Development of an Educational-Training Program for Infection Control Practitioners in Long-Term Care Hospitals Using the Dacum Method: A Descriptive Study

Background: Elderly persons in Korea are at risk of infection due to underlying diseases and weak immune systems. In addition, they require care in long-term care hospitals (LTCHs) that have well-trained infection control practitioners (ICPs). This study aimed to develop an educational-training program for ICPs working in LTCHs using the Developing A Curriculum (DACUM) method. Methods: A total of 209 ICPs participated in a survey and rated 12 duties and 51 tasks according to frequency, importance, and difficulty. Tasks that scored above the mean for each of the three factors were selected as key tasks and divided into five modules. Subsequently, 29 of the ICPs participated in a pilot educational-training program. Results: Of a maximum of 5.00, the mean task frequency, importance, and difficulty were 2.71, 3.90, and 3.67, respectively. The mean program satisfaction level was 93.23 (standard deviation: ±3.79 points) out of 100 points. The total knowledge, skills, and teaching efficacy scores were significantly higher after the program (p<0.001, p<0.001, and p<0.006, respectively). Conclusions: The DACUM method was used to develop an educational-training program based on the duties of ICPs. This systematically developed program was effective and has the potential to improve ICP performance and the quality of care in LTCHs.

infection due to relatively weak immune functions. 5 LTCHs are exposed to high risks of healthcareassociated infection (HAI) due to an insufficiency of infection control workforce and infection supervisory systems. 6,7 In order to address such problems, since January 2013, the Korean government has obligated all LTCHs nationwide to obtain a medical center certificate including a strengthening criterion regarding infection control among the certification items.
To strengthen infection control, LTCHs need to establish appropriate infection control policies and conduct educational-training programs for their employees to ensure that they become familiar with such policies. Moreover, it is necessary to monitor and evaluate whether employees implement such policies appropriately and whether infection control is practiced properly among patients through timely feedback. 8 For these purposes, LTCHs require well-trained infection control practitioners (ICPs). 9 Currently, in Korea, various educational programs are conducted by graduate schools, academic institutes, and governmental organizations for ICPs. 10 However, most of the programs focus on infection control theories, with the practical training based on large-scale acute phase medical center cases.
DACUM stands for "Developing A Curriculum." The term itself represents the function of an educational development process, but it has been widely used as a job analysis method. 11 This method is systematic in that it effectively helps to identify tasks to be implemented based on a job analysis and the development of an educational process through which trainees can acquire knowledge, attitudes, and skills necessary for their tasks. 12

Study Subject and Data Collection
In order to analyze the duties of ICPs in LTCHs, a six-member DACUM committee was organized with experts including ICPs in LTCHs, nurses specializing in infection control, and nursing professors.
DACUM committee members included two infection control nurses with at least 10 years of professional experience, two ICPs working in LTCHs, and two nursing professors who conduct a Master's degree course on infection control. By means of the simplified DACUM method, 13 the researcher examined, in a preliminary step, duties of ICPs in long-term care facilities based on a literature review. 8,9 A one-day workshop was then conducted to identify the duties and tasks of ICPs in LTCHs.
In order to verify the identified tasks, a list of 1,408 LTCHs was presented by the Korean Association of Geriatric Hospitals. From this list, 250 LTCHs were selected in total, with 10-20 from each region and hospital level, through convenient sampling, and then instructions and questionnaires were distributed among their nursing departments. Completed questionnaires were collected using enclosed self-addressed envelopes. Tasks with average frequency, importance, and difficulty levels were selected as key tasks for the educational-training program development. DACUM committee members identified task elements for each key task during a workshop, with a subsequent process to derive knowledge, skills, and tools required for each task element. Finally, a 4-day educationaltraining program that included five modules was developed.
A survey was conducted on 209 ICPs to determine their preference to undertake the program by email. In order to verify the effectiveness of the educational-training program, 30 ICPs who volunteered were recruited on a first come, first served basis to participate in a pilot study. The sample size was estimated using the G*power 3.1.1 software program. Sample size estimation was based on the following Wilcoxon signed-rank test criteria: statistical power of 0.80, significance level of 0.05, effect size of 0.50, and one-sided test. Therefore, we needed a sample size of 28 participants. Allowing for attrition, we recruited a total of 30 participants for the study. Of the 30 ICPs, the 29 who completed the 4-day program had their post-program satisfaction level measured as the process evaluation. To evaluate the effectiveness before and after the program, the level of knowledge, skills, recognition of the importance of infection control, teaching efficacy, and teaching state anxiety were measured.

Knowledge and Skills
In order to determine whether the learning goals of each module were achieved, 30 questions each about knowledge and skills were developed. Each correct answer was given 1 point, and each incorrect or no answer was given 0 points. The perfect score of the knowledge questions was 30 points, and that of skill questions was 30 points.

Recognition of the Importance of Infection Control
The tool developed by Hong and Park (2016) was utilized. 15 The two questions regarding catheter that were not applicable to ICPs in LTCHs were excluded, while 35 questions in total including hand hygiene, employee safety, intravascular catheter infection control, urinary tract infection control, pneumonia control, isolation, as well as disinfection and sterilization management were included.
Each answer was measured on a 5-point scale. Cronbach's alpha indicating the reliability of the tool before and after the education program was .962 and .965, respectively.

Teaching Efficacy Belief and Teaching State Anxiety
To measure infection control teaching efficacy, the revised version of the Science Teaching Efficacy Belief Instruments (STEBI) developed by Riggs and Enochs (1990) was utilized. 16 The infection control teaching efficacy measuring tool included 22 questions in total. In order to measure the teaching state anxiety, 20 questions about state anxiety were selected from the State-Trait Anxiety Inventory (STAI) method developed by Spielberger et al. (1970) and revised for infection control teaching state anxiety measurement. 17 Two infection control nurses and two nursing professors evaluated the content validity. The infection control teaching efficacy and teaching state anxiety were assessed on a 5-point scale. Cronbach's alpha was .782 and .814 before and after the education, respectively. The tool reliability of teaching state anxiety measurement Cronbach's alpha was .943 and .953 before and after the education, respectively.

Data Analysis
Subjects' general characteristics; each task's degree of frequency, importance, and difficulty; and educational level of satisfaction were analyzed using descriptive statistics and reported as frequency, percentage, average, and standard deviation. Differences before and after the education program in scores of knowledge, skill, recognition of the importance of infection control, teaching efficacy, and teaching state anxiety were analyzed by means of Wilcoxon signed-rank test. Data analysis was conducted using SPSS (IBM SPSS Statistics for Windows, Version 18.0. Armonk, NY: IBM Corp.)

Job analysis: Duties and Tasks of ICPs in LTCHs
Based on the results of the literature review and the DACUM committee workshop, 12 duties and 51 tasks of ICPs were identified (Table 1). Specifically, the following were the 12 duties: preparing policies and guidelines; monitoring the infection process; planning and evaluating the infection control program; improving hand hygiene practice; managing tool disinfection and sterilization; isolating patients with infectious diseases including reportable diseases; infection control for each strain; infection control for each infection site; infection control over employees; environmental infection control; counseling and communicating with internal and external departments and self-development. One to seven tasks were included for each duty.

Task Verification
The degrees of frequency, importance, and difficulty of each task are presented in Table 1. The degree of frequency was 2.71±0.64 on average, on the 5-point scale. The following included tasks with high frequency in that order: laundry management (3.92±0.82), medical waste management (3.91±1.01), and hand hygiene practice investigation (3.63±0.92).
On a 5-point scale, the score indicating the level of importance was 3.90±0.05. Thus, the following included tasks with a high level of importance in that order: scabies control (4.32±0.72), hand hygiene practice investigation (4.27±0.68), and hand hygiene promotion activity (4.27±0.68).
Furthermore, on a 5-point scale, the score indicating the level of difficulty was 3.67±0.44. The following included tasks with a high level of difficulty in that order: preparation for certification evaluation (4.07±0.75), HAI result analysis (3.89±0.83), and scabies control (3.89±0.74).
In summary, although laundry and medical waste management were performed frequently, the scores indicating their levels of importance and difficulty were lower. Hand hygiene-related tasks had high frequency and importance. However, despite the low frequency of preparation for certification evaluation, the degree of difficulty was very high.

Key Task Selection and Analysis
For educational-training program development, the selected key tasks among the actual tasks of ICPs in LTCHs were those with an average that were as high as the average levels of frequency (average 2.71), importance (average 3.90), and difficulty (average 3.67). These tasks included the following nine tasks: selecting disinfectant, identifying and advising how to disinfect medical equipment, methicillin-resistant Staphylococcus aureus (MRSA) infection control, influenza control, scabies control, bacteremia control, pneumonia control, urinary tract infection control, and preparing for the Korean accreditation program for healthcare organizations ( Table 1). The elements for each key task were derived from the workshop involving the DACUM committee members. Several elements of the nine key tasks are shown in Table 2.

Educational-training Program Development
Knowledge, skills, and tools required for each element of each task were analyzed and the expected subject areas from the nine key tasks were classified into five modules of the educational-training program ( Figure 1; Table 3). For each module, the lecture standards, practice standards, and monitoring of feedback forms were developed.

Educational-training Program Operation
The five educational-training program modules were conducted over a period of 32 hours during the 4-day educational process from February 8 to 11, 2017 (Table 3). Each module was conducted with lectures and practical sessions based on the developed lecture standards, practice standards, and monitoring of feedback forms.

Educational-training Program Evaluation
As a result of the process evaluation, the program satisfaction level was 93.23±3.79 points on an average on a 100-point scale. All the modules had a minimum of 90 points on the satisfaction level.
The average scores of infection control knowledge before and after the program were 18.89±2.39 and 26.13±1.09 points, respectively, indicating a significantly higher score after the education (z=-4.70, p<.001). The average score of infection control skills before and after the program (13.98±2.39 and 24.91±2.46 points, respectively) was also significantly higher after the education (z=-4.70, p<.001).
Furthermore, the average score of teaching efficacy before and after the program (78.02±8.58 and 81.84±9.81 points, respectively) was also significantly higher after the program (z=-2.75, p=.006).
However, the average scores of teaching state anxiety before and after the program (63.66±11.67 and 66.48±14.20 points, respectively) showed no statistically significant difference (z=-1.92, p=.055). The average scores of infection control recognition on a 175-point scale (168.90±8.74 and 171.10±7.36 points, respectively) also showed no statistically significant difference (z=-1.77, p=.077) (Table 4). In summary, program satisfaction was higher than 90 points, and knowledge, skills, and teaching efficacy improved after the program.

Discussion
This present study developed an educational-training program for ICPs working in LTCHs based on a job analysis that utilized the DACUM method. Following the analysis of the job of ICPs in LTCHs in Korea, 12 duties and 51 tasks were identified. In general, these duties and tasks were similar to those reported in previous studies on the activities of ICPs in acute-phase medical centers in Korea,18 guidelines for infection control in long-term care facilities in Japan, 5 and core competencies of infection control nurse specialists in Hong Kong, 8 as well as on the roles and competencies of the Association for Professionals in Infection Control and Epidemiology (APIC) infection preventionists. 19 When the findings of this study were compared with those of Hobbs (2007)  Furthermore, as the main role of ICPs was changed recently from "control" to "prevention," it is thought that their duties on program and financial management, and regulatory and accreditation compliance were emphasized, in addition to previous main duties of surveillance, reporting, and educational duties. 22 However, additional tasks derived in this study were similar to duties aimed at minimizing risks of infection and transmission derived by Hobbs. 20 Thus, it is thought that there is not much difference in the duties of ICPs between those at LTCHs and at acute-phase medical centers. The purpose of infection control in medical centers is to enhance patient safety by reducing HAI. 22 Although the priorities might differ depending on the patient groups and infection control infrastructures between acute-phase medical centers and long-term care facilities, 9 there is no significant difference in the duties of ICPs themselves.
In this study, tasks with levels of frequency, importance, and difficulty that were as high as the average included the following nine tasks: selecting disinfectant, identifying and advising how to disinfect medical equipment, MRSA infection control, influenza control, scabies control, bacteremia control, pneumonia control, urinary tract infection control, and preparing for the Korean accreditation program for healthcare organizations. These tasks were selected as key tasks for educational and training program development. In long-term care facilities, patient to patient transmission of infection by MRSA carriers or infected patients is more common than transmission by employees. 23 Accordingly, the importance of MRSA screening tests and proactive isolation is emphasized in addition to hand hygiene among employees. March et al. (2010) reported that long-term care patients were colonized with various multidrug-resistant bacteria such as MRSA, 6 vancomycin-resistant Enterococci, metallo-b-lactamase-producers, and extended spectrum beta-lactamase-producers. Antibiotic treatment, indwelling devices, and immobility are risk factors for multidrug-resistant colonization. 6 Particularly, the fact that > 78.5% of patients in long-term care facilities have urinary catheters, and 93% receive influenza vaccines indicates the importance of urinary tract infection and influenza control in long-term care facilities. 24 Accordingly, it is thought that the five module (hand hygiene and safe injection practice, disinfection and environment control, risk assessment and multidrug-resistant strain control, urinary tract infection control, and respiratory infection and visitor control) program developed in this study is effective for competency enhancement of ICPs in LTCHs.
As part of this study, an educational-training program of lectures and practical sessions was conducted over a period of 32 hours in total during a 4-day program by means of lecture standards, practice standards, and monitoring of feedback forms for each of the five modules. This program is of significance in that it included both lectures and practical sessions as a reflection of the demands of ICPs in Korean LTCHs. 7 In order to help hospital employees demonstrate their infection control knowledge, ICPs need to apply various educational methods including both theories and practical sessions during workshops, team-based learning, problem-based learning, on-site training, and through simulation. 9 For ICPs to be able to apply such various educational methods, they need to be exposed to such methods in their natural settings.
The educational contents developed in this study are similar to those developed by the Nebraska Infection Control Network in 2002 for ICPs in long-term care facilities including surveillance, multidrug-resistant organisms control, isolation, and infection control program. 21 However, this present study is of significance in that it reflected duties of high priority to the educational process based on the frequency, importance, and difficulty of tasks according to results of the job analysis conducted among ICPs in LTCHs through the application of the DACUM method.
The effect of the educational-training program developed in this study was measured through process evaluation and effectiveness evaluation. The level of satisfaction of subjects with the program measured through the process evaluation was high for each of the following aspects: educational theme, educational content, educational method, educational material, and educational condition.
The effectiveness evaluation was used to measure the effect of the program on subjects' knowledge, attitude (teaching efficacy, teaching state anxiety, infection control recognition), and skills. In this study, the scores of knowledge and skills were higher after the program. Regarding attitude, however, significant improvement was shown only with regard to teaching efficacy, whereas there was no difference regarding teaching state anxiety and infection control recognition. This was probably because of the difficulty in verifying such factors; this methodological study developed the educational-training program and tested the program only among 29 individuals as a pilot project. Thus, a future study needs to include more subjects. Regarding infection control recognition, it is thought that because the subjects were ICPs in LTCHs, they could already recognize the importance of infection control even before the program.
This study is of significance in that it developed a program systematically based on the duties of ICPs in LTCHs by means of the DACUM method in order to improve infection control in LTCHs where human resources and infrastructure, such as facilities and devices, are inadequate in comparison to that of acute-phase medical centers. Nonetheless, it is necessary to include more ICPs in the DACUM panel to verify their duties more specifically. Since it takes more time to change attitudes than merely acquire knowledge, follow-up research needs to continue to verify the extent of HAI performance improvement and HAI rate decrease as indexes of educational-training program performance evaluation. To this end, it is necessary to form a network of ICPs working in LTCHs and continue to monitor HAI and obtain feedbacks.

Conclusions
An infection control education-training program was developed systematically in this study for ICPs working in LTCHs by means of the DACUM job analysis method and thorough application of the educational process development procedures. The process evaluation and effectiveness evaluation conducted before and after the educational-training program proved the outstanding training program performance. Particularly, regarding knowledge and skills, the scores after program implementation were significantly high for all five modules. The educational satisfaction level was as high as 90 points in every module. This program, therefore, can be utilized for ICPs in various LTCHs.
Additionally, the policy plans, lecture plans, monitoring feedback forms, and report forms developed for each module in this educational-training program can be applied directly to infection control work in LTCHs, being expected to contribute to improved infection control practices in such facilities.

Declarations
Ethics approval and consent to participate: In order to protect the rights of the subjects, this    Figure 1 Educational-training program modules based on the identified key tasks using the DACUM method. This figure shows that five modules were developed to teach the knowledge and skills needed to perform nine key tasks. For example, the "risk assessment and multidrugresistant strains control" module was developed to teach knowledge and skills required for "MRSA infection control," "scabies control," and "preparing for the Korean accreditation program for healthcare organizations." MRSA, methicillin-resistant Staphylococcus aureus;