Development and evaluation of a training of trainers intervention for nursing professionals during COVID-19 pandemic in India

The COVID-19 pandemic had posed a devastating effect on humankind across the world. According to a report in 2021, more than 30 million people had been affected1UN Women—HeadquartersFrom immediate relief to livelihood support , UN Women drives investment and support for women and girls impacted by COVID-19 in India.https://www.unwomen.org/en/news/stories/2021/6/news-driving-investment-and-support-for-women-and-girls-impacted-by-covid-19-in-indiaGoogle Scholar and latest statistics by World Health Organization revealed that there were more than 44 million confirmed cases in India till July 2023.2World Health OrganizationWHO coronavirus (COVID-19) dashboard with vaccination data.https://covid19.who.int/region/searo/country/inDate: 2023Google Scholar Health care professionals, especially those working in hospitals caring for people with confirmed or suspected COVID-19, were vulnerable to infections and mental health problems.3Firew T. Sano E.D. Lee J.W. et al.Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers' infection and psychological distress during the COVID-19 pandemic in the USA.BMJ Open. 2020; 10: 1-12Crossref Scopus (176) Google Scholar,4Khanal P. Devkota N. Dahal M. Paudel K. Joshi D. Mental health impacts among health workers during COVID-19 in a low resource setting: a cross-sectional survey from Nepal.Global Health. 2020; 16: 89Crossref PubMed Scopus (182) Google Scholar Work-related stressors, long working hours, shortage of personal protective equipment, higher than normal patient-nurse ratio and fear of the unknown were repeatedly reported in various studies.5Natividad M.J.B. Aljohani K.A. Roque M.Y. Gamboa H.M. Feelings, stress, and coping of nurses amidst COVID-19 outbreak in Saudi Arabia.Sudan J Med Sci. 2021; 16: 285-300Google Scholar,6Hossain F. Clatty A. Self-care strategies in response to nurses' moral injury during COVID-19 pandemic.Nurs Ethics. 2021; 28: 23-32Crossref PubMed Scopus (0) Google Scholar Effective professional and self-care practices would enhance their psychological preparedness, and aid in better patient care.7Gandhi S. Sahu M. Radhakrishnan G. et al.Psychological preparedness for pandemic (COVID-19) management: perceptions of nurses and nursing students in India.PLoS One. 2021; 16e0255772https://doi.org/10.1101/2020.09.24.20201301Crossref Scopus (0) Google Scholar,8Bernburg M. Groneberg D. Mache S. Professional training in mental health self-care for nurses starting work in hospital departments.Work. 2020; 67: 583-590Crossref PubMed Google Scholar We developed and evaluated a Training of Trainers (TOT) program for self-care of nursing professionals caring for persons with COVID-19 and further to create a pool of master trainers for training nurses in their respective states in stress management. The program was conducted through online training using didactics, videos, case scenarios, role plays, participant narratives, demonstrations and return demonstrations in a group of minimum 30 participants in three consecutive sessions: first session on managing emotions and stress, second session on self-care, work-life balance, and physical health. The third session was on managing interpersonal relationships (IPR) and seeking support. Pre-assessment was conducted on knowledge, attitude, and skills, and the post assessment was administered on the same variables immediately after the last of the three sessions. Totally, 463 nurses attended the program, with 410 completing pre and post assessment. Out of 410 participants, 200 participants who further trained a minimum of 5 nurses each were identified as master trainers. Thus, 200 master trainers had trained more than 2000 nurses throughout the country resulting in a cascading effect of the program. Besides, this research team mentored another team from a premiere institute of Psychiatry who further trained approximately 1000 nurses all over the country. The participants who attended the program indicated that they found the strategies learned in the TOT program to be useful and applicable in the daily life of a nursing professional as well as across other workplace settings. They informed that they could practice these skills and felt confident to train others. Findings also revealed that knowledge, attitude, and skills of the participants had improved following the TOT program. Previous studies conducted before the pandemic found similar results that professional training in mental health self-care8Bernburg M. Groneberg D. Mache S. Professional training in mental health self-care for nurses starting work in hospital departments.Work. 2020; 67: 583-590Crossref PubMed Google Scholar or mental health promotion intervention9Bernburg M. Groneberg D.A. Mache S. Mental health promotion intervention for nurses working in German psychiatric hospital departments: a pilot study.Issues Ment Health Nurs. 2019; 40: 706-711Crossref Scopus (16) Google Scholar for nurses had positive impact on decreasing perceived job stress and emotional exhaustion as well as enhanced emotion regulation skills. Nursing is a stressful profession associated with complex job demands and needs.10Babapour A.R. Gahassab-Mozaffari N. Fathnezhad-Kazemi A. Nurses' job stress and its impact on quality of life and caring behaviors: a cross-sectional study.BMC Nurs. 2022; 21: 75Crossref Scopus (67) Google Scholar Therefore, nurses need to learn self-care strategies to take care of themselves, which contributes not only to a healthy nursing workforce but also equips them to provide higher quality care in the country. Over the last decade, World Health Organization has emphasized on self-care among health care professionals to empower individuals and communities to manage their health and well-being which in turn strengthens the health care services. The present ToT program had a transformative impact on both current enrollees and future nurses, contributing to the improvement of education as well as healthcare systems. The ripple effects of enhanced skills, knowledge, and attitudes may positively influence the individuals they come across, institutions they serve, and the broader community. For the participants, ToT program focused on developing self-management skills through self-care that prepares them to adapt to a rapidly evolving healthcare landscape or an emergency like pandemic. Additionally, this TOT provided opportunity for them to be more empathetic, compassionate, and responsive to the diverse needs of patients as well as for learning leadership and inter personal skills enabling them to take on supervisory roles, and positively influence healthcare delivery. All these ultimately may lead to better patient outcomes, reduced healthcare costs, and an overall improvement in the quality of healthcare services. An e-manual on mental health self-care was widely disseminated to health care personnel in the country. This study emphasized on training the psychiatric or mental health nurses who with their additional communication and inter personal skill, are in a good position to train others. Therefore, the present study is an attempt to highlight the importance of self-care strategies among nursing professionals which can be tested among other group of professionals after modification. Conceptualization- SG. Data curation- MS. Formal Analysis- MS. Funding acquisition- SG. Investigation- SG, MS, RP, MM, PS, RB. Methodology- SG, MS. Project administration- SG. Resources- MS, SG, RP, MM, PS, RB. Software- MS. Supervision- SG, RP, MM, PS, RB. Validation- SG, RP, MM, PS, RB. Visualization- MS, SG, RP, MM, PS, RB. Writing—original draft- MS, SG. Writing—review & editing-MS, SG, RP, MM, PS, RB. Author(s) who have accessed and verified the data: MS, SG, RP. Author(s) who were responsible for the decision to submit the manuscript: MS, SG, RP, MM, PS, RB. Authors declare no conflict of interests. It is also stated that authors were not precluded from accessing data in the study, and they accept responsibility to submit for publication. The Authors are thankful to NIMHANS, Bengaluru, Ministry of Health & Family Welfare (MoH & FW), Govt. of India and World Health Organization (WHO)- India for their unconditional support. Funding: Funding was received for conducting the study from World Health Organization (WHO)–India (Reg. No.: 2020/1040302-1).