2021). Training on infection prevention and control among healthcare professionals is of high urgency (Hassan, 2018), particularly now due to the nature of cases that are the target consumers of the COVID-19 field hospitals. According to the standard precaution guidelines of the World Health Organization (2014, 2020), infection control and prevention encompass the areas of hand and respiratory hygiene, the use of Personal Protective Equipment (PPE), environmental controls, waste management, handling patient-care equipment, and preventing needle-stick injuries. In addition to the standardized isolation precautions, the Centers for Disease Control and Prevention (CDC, 2022) has issued postmortem guideline that helps professionals handle the dying body of confirmed or suspected COVID-19 (CDC, 2021). Therefore, these areas were selected for the training program in this study.
Different approaches exist in the literature suggesting methods of providing training in practice. This study used the Competency Outcomes and Performance Assessment (COPA) Model because it focuses on the outcomes and improving the clinical skills of professionals (Lenburg, 1999). The COPA model requires the training developer to follow four essential steps. The first is to identify the essential competencies and outcomes needed for the practice within its context. The second step is to determine the evaluation criteria that reflect the preset competencies. Then, the training planners need to agree on the best teaching method to achieve the desired outcome specified in step one. The final stage is the application of the training program accompanied by its documentation. Fig. 1 illustrates the project milestone.
Fig. 1.
Project milestones implementing COPA model.
According to Goniewicz et al. (2021), competency-based training is particularly valuable for healthcare professionals’ preparations to handle crises and to enhance their readiness to face healthcare challenges. In general, basic training is provided to newly hired healthcare professionals upon employment. However, the provided training is standardized, hence, does not necessarily address the specific crisis situation that requires training on specific competencies that address the challenges of handling and managing such situation (e.g., the COVID-19 pandemic). Core competencies can be significantly advanced through education and training programs (Ara et al., 2019). In this study, the purpose was to achieve competency improvements by using the COPA model.
The Study
Aims
The main aim of this study is to measure the effectiveness of COPA-based training on the competencies of healthcare professionals in infection control and prevention. To add an additional value, the second aim was to assess the level of participants’ satisfaction regarding the administration of the competency-based infection control training program. Such research can help in guiding future practice in developing training programs that best meet healthcare professionals’ needs.
Design
The project implemented a single group pretest-posttest experimental design to examine the effect of the competency-based infection control training program on healthcare professionals’ competency. Healthcare professionals’ satisfaction with the training program was measured to address the healthcare professionals’ feedback on the training experience in terms of goals, strategies, outcomes, and environment. The study was conducted between April 1, 2021, and December 20, 2021.
Sample
A single-stage cluster sampling technique was used. All field hospitals in Jordan (4 hospitals) were listed, and one hospital was randomly selected. Accordingly, the study took place in one newly established COVID-19 field hospital in which all employees were newly hired in that healthcare setting. The target population was all healthcare professionals employed in that hospital. The inclusion criteria included the ability to speak and understand English.
Based on a G*Power calculation of medium effect size, power set at 0.95, and α set at 0.05, a minimum of 54 participants is required. As per the literature review, an attrition rate of about 25% is expected (Hui et al., 2013). Therefore, 68 is the minimum required sample. A total of 89 personnel from different disciplines agreed to participate after reading the letter of information and signed the informed consent. Two persons attended late to the program although they signed the informed consent previously. They were allowed to attend the training but excluded from the analysis, and they were informed about this. A final sample of 87 was reached of people who have fully completed the training program, pretesting, and post-testing.
Data Collection and the Study Protocol
After obtaining the required institutional ethical approval, an initial meeting was organized by the principal investigator with two hospital administrators, two healthcare professionals from an academic institution, one healthcare professional in a hospital's quality control department, a nurse, and a general practitioner. The meeting included a summary of the national and international guidelines in the areas of infection control and prevention, followed by a discussion to prioritize the critical areas of improvement. A set of competencies was developed based on the discrepancies between the national/international standards and the routine training. Then, the list is sent out to the professionals to review. An additional meeting was held to discuss the list and revise it if needed. The team discussed the competencies and refined them. The competency is only retained if a 100% agreement was reached by the team to be included in the training program.
The training program was created prior to implementation and scripted by the research team and the professional trainer. All training sessions were provided by one professional who was instructed to standardize the training among all sessions. The research principal investigator was present at all training sessions to make sure that the training is standardized. Additional inquiries and comments by participants were handled after the program ended to avoid contaminating the study results.
The administrators of the selected setting were contacted, and the study proposal was fully explained. They were informed that the study will benefit their institution in terms of building the capacity of their employees. They were also informed that the training will be provided by a specialized and qualified professional for free to all employees who voluntarily accept to take part in the study. The managers collaborated with the team and facilitated access to all healthcare professionals within that institution.
The research assistant introduced the study to the healthcare professionals and invited the potential participants to provide their names and contact information. Participants were requested to sign the informed consent and grant their permission to have the research team contact them to schedule their training. After that, the research assistant contacted all participants and divided them into groups of no more than 20 people in each group, yielding in 5 subgroups. The group size was determined based on the national social distancing regulations for infection control and prevention. All protective measures were taken into consideration to avoid the cross-infection risk among healthcare professionals. Masks and gloves were distributed, hand sanitizer was also made available, each participant was given a pen to use and keep, and questionnaire kits were dropped into a box. Research assistants used PPEs and followed the infection control measures. The training was delivered to participants during their off-duty days in a hospital room equipped with audiovisual technologies specified for teaching purposes.
A pretest was performed to initially evaluate the infection control and prevention competencies among the newly hired healthcare professionals. The participants were assured that their data will be kept confidential and will not be used except for the study purposes. The training program was then executed by a qualified healthcare professional in the form of two sessions for each group, two hours in each session. After the training was completed, the participants were asked to complete the posttest kit to evaluate the effectiveness of the training program and evaluate their satisfaction with the provided training. By the end of each training day, 30 minutes were scheduled to thank the participants and close the session. The study protocol was standardized for the five subgroups.
Instruments
The study had a pretest tool kit that included the sociodemographic questionnaire and the competency assessment survey, and a posttest kit that have a training satisfaction survey in addition to the previously mentioned tools. The sociodemographic variables included gender, age, job title, educational level, marital status, and years of total experience. Healthcare professionals’ competencies were assessed using a self-reported competency checklist that was designed for the purpose of this study. The checklist included 18 items in the areas of hand hygiene, the use of PPEs, waste management, care of dying patients and postmortem, and other general competency items. Examples of these items are (I can properly don and doff the PPEs), and (I know how to wrap, transfer, and label the body of deceased patients who have had COVID-19 (suspected or confirmed). Participants can rate their competency on a Likert scale that ranges from 1 which means strongly disagree to 5 which reflects strong agreement with the statement.
The training satisfaction survey included 14 items concerning four training aspects: goals and objectives, methods and strategies, outcomes, and environment. Each item's response can range on a Likert scale from 1: strongly disagree to 5 strongly agree. All three tools were newly developed by the research team members; therefore, the tools were tested to assure their validity and reliability.
Ethical Considerations
Approvals from the Institutional Review Boards (IRB) of Jordan University of Science and Technology and the study site were obtained before conducting the study. The study has no potential harm, on the opposite, the study provided an opportunity to benefit the institution and the professionals from the training program. The confidentiality and anonymity of the participants were preserved. To assure that, codes were given to participants to allow pairing the responses of the participants before and after training. All identifying information was kept confidential by saving the data on a password-protected computer at the principal investigator's office. Participants were informed that they can withdraw from the study at any time without any penalties and that all of those who complete the training will receive a certificate of attendance from the training providers, and their names will be entered into the draw for a prize.
Data Analysis
Data were analyzed using the IBM SPSS Statistics version 25.0 (IBM Corp, 2017). For descriptive analysis, the mean and standard deviation were run for continuous variables, and frequencies and percentages were used to describe the categorical variables. Paired t-test analyses were used to measure the effectiveness of the training program.
Validity and Reliability
The validation for the study instruments (i.e., competency assessment survey and training satisfaction survey) was performed to assure their validity and reliability. For face and content validity, the competency and satisfaction tools were developed for the purpose of the current study using the targeted competency in the training program. The lists of items for each tool were sent out to the team members to check for the face validity of the tools. Then, the team met and discussed the tools item by item to check their relevance and importance in accessing competency and satisfaction. The items retained if they have high importance and relevance to the measure's domain. Items that were deemed questionable were omitted or modified. As a result of this process, one item was deleted, and another was modified. Finally, the team discussed if there is a need to add up any other items to cover all aspects of the measured domains.
Internal consistency was evaluated using the participants’ pretest scores. The internal consistency scores for the competency assessment survey were 0.91, 0.73, 0.82, 0.73, 0.81, and 0.79 for total, general, hand hygiene, PPE, waste management, and caring for dying patients, respectively. For the training satisfaction survey, the internal consistency scores were 0.93, 0.85, 0.92, 0.90, and 0.67 for total, goals and objectives, methods and techniques, outcomes, and environment, respectively.
Results
Participants of this study were compromised of around 63% registered nurses and the rest were from a variety of healthcare disciplines/professions including technicians (8%), pharmacists (7%), and Physicians (7%). About 45% of these healthcare professionals were employed in the medical-surgical units with about 60% of them have had received professional training previously on infection control and quality management previously. The study participants averaged 31.5 ± 6.34 years of age, with an average of 6.7 ± 5.95 years of experience. Although participants in this research are newly hired in the field hospital, they vary in their previous experiences in other healthcare settings. See Table 1 for a summary of the participants’ characteristics.
Table 1.
Participants’ Characteristics (N = 87)
| Variable | Frequency | Percent | Mean | Standard Deviation | |
|---|---|---|---|---|---|
| Age | 31.53 | 6.34 | |||
| Years of experience | 6.66 | 5.95 | |||
| Gender | Male | 42 | 48.3 | ||
| Female | 45 | 51.7 | |||
| Education | Diploma | 14 | 16.1 | ||
| Bachelor's degree | 60 | 69.0 | |||
| Master's degree | 12 | 13.8 | |||
| Doctoral degree | 1 | 1.1 | |||
| Marital status | Single | 32 | 36.8 | ||
| Married | 52 | 59.8 | |||
| Divorced | 3 | 3.4 | |||
| Unit | Medical-surgical | 39 | 44.8 | ||
| Critical care | 23 | 26.4 | |||
| Triage | 9 | 10.3 | |||
| Pharmacy | 9 | 10.3 | |||
| Others | 7 | 8.0 | |||
| Job title | Registered nurse | 55 | 63.2 | ||
| Sterilization technician | 7 | 8.0 | |||
| Pharmacist | 6 | 6.9 | |||
| General practitioner | 6 | 6.9 | |||
| Health record specialists | 5 | 5.7 | |||
| Technicians | 3 | 3.4 | |||
| Previous training | Yes | 52 | 59.8 | ||
| No | 35 | 40.2 | |||
| Previous training timing | Did not receive training | 33 | 37.9 | ||
| Less than 1 year ago | 31 | 35.6 | |||
| 1-5 years ago | 13 | 14.9 | |||
| >5 years ago | 10 | 11.5 |
The pretest mean score for the healthcare professional's infection control competency was found to be 68.3 ± (9.3SD), compared to the posttest mean score of 75.91 ± (8.1 SD); yielding a difference of 7.54 ± 6.53. Table 2 summarizes the statistical findings of the paired-samples t-test executed to determine the differences in healthcare professionals’ competencies before and after the training. To avoid false findings of the paired t-test, Bonferroni adjustment was performed by dividing alpha (0.05) by the number of tests which is 7. Accordingly, the P value was set as less than or equal to 0.007. The results revealed significant differences between participants’ pretest and posttest scores in all infection control domains and the total scores. For example, the increase in participants’ total competency scores after the training was statistically significant (t = 10.71 (85); P < 0.007) with a 95% confidence interval of the difference between the pretest and posttest means range of 6.15 and 8.95. Therefore, a conclusion can be made that the participants’ competencies in infection control and prevention positively increased after the training program.
Table 2.
Paired Differences of Participants’ Competencies Before and After the Training (n = 87)
| Competencies | Mean Differences ± SD | Statistical Evaluation |
|||||
|---|---|---|---|---|---|---|---|
| t (df) | 95% CI of the Difference | P | |||||
| 1 | Hand and respiratory hygiene | 0.95 ± 2.10 | 4.25 (86) | 0.51 | 1.40 | 0.00* | |
| 2 | The use of PPE | 1.32 ± 1.50 | 8.23 (86) | 1.00 | 1.64 | 0.00* | |
| 3 | Waste management | 0.50 ± 2.02 | 2.28 (86) | 0.06 | 0.93 | 0.03 | |
| 4 | Care of dying patients | 2.33 ± 2.16 | 10.08 (86) | 1.87 | 2.79 | 0.00* | |
| 5 | Policies and guidelines | 2.31 ± 2.07 | 10.4 (85) | 1.87 | 2.76 | 0.00* | |
| 6 | General competency item | 0.46 ± 0.87 | 4.91 (85) | 0.27 | 0.65 | 0.00* | |
| 7 | Total competency score | 7.54 ± 6.53 | 10.71 (85) | 6.15 | 8.95 | 0.00* | |
P< 0.007.
The results of the training satisfaction survey revealed a range of moderate to high satisfaction in all aspects of training satisfaction as summarized in Table 3 . The mean for the total satisfaction score was 61.18 + 7.00 reflecting that the participants were highly satisfied with the provided training.
Table 3.
Participants’ Satisfaction With the Competency-Based Training Program
| Satisfaction Domain | Mean ± SD | Min | Max |
|---|---|---|---|
| Goals and objectives | 13.28 ± 1.70 | 9.00 | 15.00 |
| Methods and strategies | 12.99 ± 1.86 | 8.00 | 15.00 |
| Training outcomes | 17.83 ± 2.15 | 12.00 | 20.00 |
| Training environment | 17.09 ± 2.08 | 12.00 | 20.00 |
| Total score | 61.18 + 7.00 | 42.00 | 70.00 |
Discussion
The aim of this study was to evaluate the effectiveness of a COPA-based training program on the healthcare professionals’ competencies in infection control and prevention. This study proved that competency training programs can be an excellent method for enriching the practical knowledge and experiences of healthcare professionals. This covers a limitation previously highlighted in the systematic review of Lee et al. (2019) on the scarcity of studies on the effectiveness of infection prevention programs in healthcare facilities.
Despite the availability of national and international guidelines on infection control and prevention among healthcare professionals, this study showed that there is a continuous need for training programs to ensure increasing the competencies of healthcare professionals. Consistently, Ara et al. (2019) used a pretest post-test approach to assess the implementation of a training program that was proven to be effective in enhancing compliance with the standard infection control practices among nurses and recommended further international studies on the topic. Similar results were also reported in a study that included 76 healthcare professionals in Canada to examine the effect of an online course on their infection control competency (Atack & Luke, 2008). The study showed that the program is effective in improving the participants’ competency, however, reported the limitation of not being able to directly observe the trainees (Atack & Luke, 2008). One previous Jordanian study reported low initial levels of knowledge and compliance with standard precautions among nursing students, and statistically significant improvement after the provision of online training (Hassan, 2018).
Previous studies focused on the standard infection control training in generic form, on the other hand, this training was tailored to meet the current urging need of handling the COVID-19 crisis. Therefore, the focus was on the domains of hand and respiratory hygiene, the use of PPE, waste management, care of dying patients, and the policies and guidelines in relation to managing and preventing the spread of Coronavirus. In this study, the program was developed based on the need of the target population who were recently employed at a COVID-19 field hospital, but also can benefit healthcare professionals in other settings that provide care to patients with droplet-transmitted infections. Although the competency-based training was crisis specific and it might be irrelevant to all other healthcare settings that do not have to deal directly with the crisis, we believe that our results showed the need for continuous re-evaluation to address the changes in healthcare needs in facing similar crises.
A previous study focused on infection control training during the COVID‑19 pandemic by implementing video modules (Singh et al., 2021). They found that the participants’ knowledge had increased by 16%. Another study during the pandemic implemented video training reported similar results, however, recommended future training programs that rely on live training for increased effectiveness (Sharma et al., 2021).
Healthcare professionals work in a physically and emotionally demanding environment that requires efficient training programs (Cleary et al., 2018). However, it is crucial to be attentive to healthcare professionals’ satisfaction with the provided programs (Niskala et al., 2020). In the current study, participants reported a high level of satisfaction with the competency-based training program. For example, the participants were satisfied with the training methods and their suitability for the goals of training. They reported that the training was successful in improving their skills in infection control. Also, they described the used resources in the training as sufficient. These results reflect that implementing competency-based training was successful in meeting the needs of healthcare professionals and that such an approach is welcomed in the healthcare environment which encourages the future replication of similar programs in different areas.
Limitations
One limitation of this study was the use of a single setting to implement the program, which may reduce the generalizability of the study's findings. Another limitation was not using a control group. Self-report data collection methods inherently have a possibility of self-rating bias which may pose a threat to the generalizability of study findings. The COPA model focuses on both, competencies, and skills. The initial plan for our study was to evaluate both of them. However, to assess the skills, we needed first to apply the learned skill in the field hospitals. To apply the learned skills, policy change is required at the institutional level which we could not accomplish until now due to the administrative routine followed by the hospital to approve such change. Finally, Because of the short time between intervention and competencies testing, nurses' competencies over time may not have been accurately reflected. Further studies are required to use control groups and include participants from different settings. In addition, follow-up studies are required to further assess the long-term impact of COPA infection control programs on the nurses' competencies.
Conclusion
This study determined that COPA-based infection control training positively impacted the newly hired healthcare professionals’ competencies in infection control and prevention. It is important to provide healthcare professionals with adequate clinical training to ensure that healthcare services are going to be delivered in the highest possible quality and minimize the possible adverse events. In Jordanian hospitals, training for newly employed healthcare professionals is limited to basic training and therefore, is not designed to meet the highest priority needs of their current situations. This program and the process in which the program was designed and implemented can guide future practices in the area of professional training and development. It is highly important not to omit the training participants’ experiences and reflections on the provided training. This study found that the participants perceived the training as highly satisfactory which indicates that the process in which the training happened can be adopted in future training practices.
Funding
This research was funded by Jordan University of Science and Technology - Deanship of Scientific Research (53/139/2021).
Ethical Approval
Obtained from Institutional Review Board of Jordan University of Science and Technology (IRB reference number: (53/139/2021).
Declaration of Competing Interest
None to declare.
Acknowledgment
The authors are thankful to Jordan University of Science and Technology and Deanship of Scientific Research for their support.
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