The Journal of Continuing Education in Nursing

Original Article 

Effects of Training-for-Transformation Program on TB/MDR-TB Developed by the International Council of Nurses in China

Xiangfeng Li, MSN, RN; Hong Zhao, PhD, RN; Aimin Guo, PhD, RN; Carrie Tudor, PhD, MPH, RN; Ce Tian, BSN, RN

Abstract

Background:

This study evaluated the effects of the Training-for-Transformation (TFT) program on tuberculosis (TB)/multidrug-resistant TB (MDR-TB) in China.

Method:

Participants who received training from 2009 to 2017 (n = 230) were invited to complete an online survey using a self-designed questionnaire.

Results:

A total of 130 (56.5%) trainees completed the survey for a valid response rate of 70% (91 of 130). All of the participants created a schedule and offered a TFT program on TB/MDR-TB for health care providers, clients, and communities by a variety of methods that included brainstorming, group work, and role-play, in addition to lectures. The most important supporting factors to train others were related to opportunity and managers' support, and the biggest barriers were lack of space and time. Trainees also made changes to practices that influenced the way nurses worked within their institution, infection control, team cooperation, extended care, and nurses' attitudes toward patients.

Conclusion:

The TFT program led to ongoing training provision and practical improvements, and can transform attitudes, practices, and changes in patient care. [J Contin Educ Nurs. 2020;51(5):233–237.]

Abstract

Background:

This study evaluated the effects of the Training-for-Transformation (TFT) program on tuberculosis (TB)/multidrug-resistant TB (MDR-TB) in China.

Method:

Participants who received training from 2009 to 2017 (n = 230) were invited to complete an online survey using a self-designed questionnaire.

Results:

A total of 130 (56.5%) trainees completed the survey for a valid response rate of 70% (91 of 130). All of the participants created a schedule and offered a TFT program on TB/MDR-TB for health care providers, clients, and communities by a variety of methods that included brainstorming, group work, and role-play, in addition to lectures. The most important supporting factors to train others were related to opportunity and managers' support, and the biggest barriers were lack of space and time. Trainees also made changes to practices that influenced the way nurses worked within their institution, infection control, team cooperation, extended care, and nurses' attitudes toward patients.

Conclusion:

The TFT program led to ongoing training provision and practical improvements, and can transform attitudes, practices, and changes in patient care. [J Contin Educ Nurs. 2020;51(5):233–237.]

Tuberculosis (TB) is a preventable disease that killed 1.3 million people in 2017 (World Health Organization [WHO], 2018). Each year, nearly a half million people worldwide are infected with multidrug-resistant TB (MDR-TB), which is difficult to treat and represents a growing threat to global public health (WHO, 2017). In the WHO's Global TB Report (2017), China was described as having the third highest burden of TB, with an estimated 895,000 new TB cases in 2016 and 58,000 with drug-resistant TB (DR-TB).

In the current era of TB, nurses play an important role in delivering health care services, and overall nursing competence in detection, control, and care is crucial. In recognition of the important role of nurses, the International Council of Nurses (ICN) has been working to develop nursing capacity in TB prevention, proper care, and treatment. The ICN conducts a Training-for-Transformation (TFT) program that targets nurses working in hospital and primary health care settings in TB high-burden countries to improve their knowledge and practice in the care and support of those affected by TB and nurses' ability to provide training and leadership to their colleagues.

In 2009, the Chinese Nursing Association (CNA) joined the ICN TB/MDR-TB Project. Since then, the CNA has conducted a 4-day course each year, during which a total of 230 nurses have undergone training. This article describes the effect of this TFT program, which was assessed as part of the reporting mechanism built into the ICN TB project.

Method

Study Design and Population

To evaluate the effect of the TFT program, a cross-sectional posttraining online evaluation was conducted. The eligible study population included all 230 trainees who attended the training from 2009 to 2017. The trainees were sent an introductory letter describing the purpose of the evaluation and a link to the online questionnaire through WeChat (a Chinese mobile social media app that provides instant messaging services). Data were collected between February and May 2018.

The questionnaire was developed by the ICN based on the training action plan and contained demographic questions, as well as open-ended questions to assess the type and number of health care workers who were trained, the training methods used, the type of training conducted, and supporting factors and barriers. In addition, questions were included on the changes nurses made in their practice following the training and their attitudes toward patients. Questions were written in English and translated into Chinese. The translated questionnaire then was tested for content validity and face validity. Five nurses with expertise in TB rated each item for its relevance, and the average content validity was 0.91. A pilot study was conducted to examine face validity. Ten trainees completed the survey and then provided their interpretation of the items. Items were revised or deleted based on the trainees' comments.

TFT Program

The TFT program was held from 2009 to 2017. The ICN transformational training method was based on a training-the-trainer method but was expanded to address nurse knowledge, change in nursing practice, leadership, and capacity building. The ICN TFT method was developed by the ICN TB/MDR-TB project as part of the Lilly MDR-TB Partnership. TFT is more than a function of original learning in a training program. For transfer to have occurred, learned behavior must be generalized to the job context and maintained over a period of time on the job. Therefore, one aim throughout the course was to give experienced nurses the skills to train others on what is required to improve patient care and service delivered at the local level.

The training materials and method were adapted to the local context by trainers in China. The training used a variety of participatory methods, including brainstorming, group work, discussion, and a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis, in addition to lectures.

All trainees were asked to sign a letter committing to train a minimum of 10 nurses and 10 other health care workers following the training program. It was important to evaluate the effect of the training. The evaluation plan was to determine whether the training led to practical improvements and changes in patient care, and also to assess the effectiveness of the method used, to determine what could be improved, and to justify further investment.

Data Analysis

Data were analyzed using SPSS® for Windows version 20.0. The characteristics are reported as means and standard deviations, or as median (interquartile range) for continuous variables and as counts and percentages for categorical variables.

Ethical Considerations

This study was approved by the School of Nursing, Peking Union Medical College. The project was determined not to be human subject research and did not require institutional review board approval.

Results

Trainees' Characteristics

Of the 230 trainees, 130 completed the online survey for a 56.5% participation rate; the valid response rate was 70% (91 of 130). Participants were between 31 and 56 years of age, with an average age of 43.36 ± 6.46 years. The years of work experience were between 10 and 37 years; the average number of years of working in TB as a nurse was 23.82 ± 6.99 years. Ninety percent (n = 82) of the participants reported their current workplace was a TB hospital. Fifty-two participants (57.1%) reported the TFT course to be their first training on TB. The characteristics of the trainees are summarized in Table 1.

Demographics and Work Information of Trainees Trained Through The ICN TB/MDR-TB Project in China from 2009 to 2017 (N = 91)

Table 1:

Demographics and Work Information of Trainees Trained Through The ICN TB/MDR-TB Project in China from 2009 to 2017 (N = 91)

Training of Others

Trainees were asked whether they had trained others, the number and type of individuals they had trained, and the training methods they used after attending the ICN TFT course. All of the 91 trainees had performed according to the action plans, and all had used and distributed ICN training manuals during knowledge transfer to health professionals. From 2009 to 2017, the 91 nurses trained 31,443 nurses, 4,158 doctors, 884 health care workers, and 1,574 managers. In addition, education was provided to 5,272 teachers and students, 1,588 community members, 8,280 public members, and 500 patients and families, equating to an average of 590 individuals trained per person (Table 2). The type of training used by trainees in TB/MDR-TB is summarized in Table 3. The top three types were regular rounds and duty or shift report (n = 72; 15.4%), feedback from training (n = 61; 13%), and staff orientation (n = 59; 12.6%). The methods of training used by trainees in TB/MDR-TB are summarized in Table 4. Results showed the most common methods used by trainees were lectures or presentations (n = 85; 93.4%), discussions (n = 59; 64.8%), and demonstrations (n = 43; 47.3%); brainstorming (n = 19; 20.9%), role-play (n = 17; 18.7%), and SWOT (n = 8; 8.8%) also were used.

People Trained by Trainees in TB/MDR-TB between 2009 and 2017 (N = 91)

Table 2:

People Trained by Trainees in TB/MDR-TB between 2009 and 2017 (N = 91)

Type of Training Conducted by Trainees in TB/MDR-TB from 2009 to 2017 (N = 91)

Table 3:

Type of Training Conducted by Trainees in TB/MDR-TB from 2009 to 2017 (N = 91)

Training Methods Used by Trainees in TB/MDR-TB from 2009 to 2017 (N = 91)

Table 4:

Training Methods Used by Trainees in TB/MDR-TB from 2009 to 2017 (N = 91)

After the training, 79.1% of the participants in this study developed health education materials for use in their settings. The types of materials developed included PowerPoint® presentations (76.4%), leaflets (72.2%), brochures (63.9%), posters (18.1%), and other (16.7%). The target audience for the health education materials included nurses (78%), health care workers other than nurses (44%), patients and families (96.7% and 94.5%, respectively), students (39.6%), members of the public (51.6%), and prisoners (3.3%).

Supporting Factors and Barriers to Implementation of Training

Trainees discussed supporting factors and barriers they experienced in implementing training in their setting. Among the trainees, the most frequently mentioned supporting factors included the following: “I trained a few people but would have trained more if I had the opportunity” (n = 78; 85.7%), “My manager supported my efforts to train others” (n = 84; 92.3%), and “I was able to take advantage of other training programs to give sessions on TB and MDR-TB” (n = 39; 42.9%). The most frequently mentioned barrier the trainees faced was related to space and time (n = 55; 60.4%).

Changes Made to TB Practice

Trainees were asked to describe which area they changed in their TB practice after they attended the TB TFT course. More than three-fourths (n = 71; 78%) reported they changed their practice in general TB area, whereas 61% reported they changed their practice in the MDR-TB area. In addition, 22% (n = 20) changed their practice in HIVTB, 14.6% (n = 13) changed their practice in research, and 35.4% (n = 32) changed their practice in infection control. The changes in TB practice included the following:

  • Changes at an institutional level. After training, a number of trainees reported they negotiated with their facility managers to make changes to reduce the risk of TB transmission. These included installing a central ventilation system in the work area, using access control systems in inpatient wards, and providing free diagnostic testing for TB to health care workers. Following the training, they applied for N95 respirators for health care workers.
  • Improvements in infection control. Most of the trainees reported that more infection control measures had been introduced in TB units after the training. Changes included separate wards for suspected or confirmed MDR-TB patients, proper cough etiquette, safe disposal of sputum, and hand washing. In addition, the use of surgical masks and N95 respirators by patients and health care providers had increased. Ninety percent reported that N95 respirators were now available to nurses, and the use of surgical masks by patients increased.
  • Enhancement in team cooperation. After the training, trainees began to cooperate with community members and patients' family to ensure continuous treatment. They also worked closely together with the laboratory. They found that the quality of sputum samples and case detection improved after training.
  • Changes in extended care. The burden of remembering to take medications does not necessarily need to fall on patients. After training, some nurses built social media applications to remind patients to take medication. Approximately one third of nurses (35.2%, n = 32) reported that to provide more personalized services to TB patients, they created a WeChat group to answer patients' questions.
  • Improvement of attitudes toward patients. One-half of the trainees (50.5%, n = 46) reported seeing a much better attitude among health care providers toward TB patients. In addition, the nurses reported less stigma against patients as well.

Discussion

Globally, nurses comprise the largest cadre of health care providers and provide the majority of care to patients with TB, but they rarely have the opportunity to participate in training. The results of this study indicated that 57.1% of trained nurses reported they had never received prior training on TB, and 74.7% and 42.9% of the trainees reported they worked in MDR-TB and HIV/TB care, respectively. Therefore, the ICN TFT project on TB/MDR-TB was welcomed by Chinese TB nurses and helped them improve competency and care provided to patients.

Only 10% to 20% of what people learn in a training session is transferred back to the workplace (Freifeld, 2012). Two studies have shown some problems in training nurses, such as no positive organization climate or a lack of a well-designed training program, so that training cannot be effectively transformed into clinical nursing practice to improve patient outcomes. Nurses have accepted new knowledge but have not been able to apply this knowledge to practical work (Ma & Li, 2015; Ma & Liang, 2015). The ICN TB/MDR-TB project was developed based on a transformational training method that not only provided knowledge on TB to nurses but also helped to build their capacity in prevention, care, and treatment of TB and health education. Trainees were asked to develop an action plan to train other health care providers in their own hospitals, teaching methods were taught, and the ICN TB/MDRTB project provided training materials for nurses to use. These strategies strongly supported trainees' activities.

Through the TFT program, the ICN has prepared 2,224 nurses in 18 countries in Africa, Asia, and Eastern Europe since 2005. These nurses have in turn rolled out the training to more than 176,000 nurses, doctors, allied health workers, and community members (ICN, 2018). The results show that from 2009 to 2017, trainees in China have transferred the knowledge and skills to nurses, doctors, health care workers, patients and family members, students, community health care workers, and even prison staff. The results show that the most common methods used by trainees were lecture, presentation, and demonstration; in addition, role-play and SWOT also were used. The results show that some trainees used communication and negotiation skills to lobby the heads of hospitals, equipped nurses with N95 respirators, and made other changes to infection control practices to improve patient care and support.

Other trainees improved the quality of sputum specimens by optimizing the process so that the positive rate of sputum increased. This is similar to experiences in other countries where these training methods have been used (Tadesse et al., 2013). The trainees also reported some factors that helped or hindered them in training other nurses. Studies indicate that support from organization and senior managers are important. Coping with the difficulties faced requires leadership and negotiation skills with managers and colleagues to change the way things are done, and a strong heart to face the inevitable barriers (Baldwin & Ford, 1988). Future research should explore changes in clinical practice and factors affecting the transfer of training. Training for nurses should stress transformation of knowledge and skills, focusing on the evaluation of clinical changes brought about by training.

Limitations

This evaluation is subject to several limitations. First, the evaluation focused on all of the trainees from 2009 to 2017. First, because the nurses were trained at different times, the growth of those trained year on year could not be determined. Second, this evaluation collected self-reported data from trainees, and thus was subject to both recall and social desirability bias (Malham & Saucier, 2016). Third, the evaluation was subject to nonresponse bias (the participation rate was 56.5%). The reasons for not responding may be that the trainees were not familiar with completing an online survey through a mobile app.

Conclusion

The ICN TB/MDR-TB Project has been part of the Eli Lilly MDR-TB Partnership since 2005. The project aims to build global nursing capacity in the prevention, care, and treatment of TB. This is achieved by training experienced nurses to cascade information to nursing colleagues and other health care workers with the purpose of making improvements to patient care delivery. The nurses who were trained are convinced that the improvements are due to training they received as part of this project. The training can indeed transform attitudes, practice, and outcomes. This project has promoted the development of domestic tuberculosis nursing training. More pre- and posttraining evaluations are required in future research.

References

  • Baldwin, T.T. & Ford, J.K. (1988). Transfer of training: A review and directions for future research. Personnel Psychology, 41(1), 63–105.
  • Freifeld, L. (2012). Transfer of training: Moving beyond the barriers. https://trainingmag.com/content/transfer-training-moving-beyond-barriers
  • International Council of Nurses. (2005). ICN project to increase nursing's capacity to assist in global TB control. International Nursing Review, 52, 8. doi:10.1111/j.1466-7657.2004.00412_4.x [CrossRef]
  • International Council of Nurses. (2018). TB/MDR-TB project. https://www.icn.ch/what-we-do/projects/tbmdr-tb-project
  • Ma, F. & Li, J.P. (2015). Research progress on evaluation of effect and influencing factors of inservice training for nurses in China. Chinese Journal of Nursing, 50(4), 472–475.
  • Ma, F. & Liang, H.M. (2015). Application of Baldwin's theory of transfer of training in the training of nurses. Northwest Medical Education, 23(3), 555–558.
  • Malham, B.P. & Saucier, G. (2016). The conceptual link between social desirability and cultural normativity. International Journal of Psychology, 51(6), 474–480. doi:10.1002/ijop.12261 [CrossRef]
  • Tadesse, Y., Yesuf, M. & Williams, V. (2013). Evaluating the output of transformational patient-centred nurse training in Ethiopia. The International Journal of Tuberculosis and Lung Disease, 17(10, suppl 1), 9–14. doi:10.5588/ijtld.13.0386 [CrossRef]
  • World Health Organization. (2017). Global tuberculosis control 2017. Geneva, Switzerland: Author.
  • World Health Organization. (2018). Global tuberculosis report 2018. Geneva, Switzerland: Author.

Demographics and Work Information of Trainees Trained Through The ICN TB/MDR-TB Project in China from 2009 to 2017 (N = 91)

Characteristicn (%)
Training class
  20099 (9.9)
  20108 (8.8)
  201112 (13.2)
  20127 (7.7)
  201310 (11)
  20148 (8.8)
  201511 (12.1)
  201621 (23.1)
  20175 (5.5)
Status
  Director of nursing department18 (19.8)
  Chief head nurse12 (13.2)
  Head nurse46 (50.5)
  Staff nurse7 (7.7)
  Other8 (8.8)
Professional rank
  Professor of nursing9 (9.9)
  Associate professor of nursing43 (47.3)
  Supervisor nurse33 (36.3)
  Nurse practitioner5 (5.5)
  Other1 (1.1)
Specialist area of TB practice
  General TB84 (92.3)
  HIV/TB39 (42.9)
  MDR-TB68 (74.7)
  Pediatric TB25 (27.5)
  TB in women/pregnancy25 (27.5)
  National TB program23 (25.3)
  Research11 (12.1)
  Infection control27 (29.7)
  Other7 (7.7)

People Trained by Trainees in TB/MDR-TB between 2009 and 2017 (N = 91)

CategoryNo. of AttendeesNo. Trained per Trainee
Nurses31,443345.5
Doctors4,15845.7
Managers1,57417.3
Nurse lecturers720.8
Students5,13756.5
School teachers630.7
Cleaners/orderlies5245.8
Laboratory workers2743
Radiographers560.6
Pharmacists300.3
Drivers400.3
Community health workers1,58817.5
Members of the public8,24090.5
Others (patients, families,5005.5
nursing home)
Total53,699590

Type of Training Conducted by Trainees in TB/MDR-TB from 2009 to 2017 (N = 91)

Trainingn (%)
Regular rounds/duty or shift report72 (15.4)
Feedback from training61 (13)
Staff orientation59 (12.6)
Official health education events54 (11.5)
World TB Day48 (10.2)
Student lectures45 (9.6)
Official meetings36 (7.7)
Separate training session (e.g., workshop)34 (7.2)
One-to-one (on-the-job training)28 (6)
World AIDS Day14 (3)
General public events9 (1.9)
Church gatherings6 (1.3)
Other3 (0.6)
Total469 (100)

Training Methods Used by Trainees in TB/MDR-TB from 2009 to 2017 (N = 91)

Methodn (%)
Lecture/presentation85 (93.4)
Discussion59 (64.8)
Demonstration43 (47.3)
Group work22 (24.2)
Brainstorming19 (20.9)
Role-play17 (18.7)
SWOT analysis8 (8.8)
Other3 (3.3)
Total256 (100)
Authors

Ms. Li is Clinical Nursing Instructor, Department of Rheumatology and Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences; Dr. Zhao is Professor, Dr. Guo is Professor, and Ms. Tian is Graduate Student, School of Nursing, Peking Union Medical College; and Dr. Tudor is TB Project Director, International Council of Nurses, Beijing, China.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the International Council of Nurses (ICN) TB project for supporting the training and this survey. The ICN TB Project is supported by a United Way Worldwide Grant made possible by the Lilly Foundation on behalf of the Lilly MDR-TB Partnership. The authors also acknowledge the contribution made by the Chinese Nursing Association and the School of Nursing, Peking Union Medical College, to the organization and management of activities locally.

Address correspondence to Hong Zhao, PhD, RN, Professor, School of Nursing, Peking Union Medical College, 33 Badachu Road, Shijngshan District, 100144 Beijing, People's Republic of China; e-mail: zhaohong@nursing.pumc.edu.cn.

Received: February 27, 2019
Accepted: October 07, 2019

10.3928/00220124-20200415-08

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