A Hypothetical Model to Predict Nursing Students ’ Perceptions of the Usefulness of Pre-Service Integrated Management of Childhood Illness Training

OBJECTIVES
This study aimed to test a hypothetical model to predict nursing students' perceptions of the usefulness of pre-service Integrated Management of Childhood Illness (IMCI) training and their intention to apply this training in clinical practice.


METHODS
This study was carried out at the Sur Nursing Institute, Sur, Oman, in May 2015. Using six predefined constructs, a hypothetical structural model was created. The constructs were used as latent variables to highlight their probable impact on intention to apply IMCI-related knowledge and skills in practice. A structured validated questionnaire was subsequently developed to assess the perceptions of nursing students. Factor loadings and calculated variances were examined to ensure convergent validity. Cronbach's alpha was used to calculate internal consistency reliability.


RESULTS
Factor loadings for each item in the model were above 0.70. All of the constructs had Cronbach's alpha values over 0.700, except for enhanced assessment skills (Cronbach's alpha: 0.694). The variance extracted value was 0.815 for perceived usefulness, 0.800 for enhanced assessment skills, 0.687 for enhanced knowledge, attitudes and skills, 0.697 for enhanced confidence, 0.674 for enhanced counselling skills and 0.805 for future intention to use IMCI in a clinical setting.


CONCLUSION
Overall, the results support the hypothetical model and indicate that nursing students perceive IMCI training to be beneficial and intend to apply IMCI-related knowledge and skills in clinical practice.


C
hildhood illnesses continue to increase the global disease burden, especially in low-to middle-income countries. 1In the mid-1990s, the World Health Organization and United Nations International Children's Fund initiated the Integrated Management of Childhood Illness (IMCI) strategy in order to improve the health standards of children under five years of age. 1,2This approach focuses on improving health worker skills, refining healthcare systems, enhancing knowledge of child health among families and communities and disease-specific interventions. 3 IMCI relies on trained healthcare professionals to improve symptom assessments, illness classifications and treatment needs and provide better counselling to caregivers. 1,25][6][7][8] In Tanzania, IMCI implementation resulted in a 13% reduction in the child mortality rate. 5][8][9][10] These promising findings have resulted in the implementation of IMCI in over 100 countries. 11In Oman, IMCI was introduced into the healthcare system in 1999.][14][15][16][17] There are evident benefits of IMCI implementation for families and communities.In Nigeria, IMCI implementation was reported to be a cost-effective intervention. 18The positive effects of IMCI on case management and in improving illness classifications and enhancing skills in managing childhood illness are frequently reported. 7,10,18However, limitations of healthcare systems, long duration of training courses, extended consultations and resistance from experienced doctors have been identified as barriers to the acceptance and practice of IMCI. 19In order to predict the effectiveness of IMCI implementation, it is essential to understand how IMCI-trained healthcare workers perceive IMCI training and whether they intend to use IMCI-related skills and knowledge in clinical practice.However, there is a lack of research on how healthcare professionals perceive IMCI training; this is important, as IMCI emphasises a new role for both doctors and nurses as educators as well as healthcare professionals. 19Moreover, healthcare professionals, such as nurses, play a vital role in paediatric health management. 20is study therefore aimed to test a hypothetical model to predict the perceived benefits of preservice IMCI training among nursing students and their intentions of applying IMCI-related skills and knowledge in future.It was hypothesised that IMCItrained nursing students would perceive IMCI training to useful in improving knowledge, skills and confidence, leading to the use of these skills in future clinical practice.This hypothesis was based on the theory of reasoned action, which suggests that the decision to perform a specific behaviour is strongly linked with the expected outcome or benefit of the behaviour. 21,22

Methods
This study was carried out in May 2015 at the Sur Nursing Institute in Sur, Oman.A hypothetical structural model was developed with the help of six healthcare professionals, including two IMCI experts.The following six predefined constructs were used: perceived usefulness, enhanced assessment skills, enhanced knowledge, attitudes and skills (KAS), enhanced confidence, enhanced counselling skills and future intention to use IMCI in a clinical setting.These constructs were used as latent variables to highlight their probable impact on a formative variable (i.e.intention to apply IMCI-related knowledge and skills in practice).The model was designed to indicate relationships between the constructs.Subsequently, a total of 114 nursing students were recruited via the distribution of posters at the Sur Nursing Institute.All of the nursing students had received pre-service IMCI training via workshops, lectures, laboratory sessions and field trips for a mean duration of 3.155 ± 0.361 years.The minimum sample size for this type of analysis was calculated using the heuristic method by multiplying by 10 the largest number of independent constructs influencing the dependent construct (i.e.six). 23Thus, the minimum sample size for the current study was calculated to be 60.An English-language structured questionnaire was created to assess the students' actual perceptions of IMCI training and intention to use this training in future practice.The questionnaire was developed and validated with the help of six practicing healthcare professionals to ensure that the language and terminology used in the questionnaire could be easily understood.The items were pretested by the healthcare professionals to ensure that each construct was loaded with three items.Participants completed and returned the questionnaires in sealed envelopes.
The reliability and validity of the model was analysed using Smart Partial Least Square software, Version 3.2.5 (SmartPLS GmbH, Bönningstedt, Germany).This software was chosen because it is appropriate for exploratory research aiming to test a new predictive model rather than re-examining existing models or theories. 24In the analysis, a twostep approach was applied (i.e.assessment of reliability and validity of the hypothetical model). 25The properties of the constructs were assessed in terms of factor loadings, discriminant validity and internal consistency.Factor loadings and calculated variances were examined to ensure convergent validity; factor loading and internal consistency values of over 0.700 were considered adequate.Cronbach's alpha was used to calculate the internal consistency reliability of the items.The Fornell-Larcker criterion was used to determine discriminant validity between the studied constructs. 24However, as previous research has indicated that the Fornell-Larcker criterion may not necessarily detect discriminant validity reliably, the heterotrait-monotrait (HTMT) ratio of correlations was also assessed. 26A HTMT value of below 0.90 indicated satisfactory discriminant validity. 26The effect sizes indicated by the path coefficients were noted to be either small (0.02), medium (0.15) or large (0.35).
Ethical approval for this study was obtained from the Ministry of Health of Oman.Each student gave written informed consent before participating in the study.The students were not offered any financial rewards or incentives for participating in the study.

Results
Of the 114 students invited to participate in the study, 110 completed the entire questionnaire (response rate: 96.5%).There were 77 females (70%) and 33 males (30%).Figure 1 shows the relationships between the constructs in the hypothetical model.Factor loadings and calculated variances for each item exceeded 0.70 and 0.50, respectively, indicating that all of the items loaded well.The average variance extracted value was above 0.607.All of the constructs had Cronbach's alpha values over 0.700, except for enhanced assessment skills (Cronbach's alpha: 0.694).The composite reliability of all of the constructs in the model exceeded 0.821 [Table 1].
The discriminant validity of all of the correlations was below the threshold HTMT ratio value of 0.90.Upon analysis of the path coefficients, enhanced assessment skills (P <0.010), enhanced confidence (P <0.050), enhanced counselling (P <0.050) and perceived usefulness (P <0.001) had a significant influence on future intention to use IMCI in a clinical setting.Finally, the cross-loadings of the items on their assigned latent variables were larger than any other loading.Therefore, the reliability and validity of the constructs in the model were acceptable.
The studied constructs were complexly interrelated.There was a 36.2%variance in the enhanced KAS construct.The enhanced KAS construct predicted 14.6% variance in enhanced confidence and 20.1% variance in future intention to apply IMCI-related knowledge and skills.The main direct contributors of the variance in future intention to apply IMCIrelated knowledge and skills were enhanced KAS (36.2%), enhanced confidence (14.7%) and enhanced counselling skills (17.1%).When taken together, enhanced confidence and enhanced counselling skills resulted in a 31.8%variance in future intention to apply IMCI-related knowledge and skills.The R 2 values were 36.2 for enhanced KAS, 14.7 for enhanced confidence, 17.1 for enhanced counselling and 14.0 for future intention to use IMCI.The constructs expressed significant variance (60%) in future intention to apply IMCI-related knowledge and skills (P <0.010).The significance of the total effects are displayed in Table 2.
Based on these statistical findings, the central hypothesis of the study was supported.

Discussion
The current study was performed to test a hypothetical model to predict perceived benefits of preservice IMCI training among trainee nurses and their subsequent intentions of using learned skills in clinical settings.To the best of the authors' knowledge, this is the first IMCI-related hypothetical model in the available literature.The results from the analysis substantially supported the hypothetical structural model.Factor loadings for each item in the model were above the minimum required threshold; 27 moreover, the majority of the constructs had Cronbach's alpha values above the minimum cut-off level. 25,28Indeed, previous research has indicated that even reliability ranges of 0.5-0.6 can be regarded as significant for experimental studies. 29Overall, the composite reliability of all constructs in the model exceeded the recommended value of 0.700. 29While the R 2 values were relatively low, lower R 2 values can nevertheless still indicate some level of significance. 30his is particularly true in any research work seeking to predict human behaviours and intentions. 31As the central assumption in the presented model was future intentions of healthcare professionals to use IMCIrelated knowledge and skills, even a lower R 2 value should be viewed as significant.
The current study revealed strong correlations between the studied constructs and intentions of using IMCI-related knowledge and skills in the future.Importantly, the current study found that the

C o m p o s it e r e li a b il it y C r o n b a c h 's a lp h a F u tu r e in te n ti o n to u s e IM C I E n h a n c e d a s s e s s m e n t s k il ls E n h a n c e d c o n fi d e n c e E n h a n c e d c o u n s e ll in g P e r c e iv e d u s e fu ln e s s E n h a n c e d K A S
A V E V IF constructs expressed significant variance in future intention to apply IMCI-related knowledge and skills.
In other words, this implies that nursing students are more likely to plan to apply IMCI-related skills in future if they perceive IMCI to be useful in helping improve their assessment skills, counselling skills, selfconfidence and KAS.All of the studied constructs were found to be contributors towards a positive intention to use the IMCI-related skills and knowledge.Based on this finding, it is likely that IMCI-trained nurses will actually apply the skills learned from pre-service IMCI training.However, it is critical to note that improved knowledge of caregivers and the synchronised func-tioning of the entire health system is necessary for the successful integration of IMCI. 1,2he findings of the current study add to the existing literature by highlighting the importance of IMCI among nursing students who will go on to practice in clinical settings after their graduation.To the best of the authors' knowledge, no previous studies have examined how nursing students perceive the usefulness of IMCI training.Moreover, this study is important in terms of furthering efforts to implement IMCI training in Oman.Although the findings from this study may not have a direct impact on practices, public health policy-makers are advised to take appropriate steps to integrate IMCI training at all medical and nursing institutions in the country.Governmental institutions and policies may help establish healthcare systems that embrace IMCI as a holistic approach.Healthcare policy-makers and senior medical professionals should consider the potential benefits of IMCI and encourage its implementation, allowing for sick children to receive timely, accurate and effective treatment.Future studies are recommended to identify factors that contribute to the high mortality rate of children under five years old. 32his study is subject to certain limitations.First, the studied sample was taken from a single educational institution so there may be potential selection bias.Second, due to the small sample size, it is hard to generalise the results.Third, while the statistical results indicate that IMCI-trained nursing students intend to apply their acquired skills in clinical settings, further investigation is necessary to establish whether these intentions hold true in the future.In future research, the authors recommend that efforts are made to investigate the extent to which IMCI-trained nurses apply their skills and knowledge in clinical settings and the factors which hinder them from doing so.

Conclusion
An IMCI-related hypothetical model was developed and evaluated for the first time.Perceived benefits of IMCI training were found to lead to an intention to apply related skills and knowledge in future clinical practice among nursing students.Overall, nursing students perceived IMCI to be a useful approach that could improve their skills, knowledge and confidence; as such, they intended to apply skills and knowledge learnt as result of this training in the future.

Figure 1 :
Figure 1: A hypothetical structural model to predict nursing students' perceptions of the usefulness of pre-service Integrated Management of Childhood Illness training and their intention to apply this training in future clinical practice.KAS = knowledge, assessment and skills.
c o n f l i c t o f i n t e r e s tThe authors declare no conflicts of interest.fu n d i n gNo funding was received for this study.a c k n o w l e d g e m e n t s

Table 1 :
Latent variable coefficients and correlations of a hypothetical structural model to predict nursing students' perceptions of pre-service Integrated Management of Childhood Illness training

Table 2 :
Total effect of constructs in a hypothetical structural model to predict nursing students' perceptions of pre-service Integrated Management of Childhood Illness training