Assessment Framework for Infection Prevention and Control Competence in Trained Nurses in Regional Medical Communities: Development and Implementation

Introduction

Hospital infection management is a critical component of healthcare quality and patient safety, particularly in primary healthcare institutions. However, China faces several challenges in the status and competence evaluation of hospital infection management personnel. Hospital infection management personnel in primary healthcare institutions are predominantly nurses, resulting in a uniform professional structure that lacks experts in clinical medicine, public health, and microbiology.¹ This structure often leads to limited capacity and expertise for comprehensive hospital infection management. For example, a study in Zhejiang province found that many primary healthcare institutions lacked basic training materials and knowledge regarding sterile item procurement and waste management.¹ Additionally, resource constraints in primary healthcare institutions affect their ability to implement effective infection control measures, including the absence of dedicated hospital infection management organizations and standardized practices for sterilization and waste management.²

To address these challenges, structured evaluation systems have been proposed. The World Health Organization (WHO) ‘s Infection Prevention and Control Assessment Framework (IPCAF) includes eight core components, such as Infection Prevention and Control (IPC) education and training, nosocomial infection surveillance, and implementation of multimodal strategies.² This framework helps identify strengths and weaknesses in IPC resources and practices. Hierarchical analysis is also used to simplify complex issues by breaking them down into multiple tiers and computing cumulative weights based on the relative significance of indicators.³ This method helps prioritize key areas like hand hygiene compliance and sterilization practices. However, due to the lack of theoretical foundation, practical capacity and financial resources, IPCAF is not fully applicable to primary health care institutions^4–6. The WHO has set forth new requirements for professional nurses in hospital infection prevention and control, encompassing aspects such as scientific research and management.⁷ Therefore, it is necessary to develop a scientific and comprehensive evaluation framework to guide the infection prevention and control training and practice of nurses in community hospitals.

Analytic Hierarchy Process (AHP), developed by Saaty, is a powerful multicriteria decision-making tool that has been used in numerous applications in various fields of economics, politics and engineering.⁸ The analysis has several advantages in establishing evaluation systems, including strong systematicity, clear logic, integration of qualitative and quantitative analysis, scientific weight allocation, intuitive comparison of multiple alternatives, and strong capacity for dynamic adjustment. These features make it particularly suitable for fields such as hospital infection management and medical quality evaluation, where it can provide scientific and effective solutions for complex decision-making problems.^9,10 This judgment and decision-making way on intricate issues could be applied in the development of the evaluation system for the competence in infection prevention and control.

Therefore, we aimed to develop an assessment framework for improving the competence of professional nurses in infection prevention and control within a regional medical community, and to evaluate the effectiveness of this system in the actual clinical work environment.

Materials and Methods

Participants

Based on the AHP method, 8 experts in the field of infection prevention and control helped to establish the evaluation framework system of this study by independent evaluation of WHO system indicators. From January 2018 to December 2023, 20 IPC nurses in the community hospital were included in the study and trained according to this evaluation framework system. We compared the improvement in infection prevention and control indicators of participants before and after training.

The Establishment and Content of the Evaluation Framework System

With input from 8 authorized experts in the municipal hospital infection quality control center, each with credentials issued by the provincial training course and over six years of experience in infection prevention and control management, a set of well-structured and comprehensive index guidelines were developed for supporting professional nurses in infection prevention and control. These guidelines were developed based on the WHO’s IPC evaluation system and Guidelines for Training Professionals in Hospital Infection Management (WS/T525-2016).¹¹ The evaluation index system for infection prevention and control competence among nursing staff was established and the formulated rules encompassed 3 primary indexes, 9 secondary indexes, and 28 tertiary indexes (Table 1).¹² Key components of this framework included establishing a quality control organization for hospital infection management, delineating clear roles and responsibilities, enhancing the training and supervision system, and creating a collaborative network for open information exchange, communication channels, resource sharing, and talent exchange.

Table 1 Assessment Framework with Three-Tiered Indexes for Professional Nurses in Hospital Infection Prevention and Control

Determination of the Weights of Evaluation Indexes

For each index tier, we aggregated the average scores given by the eight experts in infection prevention and control to assess their relative importance. Hierarchical analysis was utilized to determine the weights assigned to each evaluation index. In this context, “a_ij” represented the assigned importance value of the i_th index relative to the j_th index, while “a_ji” denoted the assigned importance value of the j_th index relative to the i_th index. The value “a_ii” indicated the comparison of the i_th index with itself. The method of assigning relative importance is outlined in detail in Table 2. According to mathematical principles, “a_ii = 1” and “a_ij * a_ji = 1.” By utilizing the mean scores allotted by the experts to determine relative importance, a judgment matrix was constructed and subjected to consistency testing to compute the weight of each index.

Table 2 Relative Importance Assignment Scale

Training Method and Data Collection

20 IPC nurses in community hospitals received unified training. The training covers organizational capacity for managing infections, Ability to execute infection prevention and control protocols and capability for enhancing quality in infection Three aspects of management to ensure that all participants receive the same training and assessment. Data of participants before and after the training were obtained through interviews and questionnaires.

Statistical Analysis

We utilized Excel 2010 to aggregate and organize the data, while statistical analysis was conducted using SPSS 23.0 software. Quantitative data were presented as mean ± standard deviation, and intergroup comparisons were performed using the t-test. Count data were expressed as the number of cases and percentages, with intergroup comparisons conducted using Fisher’s exact probability method. A significance level of P ≤ 0.05 was deemed statistically significant. Weight calculations were performed using the weighting method in hierarchical analysis, with a consistent ratio (C.R). < 0.10 indicating that the judgment matrix successfully passed the consistency test.

Results

Display of AHP Index

A judgment matrix was formed for the three primary-level indexes, yielding a C.R. of 0.001. The cumulative weights assigned to ‘Development of organizational capacity for managing infections’, ‘Ability to execute infection prevention and control protocols’, ‘Capability for enhancing quality in infetion management’ were 0.463, 0.317, and 0.220, respectively (Table 3).

Table 3 Assigning Weights to the Primary-Level Indexes for Professional Nurses Involved in Hospital Infection Prevention and Control

Three judgment matrices were established for the nine second-level indexes, resulting in C.R. of 0.016, 0, and 0.012, respectively. The cumulative weights assigned to ‘Proficiency in fundamental infection prevention and control practices’, ‘Capacity to deal with outbreaks’, ‘Training and education capacity’, ‘Proficiency in understanding policies and regulations regarding infection prevention and control’, ‘Capacity for infection risk assessment’, ‘Capacity for data collection and utilization’, ‘Sense of responsibility’, ‘Critical thinking ability’, ‘Autonomous learning capacity’ were 0.293, 0.108, 0.062, 0.212, 0.105, 0.106, 0.054, 0.035, and 0.025, respectively (Table 4). Nine judgment matrices were formulated for the 28 third-level indexes. The cumulative weights assigned to these indexes were as follows: 0.076, 0.029, 0.026, 0.041, 0.015, 0.049, 0.036, 0.021, 0.070, 0.025, 0.013, 0.037, 0.017, 0.008, 0.080, 0.032, and 0.100, respectively, and 0.105, 0.041, 0.018, 0.047, 0.043, 0.011, 0.003, 0.020, 0.012, 0.019, and 0.006, respectively. The C.R. for these judgment matrices was 0.097, 0.002, 0.003, 0.027, 0, 0.009, 0, 0.012, and 0, respectively (Table 5).

Table 4 Allocating Weights to the Secondary-Level Indexes for Professional Nurses Engaged in Hospital Infection Prevention and Control

Table 5 Allocating Weights to the Tertiary-Level Indexes for Professional Nurses Involved in Hospital Infection Prevention and Control

Training Effectiveness

Following homogenized training, there was a significant increase in the total score of professional nurses in infection prevention and control, rising from 79.50 to 89.75 (P < 0.001). Moreover, the number of nurses holding a bachelor’s degree surged from 7 to 20 (P < 0.001). Additionally, the number of nurses with intermediate or higher professional titles climbed from 7 to 20 (P = 0.010), including 8 with deputy senior titles and 5 with senior titles. The number of nurses who acquired the provincial certificate for professionals in infection prevention and control rose from 3 to 15 (P < 0.001), while those who obtained municipal-level or higher certificates increased from 5 to 20 (P < 0.001). Furthermore, there was a more than two-fold rise in the number of nurses publishing papers on infection prevention and control (P = 0.041). Additionally, all 20 nurses had successfully completed further studies (P < 0.001) (Table 6).

Table 6 Professional Nurses Engaged in Hospital Infection Prevention and Control Within Our Region from 2018 to 2023

Discussion

IPC programs are essential for reducing healthcare-associated infections (HAIs) and antimicrobial resistance (AMR), promoting patient and healthcare worker safety, and strengthening healthcare systems.¹³ The World Health Organization (WHO) has developed a comprehensive IPC evaluation system based on eight core components, which provide a structured framework for assessing and improving IPC practices at both national and facility levels. This study referred to the WHO’s guidelines on core components of IPC programs emphasizing the importance of structured training and the implementation of standardized evaluation tools to improve IPC capacity. The evaluation system of our study is based on evidence-based guidelines and expert consensus, ensuring that the evaluation criteria are grounded in the latest scientific knowledge, which is both scientific and comprehensive. The system’s comprehensive nature is evident in its coverage of multiple dimensions of IPC, from program implementation and guideline development to education, surveillance, and infrastructure. This multi-faceted approach ensures that all critical aspects of IPC are assessed and addressed. Compared with WHO’s IPC evaluation system, the evaluation system of this study also took ‘Critical thinking ability’ and ‘Autonomous learning capacity’ into account. Critical thinking and self-learning abilities are essential for healthcare professionals as they enable effective problem-solving, continuous professional development, and adaptation to evolving healthcare challenges. These skills empower professionals to critically assess clinical situations, challenge assumptions, and make informed decisions, ultimately enhancing patient care.¹⁴ Moreover, self-learning fosters a proactive approach to knowledge acquisition, allowing healthcare workers to stay updated with the latest medical advancements and best practices. This is particularly crucial in a rapidly changing healthcare landscape where lifelong learning is necessary to maintain competence and address complex patient needs.¹⁵ The use of AHP aligns with WHO’s recommendations for developing scientifically valid and reliable evaluation systems.⁷ AHP provides a structured and scientific approach to competence evaluation, addressing the challenges of limited expertise and resource constraints in primary healthcare institutions.¹⁶ This method is particularly innovative in the context of China, where the application of AHP in hospital infection management is still in its early stages.¹⁷ However, its potential for improving decision-making and resource allocation is evident^18. This study innovatively integrates AHP with standardized training programs, providing a novel approach to enhancing IPC competence in primary healthcare settings.

The scientificity of AHP lies in its ability to convert qualitative factors into quantitative weights through pairwise comparisons and consistency tests.¹⁶ This method reduces subjectivity and enhances the reliability of decision-making. In this study, C.R. for all judgment matrices was below 0.10, indicating that the evaluation system passed the consistency test. This ensures that the weights assigned to each index are scientifically grounded and reliable. Compared with WHO evaluation system, this evaluation has stronger practicability. In addition, the new system has passed the expert consultation and consistency test, which ensures the scientific and reliable scoring indicators. The new system more accurately reflects the capabilities and needs of primary IPC nurses.

The study demonstrates the practical application of AHP in enhancing the capacity of hospital infection management nurses. A practical case study in Shanghai¹⁹ demonstrated the effectiveness of AHP in evaluating IPC competence. The study found that many primary healthcare institutions lacked basic training materials and knowledge regarding sterile item procurement and waste management. By implementing an AHP-based evaluation system, the study identified key areas for improvement and provided targeted training to enhance IPC capacity. This case highlights the applicability of AHP in addressing real-world challenges in hospital infection management. Similar tools have been developed based on the WHO’s core competencies and have shown good evidence of validity and reliability.^20,21 Such tools can be applied in countries of all income classifications, making it possible to design educational initiatives and enhance core competencies globally.

However, despite its strengths, AHP also has several limitations when applied to IPC evaluation systems. While AHP provides a structured approach to developing IPC evaluation systems, its limitations in handling subjectivity, complexity, interdependencies, and dynamic environments must be considered. Combining AHP with other methodologies, such as fuzzy logic or Delphi techniques, can help mitigate some of these limitations and enhance the robustness of IPC evaluation systems. AHP relies heavily on pairwise comparisons made by experts to determine the relative importance of criteria and sub-criteria. This process introduces subjectivity, as different experts may have varying opinions and experiences.²² This can lead to inconsistencies in the evaluation results, especially when multiple experts are involved.²³ IPC environments are dynamic, with evolving threats and changing guidelines. AHP, however, is based on static pairwise comparisons and may not easily adapt to rapid changes. This can limit its effectiveness in continuously improving IPC practices. AHP assumes independence among criteria, which may not always be the case in IPC settings. For example, hand hygiene compliance may be interdependent with staff training and availability of supplies. Ignoring these interdependencies can lead to an incomplete evaluation of IPC practices.²⁴ AHP focuses primarily on quantitative metrics derived from pairwise comparisons, potentially overlooking qualitative aspects of IPC. For instance, the quality of staff training or the effectiveness of communication channels may be difficult to quantify but are crucial for IPC success. AHP uses a C.R. to validate the pairwise comparisons. However, achieving a low C.R. (typically <0.1) can be challenging, especially when dealing with a large number of criteria. This may lead to questions about the reliability of the evaluation system.

Conclusion

This study provides valuable insights into the application of AHP in evaluating the competence of hospital infection management nurses. The results demonstrate significant improvements in nurse competence and highlight the effectiveness of AHP in addressing complex decision-making problems in healthcare. Future research should focus on further refining the evaluation system and exploring its application in other healthcare settings. Policymakers should prioritize resource allocation and targeted interventions to enhance IPC capacity in primary healthcare institutions.