After the results of the Study on the Efficacy of Nosocomial Infection Control conducted by the Centers for Disease Control and Prevention in the United States in the 1970s, most health care facilities established the Infection Prevention and Control (IPC) unit. Although the focus of the role differs slightly from country to country, there are strong similarities in the elements of the responsibilities. There is commonality in the international recognition of the need for the role of infection prevention and control practitioners (IPCPs) in the maintenance of an effective infection surveillance and control program. However, there is significant variance between countries in the way IPCPs are prepared for this specialized practice area. In many countries, there is no mandatory requirement for the education or training of IPCPs and there are no additional preparation requirements for this specialized role. This is especially common in the Asia Pacific region. The aim of this brief review is to study the international state of core competencies and professional development of IPCPs as a reference for the introduction of an appropriate program in the Asia Pacific region.
1 The need of competences for IPCPs
The focus on reducing healthcare associated infections (HAIs) continues throughout the world and the introduction of patient safety improvement programs has highlighted the role of HAIs as an adverse effect on public safety and quality of care. IPCPs are key experts to identify new and emerging infections or infectious disease as well as to improve on the safety and quality of care delivered to individuals and populations. They provide colleagues across all health care settings with robust clinical expertise, advice, support, and guidance to prevent, manage, and control HAIs. Thus, competences of IPCP is critical to the success of infection surveillance, prevention, and control program in all healthcare settings. Competences framework is essential not just for IPCP. The core competences are essential in the employment and for performance review of IPCPs. This is especially important when employing advanced level IPCP who should possess the qualifications and specialist knowledge commensurate with a senior practitioner.
The term competency is defined as: “the proven ability to use knowledge, skills, and personal, social and/or methodological abilities, in work or study situations and in professional and personal development”. The framework can be useful for people such as the employer organizations who can adopt the competence framework to hire IPC expert for the job. For educational commissioners and providers, the framework forms a new curriculum for education and training provision meeting service needs. The core competence framework is especially valuable for practitioners working in IPC unit, so that they can better understand their role in all its aspects. The competency framework is particularly essential for IPCPs who have an interest in developing their knowledge, understanding and skills to plan their professional and career development in the future.
Traditionally, IPCPs mainly come from nursing background. However, as the prevention, management and control of infection have developed and in diverse settings, also the pool of people who have developed their knowledge and skills in the specific areas. Practitioners (IPCPs) generally now are coming from a wide range of clinical or healthcare-science background that include nurses, epidemiologists, microbiologists, paramedics and biomedical scientists. As IPCPs are now coming from diverse backgrounds, there is indeed a need for standardization through the credentialing of the training and for professional development.
2 The global situation
Healthcare is delivered in a dynamic environment with frequent changes in populations, methods, equipment, and settings. IPCPs must ensure that they are competent in addressing the challenges they face and are equipped to develop IPC services in line with a changing world of healthcare provision. Advances of IPCP core competencies and professional development differ among countries while some are more progressive than the others. In some of the developing countries, there is very little progress in the development. This review only includes countries or regions that have established programs.
2.1 North America - USA and Canada
Certification is seen as a fundamental standard among major health professions. It is recognized by patients, employers, and regulators as validation of competency in a specialty area. The medical specialties evaluate and recognize professional competence among physicians through board certification in a specialty area. The American Board of Nursing Specialties adopted the same process for certifying IPCPs. In North America, the core competencies and professional development of IPCP started early since 1981 by an independent body, the Certification Board of Infection Control and Epidemiology (CBIC). The goal of CBIC is to raise the standard of the IPC profession through the development, administration, and promotion of an accredited certification process. The CBIC is a voluntary autonomous multidisciplinary board that provides direction and administers the certification process for professionals in infection control and applied epidemiology. The CBIC performs a practice analysis survey approximately every 5 years to assess the current practice of infection prevention and ensure that the certification examination focuses on current IPCP practice reflecting current practice. There is recertification examination every 5 years to make sure that the competencies are up to date. There are 2 infection control academic associations, the Association for Professionals in Infection Control and Epidemiology (APIC) / Community and Hospital Infection Control Association (CHICA) and both provide the education and implements competency measures for the Certification Board of Infection Control and Epidemiology (CIC) credential. In 2012, the US APIC developed a conceptual model with four domains for what they called “future-oriented competency development”: leadership and program management, IPC, technology, and performance improvement/ implementation science. Focusing on these 4 strategic developmental domains enables the IP to build on the core competencies thereby advancing his/her career from novice to expert.
2.2 The United Kingdom (UK)
In the UK the Infection Control Nurses Association (ICNA) in 2000 first developed and published the core competencies of IPCP and subsequently in 2004. This is aimed to ensure that expectations of practitioners in IPC are clear and consistent and that appropriate education, training and development is in place. Also, the core competencies are to ensure that the right people with the right capabilities are available today and in the future. In 2010, the Infection Prevention Society (IPS), the successor organization to the ICNA introduced the new outcome competence framework. This new competence framework aims to assist practitioners to continually increase their existing knowledge, understanding and skills to reduce the burden of HAIs. The new competence model has included career and professional development for IPCP to plan for achieving high leadership posts. However, a study on the implementation of this competence framework was done and reported in 2014. Results showed that only less than half (43%) surveyed reported using the competence framework while 10% never heard of and 25% had not read the framework. There is no mandate for certification examination nor credentialing of IPCPs in UK.
2.3 The European Union
In Europe, 28 European countries are members of the EU. The European Union promotes the harmonization of IPC strategies among member states. In 2009 the European Centre for Disease Prevention and Control (ECDC) commissioned a project on standardization on the training based on the list of core competencies for IPCPs. Results were reported in 2014, showing only 10 of the 33 countries offered training and qualification for infection control doctors and nurses. Currently, there is no European-wide recognized Master or PhD program or European Board certification for doctors specializing in infection control. In collaboration with the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Improving Patient Safety in Europe has developed a first document on core competencies for infection control nurses and physicians in Europe. Their next step is European certification of IPC training for doctors and nurses by ECDC and the ESCMID. The European Committee on Infection Control (EUCIC) as standing committee of the ESCMID has now accepted the task of establishing a European certificate as the minimal standard and board certification for IPC professionals.
2.4 Australia and New Zealand
A credentialing process now managed by the Australasian College of Infection Prevention and Control has been in existence since 2000. This decision was made among national nursing organizations around the credentialing of nursing specialties. Established in 2000, the credentialing of infection control professionals remains a peer review process. The credentialing process for IPCPs in Australia involves an assessment of the experience, qualifications, and practice of the applicant. Depending on the applicant’s background and experience, the supporting documentation may include a combination of a peer review from a colleagues, curriculum vitae, reflective narrative, portfolio, and details of an implemented education program. In 2016, a study on the credentialing of infection control professionals was reported. However, the applications are very low demonstrated reluctance to participate in this peer review of their performance. The predominant reason is that credentialing is not a requirement of employers and it is not linked to any financial gain.
2.5 Hong Kong, China
In Hong Kong China, the Academy of Nursing under the college of medical nursing, is recognizing the advanced Practice of Infection Control by conferring Fellowship to IPCP since 2012. A group of “founding fellows” were conferred after the credentialing process on the specialty field experience, the academic achievement and publications. This group of founding fellows developed the competence framework for education and training as well as practicum in the field. To obtain this fellowship, one needs to have a degree in nursing with at least 2 years of general nursing experience to become an associate member of the college of medical nursing. Then within first 3 years he or she needs to finish specific training and pass the entry examination of 150 multiple choice questions examination to become a member. The next 3 years the member must finish 500 hours of practicum and 500 hours of infection control training to complete the infection control competence framework before applying for the fellowship in infection control. To pass the application the member is required to complete a project on IPC and pass the viva by infection control expert. This fellowship model is following the medical model in training medical specialist in Hong Kong. The model in fact consists of the certification examination and in depth specialist training on infection control. The fellowship program also provides guidance for IPCPs to plan for their career and professional development.
3 Discussion and way forward
This is a brief review on the core competencies and professional development in IPCPs. The level and progress of the development differs between countries and geographical regions. Some are more advanced than the others while some have not even started. The certification model in North America has been established since 1983 and is proven to be effective. The certification is done by an independent body CBIC to objectively update the competency framework every 5 years to plan the certification examination. The certification is not just for nurses and is expanded to other healthcare professionals. The academic association APIC and universities conduct training course following the competence framework to prepare candidate for the examination. Research has been done demonstrating IPCPs with CBIC credentials are more effective in prevention of HAIs.[15-16] Presently healthcare organizations in North America only employ IPCP with CBIC credentials. For the UK competencies and professional development program, there is no mandate on any certification examination nor credential. A look back study shows that uptake of such volunteer system is low. The model in Australia and New Zealand is also a volunteer system through peer review credentialing process. The uptake is low as the credential is not a requirement from employers. The European Union has just started to review and standardize the training curriculum following the competency framework. The ECDC will follow the US model. There will be EUCIC as standing committee of the ESCMID to carry out the task of establishing a European certificate as the minimal standard and board certification for IPC professionals in Europe. In Hong Kong China, like the UK, Australia, and New Zealand, the competencies framework, career and professional development is following the nursing specialist stream. The major difference of the Hong Kong system from the UK and Australia is that the process is a structure fellowship program by the academy of nursing in Hong Kong. The whole program takes at least 6 years but not more than 9 years for the IPCPs to complete the competencies framework training, pass a certification examination and critical assessment by field experts before conferring the fellowship as an IPCP specialist. The fellowship is a requirement for the lead position of large of hospital groups and the position is equivalent to the assistant director of nursing. The drawback of the UK, Australia, and Hong Kong systems are that they only credential infection control nurse specialists. The present review is showing that certification or fellowship with formal recognition from academic body is more effective than a voluntary process. It is also important that healthcare institutions recognize the importance of competency and professional development by stating the credential as an employment requisite of IPCPs and exhibit on pay scale.
It is always an advantage to start late but wise by avoiding the mistakes of others. In the Asia Pacific region, like the European Union, there are many countries speaking different languages and in different climate zones and thus the infection surveillance and control program may have slight difference. Yet the principle and basics are similar. The infection control academic societies of the different countries in the Asia Pacific region should come together to develop a common IPC competency framework to first of all standardize a structured curriculum for training of IPCPs, then develop certification process by an independent certification board to confer credential to qualify IPCP in the field of infection control.