Improvement and implementation of central sterile supply department training programme based on action research

doi:10.21203/rs.3.rs-2749551/v1

Background: This study aimed to improve and implement the central sterile supply department (CSSD) training programme through action research and to evaluate its effect.

Material and Methods: Action research was considered the theoretical frame. The problems that occurred in training were identified following scenario analysis, interviews, group discussions, and expert consultation to develop improvement measures. The training programme characterized by CSSD was developed in the spiral circular process of “Plan-Act-Observe-Reflect”.

Results: After the two rounds of training, the CSSD nurses significantly improved their professional knowledge, skills, and satisfaction with training compared with those before improvement (P < 0.05). The nurses’ overall satisfaction with the training and their performance improved.

Conclusions: The implementation of the training programme designed based on action research can improve CSSD nurses’ professional knowledge and skills and increase their enthusiasm for learning, laying the foundation for CSSD talent development.

The Central Sterile Supply Department (CSSD) is a hospital department responsible for the cleaning, disinfection, sterilization and supply of all reusable instruments, utensils, and articles within the hospital [1]. CSSDs in China are generally directly managed by nursing departments, with some are managed by the Department of Nosocomial Infection Prevention and Control. The sterile supply discipline occurred later than other nursing subjects. Many newly recruited CSSD nurses have limited knowledge of CSSD and its development prospects [2]. The training for CSSD nurses has lagged behind that of clinical nurses [3]. CSSD is one of the key units involving in nosocomial infection prevention and control. The quality of sterile articles directly affects medical quality and patient safety [4]. Professional CSSD knowledge involves a wide range of subjects, including physics, biology, and chemistry. As nursing programmes at schools do not usually provide knowledge and skills in sterile supply, on-the-job training for CSSD staff is necessary to build a professional CSSD team and promote CSSD development. The National Nursing Development Plan of China repeatedly emphasizes the significance of the development and on-the-job training of specialized nurses [5]. Adult learning is generally based on utility. In adult learning, learners care about whether the study content is closely related to the problems they encounter in their daily work [6], and want to obtain the knowledge and skills that can be applied in their work, to enable them to work better. Adults have certain social experiences, imagination, analytical ability, and a strong acceptance ability. Because adults are generally busy earning a living, it is challenge leaving their jobs to pursue study opportunities [6]. Therefore, how to efficiently develop on-the-job training is a problem that needs to be addressed urgently for CSSD management. Action research is exploratory work through collaborative self-reflection to solve practical problems [7]. It is a spiral process consisting of four steps: “Plan-Act-Observe-Reflect” [8]. It can greatly ensure that the improved training is in line with the needs of the trainees and is trainee-oriented, not developed unilaterally by the trainers or managerial personnel. This study aimed to use the action research method to perfect the training system and improve the training effect, to improve CSSD staff’s job satisfaction.

Research Participant

The CSSD nurses who were working in a Grade A tertiary women’s and children’s hospital in Sichuan Province, China were invited to participate in this study. The inclusion criteria were as follows: (1) nurses who were working in the CSSD; (2) who were working under the formal employment contract signed with the hospital or the state-guaranteed lifetime employment. The exclusion criteria were as follows: (1) who had been absent from work for ≥3 months; (2) who would retire within 1 year; and (3) age > 50. A total of 40 nurses were included. The demographic information of the included nurses is presented in Table 1.

Establishment of a Research Team

The research team consisted of the authors, 1 department-level head nurse, 2 other head nurses, and 4 instructors with more than 5 years of teaching and training experience. The research team revised the training programme content, implemented the training, and assessed learning effects of the nurses who participated in the training. The research team also designed the training assessment plan and the unified assessment criteria in advance. The 40 CSSD nurses who were the members of the action research team, received the training, and provided feedback on the problems during the training.

Action Research Method

The action research method was applied to identify the problems encountered during the training and assessment. Following the two spiral processes of “Plan-Act-Observe-Reflect”, the CSSD hierarchical training programme was perfected to improve the training effect.

Identify the Problems

Based on training satisfaction feedback, training quality control, personnel interviews, and the theoretical and skill assessment results after the hierarchical training in 2022, the following problems were identified: (1) low level of training satisfaction; (2) the assessment content was not fully targeted; (3) the nurses did not firmly grasp theoretical knowledge; (4) CSSD work was not conducted in conformity with guidelines; and (5) the training content did not show obvious progression in knowledge and learning. After semi-structured interviews were conducted with the 40 nurses, the following problems were identified: (1) the traditional training methods decreased the nurses’ interest in learning; (2) the repeated training content did not show obvious progression in knowledge and learning; and (3) the training lasted for a long time. The interviewees generally felt that the training was very important and was one of the important means of developing CSSD talents. They hoped to receive systematic and practical training to help them better deal with work and career growth. The above-mentioned problems provided a basis for improving the training programme.

Develop a Plan

Improvement strategies and plans were developed based on scenario analysis, group discussions, literature review, and expert consultation. The plan contained 5 components:

Build a CSSD knowledge system, as shown in Table 2. A perfect knowledge system is a prerequisite for effective training and can help trainers better develop training programme;
For training methods, various measures, such as face-to-face teaching, operation demonstration, workshops, simulation experiences, games, root cause analysis, and mind mapping, were used to target the delivery of relevant knowledge according to the characteristics of students. Meanwhile, online media-assisted teaching and encouraging students to participate in training could effectively improve trainees’ enthusiasm for leaning;
For assessment, an APP or public website could be used in the remote assessment and pre-test simulation stages. To ensure fairness in the assessment, the quarterly examinations were conducted offline. After the instructor who was the teaching director set the questions and the head nurses reviewed them, the exam test paper was issued to other instructors for assessment. The passing score was 60 points. The trainees who failed the exam needed to resit it until they passed it. Once they passed the resit exam, the result of the re-sit exam would be recorded as their result for the training;
Reasonably arrange the length of training sessions. The training was provided once a month and lasted 60-90 minutes per session. To promote the implementation of the training programme and strengthen the learning atmosphere within the CSSD, a two-dimensional code concerning the CSSD training content was pasted on the CSSD’s bulletin board so that the CSSD nurses could scan it to study in their fragmented time; and
Selection of training instructors. Instructors with rich work experience are an important strength in building a nursing team. They have acquired a high level of theoretical knowledge, skills, and work experience in nursing. Therefore, we selected the instructors who had more than 5 years of working experience, rich teaching and training experience, and were sterile supply experts. Because of the particularity of CSSD work which involves specialized equipment, we invited the engineers of the manufacturers for instruction. In addition, infection prevention and control and microbiology experts could also be invited for instruction to make full use of CSSD work resources.

Act to Implement the Plan

From June to December 2022, the theoretical knowledge and specialized skills were sorted out according to the revised knowledge system, and the training programme was implemented according to the improved training method and the length of training sessions. The researchers participated in the development, implementation and summary of the training programme, and organized group discussions to reflect on and summarize the monthly training. New problems encountered during the training were discussed to revise the training programme content. The research team supervised each round of training for 3 consecutive months. Two rounds last for a total of 6 months.

Observe and Reflect

Observation is the investigation and record of the process and results of an action. It highlights the importance of action research in data collection. The researchers involved in the formulation, implementation, and evaluation of the training programme, understood whether the training content was practical, communicated with the trainees to understand their participation, gave their opinions and suggestions on the content, length and method of the training, and provided training guidance. After the first round of training, the trainees’ satisfaction with the training content and method increased. During the supervision and guidance, the research team understood the trainees’ opinions and suggestions on CSSD training through semi-structured interviews and discussed and reflected with them. The research team summarized the problems observed and encountered in the training practice as follows: (1) CSSD works a 24-hour shift every day throughout the entire year. No matter when the training was conducted, some on-duty nurses were unable to participate in the training; (2) poor planning of the training. Only the training’s aims were considered, but the trainees’ needs were not fully considered. As a result, nurses’ interest in training was reduced, and they had a low level of participation; and (3) the trainees did not pay enough attention to the results of the training.

Solutions are as follows: (1) CSSD nurses were busy at work, so the training content should be tailor-made according to their work schedule. Meanwhile, the CSSD management should release the training content in advance, allow the nurses to be flexible in participating in the training, make standardized PowerPoint documents to be included in the CSSD’s teaching resource repository, and make videos for standard operating procedures so that those who could not attend the training sessions due to work reasons could study in their spare time. The 100% training rate could be achieved in this way; (2) integrate the study of human resource management, medical quality, and patient safety into the training. More attention should be paid to the job responsibilities and deficiencies in quality control; and (3) the head nurses held regular seminars for other nurses to understand their psychological status. Pictures about CSSD training achievements and staff activity scenes could be displayed to show the significance of training. Using this emotional education, the CSSD nurses could increase their attention to training.

Trainees’ Levels of Satisfaction with the Training

The evaluation of the training programme consisted of two components: (1) a theoretical exam on fundamental knowledge, specialized knowledge, rules and regulations, knowledge of nosocomial infection prevention and control, practice, team building, and management; and (2) operation skills. The trainees’ satisfaction with the length, content, method, materials and frequency of the training was investigated. The levels of satisfaction are divided into four categories: very satisfied; satisfied; basically satisfied; and dissatisfied. “Very satisfied” and “satisfied” are consider the satisfaction index [9].

Statistical Analysis

SPSS Statistics 25.0 was used for data processing. The enumeration data are expressed in frequency and percentage. The Chi-square test, pair testing, and variance analysis were conducted.

Details of the control group’s results of theoretical knowledge and operation skill assessments after 1-6 and 6-12 months of action are shown in Table 3.

All P values were less than 0.05, indicating statistically significant differences. Through the improvement of the training programme, the nurses’ results in fundamental knowledge, specialized knowledge, rules and regulations, knowledge of nosocomial infection prevention and control, practice, team building, management, and operational skills improved.

Results of the training satisfaction survey following the improvement are presented in Table 4.

The P values were all less than 0.05, indicating statistically significant differences. After implementation, CSSD nurses’ level of satisfaction with the training improved.

The implementation of the optimized training programme is helping to improve the training quality and the nurses’ learning enthusiasm. Action research is a research method that closely combines scientific research with problems arising in practical work [10]. Due to the rapid development of health care, CSSD needs to deal with more modern, precision instruments with complex structures. As an independent discipline, CSSD needs to continuously improve the training programme [11] and develop a training mode with CSSD features. Through action research, we can dynamically improve the quality of training, thereby encouraging the improvement of CSSD nurses’ theoretical knowledge, operational skills, and satisfaction with the training. Continuous improvement of the weak points in work procedures can be used to improve the training programme, promote the overall improvement of CSSD work, and gain more recognition of clinical departments so that the CSSD nurses can improve their professional identity and greatly increase their learning enthusiasm.

An optimized training program can improve training efficiency. Frequent or lengthy training sessions may increase nurses’ aversion to training and increase their job burnout [12]. Traditional training does not pay attention to the length of training sessions and the maximization of time and planning, resulting in a waste of fragmented time. Our training was based on fragmented time management [13], including the use of mobile learning tools (such as mobile phones and two-dimensional code on the CSSD’s bulletin board), which allowed the nurses to study in the fragmented time of their daily life and work. For the nurses to study together, the length of each training session is short, so they can maintain a high level of concentration and achieve better leaning effect. This can save the nurses’ time and improve training efficiency.

Action research can help nursing managers effectively improve training programmes. Action research is a circular process of continuous improvement through practice. In nursing, researchers who engage in continuous improvement of nursing quality use action research to conduct the research, give feedback on problems that occurred in the research, and constantly adjusted the plans, modes and methods of training. Continuous attention to the implementation process can improve the training effect [14]. It is advisable to design the training plan according to the clinical needs and key points of quality control each month. If a cleaning problem is found to be the key source of quality control problems in a given month, it is necessary to adjust the training content in time to meet the needs of solving the cleaning problems. The wisdom and abilities of researchers and practitioners should be combined to solve problems together. Given the low enthusiasm for training, innovative training methods can be adopted, such as conducting root causes analyses of some frequently occurring problems through group discussions. The nurses can review the theoretical knowledge by identifying the root causes via brainstorming.

High-quality training is an important prerequisite for building a professional team. The CSSD’s development is critical to the development of the sterile supply discipline. The development of the sterile supply discipline is inseparable from high-quality technical and management personnel with a reasonable knowledge structure [15]. However, many CSSD managers in our country do not pay enough attention to this. Many CSSD staff possess low educational attainment, and CSSD team building is not reasonable [16]. Using high-quality professional and technical training to actively promote new ideas, new knowledge, new technology, and new methods to cultivate high-quality CSSD talents is imminent. The training programme optimized by action research can effectively develop CSSD talents.

Because action research is a long-term research process and the long-term research conclusion is not clear, the assessment of the training programme may have some defects. Developing a more authoritative and accurate training programme will be the focus of further studies.

The implementation of the training programme designed based on action research can improve CSSD nurses’ professional knowledge and skills and increase their enthusiasm for learning, laying the foundation for CSSD talent development.

Ethics approval and consent to participate

The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Ethics Committee of West China Second Hospital of Sichuan University. Written informed consent was obtained from individual or guardian participants.

Consent for publication

Not applicable

Availability of data and materials

The data analysed during the study will be made available by the corresponding author upon reasonable request.

Competing interests

The authors declare no conflict of interest

Funding

No funding was received for this study

Authors' contributions

All authors participated in the conception and design of the study. Ting Hu: Conceptualization, Software, Writing, Original draft preparation; Juanli Huang: Data curation; Sixing Jiang: Visualization; Ruixue Hu：Investigation; Yongdeng Huang: Data curation; Wei Pan：Writing-Original Draft, Conceptualization;

Acknowledgements

Thanks to all the participants for their timely support and advice throughout the research process.

Wang Y, Wang Y, Wang H, Xue F. The influence of strengthening quality monitoring management on the quality of instrument disinfection and sterilization in the center of disinfection and supply. Clinical Engineering. 2023;30(1):7-8.
Wang P, Lu H, Tian H. Investigation on the knowledge of sterilization in supply center among clinical nurses. Journal of Qiqihar Medical University. 2012;33(13):1816-1818.
Jia Y. Training practice and effect analysis of nurses in disinfection supply center. Health for All. 2019(9):144-145.
Wang S, Ma J, Wu X, Xing D, Peng F. Research progress on “Five in one” training and management of staff in disinfection and supply center. Journal of hospital management. 2021;28(12):1161-1163.
National Health and Family Planning Commission. National Nursing Development Plan -LRB-2016-202J). Nursing management in China. 2017;24(1):1.
Hu P, Yang W. Influencing factors and countermeasures of Continuing education of in-service nurses. Contemporary Nurse (Mid-Week). 2020;27(3):166-169.
Cordeiro L, Soares CB. Action research in the healthcare field: a scoping review. JBI Database System Rev Implement Rep. 2018 Apr;16(4):1003-1047.
Zhang Y, Liu J, Gao F, Zhang C, Wang S. Improvement and implementation of ICU incontinent dermatitis nursing program based on action research. Journal of Nursing. 2019;34(23):36-40.
Kang J, Zhang Q, Yang H, Du H, Wu K, Xu M. Construction of post competency evaluation index for nurses in disinfection supply center. Chinese Journal of Nursing, 2021. 56(6):893-898.
Wang Y, Yao X, Li X. Action research on improving the quality of health education for junior nurses in internal medicine department. PLA Journal of Nursing. 33(18)2016:10-13.
Zhang Y, Zhang X, Cao L, He J. Methods and effects of stratified training for staff of disinfection and supply center. International Society for Digital Medicine. 2017 International Society for Digital Medicine Digital Chinese Medicine branch proceedings. International Society for Digital Medicine: Journal of Hunan University of Traditional Chinese Medicine. 2017:628
Zhang X, Hou M, Hou S, Yang C, Li P. A preliminary study on the optimal training frequency and time for ICU nurses with ventilator-associated pneumonia. General Nursing. 2018;16(30):3820-3822.
Wei Y, Yan H, Yang P, Wang F, Wang L. Applied value of fragmented time management training in theoretical study of surgical nurses. Nursing Practice and research. 2022:19(22):3450-3454.
Wang Y, Yao X, Li X. Action research on improving the quality of health education for junior nurses in internal medicine department. PLA Journal of Nursing. 33(18)2016:10-13.
Zhou B, Liang Y, Gong Y. The development course and prospect of disinfection supply center in our country. China Nursing Administration. 2021;21(10):1441-1445.
Ye H. Puzzlement and measures in the development of disinfection supply center in primary hospitals. Primary Medicine Forum. 20;24(03):416-418.

Table 1 Demographic information of CSSD nurses (n = 40)

	Item	Number (n)	Percentage (%)
Gender
	Male	4	10
	Female	36	90
Age
	18-25	1	2.5
	26-30	28	70
	31-40	8	20
	41-50	3	7.5

Educational attainment
	Junior college diploma	2	5
	Undergraduate qualification	35	87.5
	Master’s degree	3	7.5
Working years
	1-3 years	12	30
	4-6 years	15	37.5
	7-10 years	10	25
	>10 years	3	7.5
Professional title
	Nurse Practitioner	28	70
	Supervising nurse	10	25
	Associate senior nurse	2	5

Table 2 CSSD knowledge system

Zones	Steps	Training content
Decontamination zone	1.1 Environmental requirements	Temperature, humidity, ventilation rate, and zone layout
	1.2 Instrument collection	Collection criteria and tools for collection
		Dress code requirements
		Precautions for collection workflow, pre-processing, and transport
	1.3 Classification	Evaluate the risks of infections, instrument materials, and pollution levels
	1.4 Check	Count the instruments, and check the functions of the instruments and the use of tracking system
	1.5 Cleaning	Cleaning procedures for common and precise instruments
		Cleaning procedures for instruments used by patients with specific infectious diseases
		Cleaning medium: action principle and formulation of cleaning agent; requirements of cleaning water
		Use, maintenance, and troubleshooting of cleaning equipment
		Cleaning methods, including hand cleaning, mechanical cleaning, and ultrasonic cleaning
	1.6 Disinfection	Physical disinfection and chemical disinfection
	1.7 Drying	Hand drying and mechanical drying
Packaging inspection zone	2.1 Environmental requirements	Temperature, humidity, ventilation rate, and zone layout
	2.2 Inspection and maintenance	Cleaning quality, function inspection methods, and maintenance workflow of instruments
	2.3 Packaging	Packaging workflow and precautions
	2.4 Sterilization	Common sterilization methods and equipment use process and management
Sterile package storage zone	3.1 Environmental requirements	Temperature and humidity, ventilation rate, zone layout
Sterile package storage zone	3.2 Delivery	Inspection rules
Monitoring zone	4.1 Quality monitoring	Different sterilization methods: physical, chemical, and biological monitoring methods, and precautions
	4.2. Environmental and surface monitoring	Monitoring frequency, methods, and passing criteria
	4.3 Hand hygiene	Indicators of hand hygiene, monitoring frequency, and passing indicators

Table 3 Results of assessment of theoretical knowledge and operation skills

Groups	Theoretical knowledge					Overall score	Operation skills
Groups	Fundamental knowledge	Specialized knowledge	Rules and regulations	Nosocomial infection prevention and control	Practice, team building, and management knowledge	Overall score	Operation skills
1-6 months after action	14.20±2.103	13.43±2.510	13.43±2.086	13.68±2.005	13.38±2.238	68.10±9.009	86.43±3.713
6-12 months after action	17.25±1.918	16.73±2.242	16.63±2.059	16.08±2.390	16.63±2.072	83.30±8.576	93.53±3.508
T value	-10.736	-10.422	-10.172	-6.921	-8.954	-14.896	-12.597
P value	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

Table 4 Results of training satisfaction survey [n (%) N = 40]

Item	Before action	After action	c²	P
Length of training sessions	15 (37.5)	38 (95)	29.5	< 0.001
Training content	17 (42.5)	32 (80)	11.8	0.001
Training methods	21 (52.5)	36 (90)	13.7	< 0.001
Training materials	25 (62.5)	35 (87.5)	6.6	0.01
Training schedule	25 (62.5)	40 (100)	18.4	< 0.001

No competing interests reported.

Improvement and implementation of central sterile supply department training programme based on action research

Status:

Journal Publication

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Abstract

Background

Materials And Methods

Results

Discussion

Conclusions

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

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