Effect of Competency Based Training Program on the Nurses’ Performance, and Self-confidence Regarding Antenatal Care

Background: Effective prenatal nursing care is dependent on skilled and confident nurses working in a well-equipped healthcare environment with a reliable referral system. Nurses should advocate for comprehensive supportive care for women and prioritize the implementation of high quality healthcare standards. The aim of this research was to evaluate the effect of competency based training program on the nurses’ performance, and self-confidence regarding antenatal care . Research design: A quasi-experimental research design was utilized. Setting ; held in four settings; the first two settings were at outpatient clinics of obstetrics and gynecological departments at Tanta University and El-Menshawy hospitals, while the other two settings are at EImbaby Maternal and Child Health and Sigar Medical Centers in Tanta City, El-gharbia Governorate, Egypt. Data were collected using three tools: Tool (I); Nurses' knowledge regarding antenatal care questionnaire was included three parts. Part I: Nurses' socio demographic characteristics; Part II: professional history of studied nurses ; and Part III: Assessment of nurses' knowledge regarding antenatal care. Tool (II); Nurses' practical observational checklist regarding antenatal care. Tool (III); Nurses' self-confidence regarding antenatal care. Results: Nurses' knowledge , clinical performance, as well as self-confidence concerning antenatal care were high after the implementation of competency based training program. Conclusion and recommendations: Competency based program was effective at enhancing the nurses' knowledge and practice concerning antenatal care which translated into higher confidence scores. Hence, this program should be conducted continuously and adopted to enhance and refresh nurses’ performance and confidence in other different maternity nursing subjects

. No. 2 (SuppL 2 ) ,May 2024 Introduction Globally, the antenatal period poses a significant risk for both pregnant women and their babies.Research shows that one quarter of maternal deaths occur during this time.While the risks associated with pregnancy cannot be completely avoided, they can be minimized through accessible, effective, and comprehensive maternity healthcare (Amponsah-Tabi et al., 2022).Antenatal health care is a form of preventive health care as well as first contact chance for woman with the formal health services to prevent complications in this critical phase.Through antenatal health care; women can acquire from skilled health nurse the healthy behaviors through pregnancy, well understanding of warning signs throughout pregnancy as well as childbirth (UNICEF, 2024).World Health Organization (WHO), (2022); defines antenatal health care as "care provided to the pregnant mother before birth", besides compromised the education; screening; counseling; treatment of minor ailment; as well as immunization services.Globally, according to WHO (2023); every year, 303,000 maternal deaths occur as a result of pregnancy and childbirth complications.In Egypt, according to WHO, World Bank and UNDESA\ Population Division (2023); the maternal mortality ratio was calculated to be 17 deaths for every 100,000 live births.Quality of the antenatal care can decreases maternal and perinatal morbidity as well as mortality directly throughout the identification besides management of the pregnancy-associated complications, and indirectly throughout the early identification of those on high risk of evolving pregnancy danger signs besides prompt referral to suitable care facilities (Penman, Beatson, Walker, Goldfeld, & Molloy, 2023).Antenatal care also provide access to preventive and promotive services in pregnancy which include immunization against tetanus, Intermittent Preventive Treatment (IPT), screening against infections e.g.Human Immunodeficiency Virus (HIV), detection of noncommunicable diseases like hypertension, gestational diabetes, health counseling and education about mothers and child care.Antenatal care visits also provide an opportunity to receive social, emotional and psychological support and family planning services (Gebrekirstos, Wube, Gebremedhin, & Lake, 2021).Antenatal care contains a lot of components like detailed history taking, physical examination, laboratory work, and diagnostic investigations.The WHO commends that pregnant women should start antenatal care in their first trimester with a complete of eight contact visits.Scheduling prenatal care appointments during the first trimester provides the best opportunity to discuss key aspects of maternity healthcare and strengthen engagement throughout the entire pregnancy period (Abuku, Allotey, & Akonde, 2023).The World Health Organization (WHO) has praised specific approaches aimed at reducing the maternal mortality rate (MMR).One of these approaches is to support high quality of maternal care services through improving nurses' expertise, abilities, and confidence, as well as hiring skilled and competent nurses (WHO, 2023).Selfconfidence plays a vital role in affecting the timely and effective nursing care provided to patients.Nurses with elevated levels of self-confidence display increased proficiency in making precise clinical judgments and delivering superior care to their patients.(Abu Sharour et al., 2022).Nurses should receive training using modern educational methods like competency based education (CBE) (Hakimi, Kheirkhah, Abolghasemi, & Hakimi, 2022).Competency is clearly defined as specific qualities or traits that individuals aim to demonstrate in order to excel in a particular activity.These qualities include work-related behavior (e.g., task completion), motivation (e.g., feelings, emotions, and job satisfaction), and technical knowledge/skills (e.g., professional expertise related to the job).This definition emphasizes that competency is a complex combination of knowledge, performance, skills, values, and attitudes (Tallam, Kaura, & Mash, 2022).Competency Based Education (CBE) in nursing is a performance-driven approach that focuses on advancing nurses' skills through practice and demonstration.It requires nurses to actively participate in all aspects of patient care to show competence in antenatal health care (Ali, Ali, & Barakat, 2024).Moreover, Nurses can gain crucial monitoring experience through wellorganized programs that enable them to apply their expertise in a professional environment, leading to improved performance and efficiency in healthcare organizations.Consequently, nurses need thorough education and training on ensuring women's safety and health.CBE prioritizes nurses' capacity to achieve specific learning objectives (Chen, Zhang, & Li, 2022).
In CBE, nurses are encouraged to be involved in critical thinking, strong communication skills, and collaborative problem-solving.This approach differs from the traditional method that relies on timebased training and the completion of academic degrees (Ige, Ngcobo, & Afolabi, 2023).Nurses are important members of antenatal health care teams; can aid pregnant women in order to avoid and identify common health problems accompanying with pregnancy, as well as they can instill healthy habits throughout pregnancy.The nurses' effort with parents through gestational period; can teach breastfeeding techniques, suggests some parenting skills and keeping their fetus healthy before, during and after birth is a vital part with the support of a medical nurse (Spiby, Stewart, Watts, Hughes, & Slade, 2022;Franjic, 2022).Significance of the study Ensuring that maternal mortality drops to less than 70 per 100,000 live births by 2030 is a key focus of the third sustainable development goal, which aims to improve overall health and well-being (Mahada, Tshitangano, & Mudau, 2023) 8. Providing of antenatal health education skills (15 items).9. Evaluation and documentation skills (1 items).The Scoring system for nurses' practices regarding antenatal care categorized as subsequent: -The correct done was scored as (1).
-The incorrect done/not done was scored as (0).-Score for the referral item in the evaluation and documentation skills wasn't included in the total score as there weren't complicated cases for referral, so the total score of evaluation and documentation skills was one grade only.
-The total score of observational practice of initial antenatal care ranged from (0-110) which high score indicated high level of practice.The total Nurses' practical competency level was adapted by the investigators from Ali et al (2021) that built on Benners' competency stages (Benner, 2001) by way of the following: Tool (III): Nurses' self-confidence regarding antenatal care: This tool was established by investigators based on standardized competencies for antenatal health care (Sharma, 2014;Sabry et al., 2017;WHO, 2022& USAID American people, 2023).It included 24 skills statements for antenatal care.
Nurse's Confidence level was assessed on 4-point Likert scale with: not confident (1); somewhat confident (2); confident (3); and very confident (4).The question on confidence for each skill statement read by means of "How confident are you to perform this skill independently?Subscales for antenatal care: Nine domains of the antenatal care with 24 items which were labeled as follows;  Antenatal booking and good communication skills (2 items)  History taking skills (5 items)  Infection control measures (3items). Women's general examination (4 items). Women's local abdominal examination (4 items)  Women's laboratory investigations (2 items). Pregnancy related complications (1item). Antenatal health education (1 item). Evaluation and documentation skills ( 2items).
Scoring system: the response for each item ranged from 1 to 4 grades, while the total score for all items of confidence level ranged from 24-96 grades, with high value indicate high confidence level.Total score regarding nurses' confidence level: confidence responses for every subscale were summed up to form a percent as the follow:  High confidence: ≥75% of the total score ( 72-96 grades) -Second and Third sessions; their aims were to supply the entirely nurses with the accurate and required practical skills regard antenatal care including; antenatal booking and registration; application of good communication skills; application of antenatal assessment; application of infection control measures; providing of antenatal health education; in addition to evaluation and documentation.
Phase IV: Program evaluation phase: -Nurses' performance as well as selfconfidence regarding antenatal care were assessed three times; before and immediately post in addition to follow up with one month after the implementation of the training program for every studied nurse through using of Tool (I); part two, Tool (II) and Tool (III).Vol.33.No. 2 (SuppL 2 ) ,May 2024 -Finally, the gathered data was consolidated and statistically examined with proper tests.Then appraisal was completed between the three times; before, and immediately in addition to one month after the implementation of training program in order to ascertain the influence of competency based training program on the nurses' performance, as well as self-confidence regarding antenatal care.

Results
Table 1: showed that the nurses' age extended from 20-56 years with a mean and SD of 35.08±11.64,as well as 45% of them whose age extended from 20-fewer than 30 years old.Slightly less than three quarters (73.8%) of the studied nurses were married compared to 26.2% of them were single.Slightly more than half (55%) of the studied nurses came from rural area, while 63.8% of them hadn't enough income and had diploma in nursing technician.presented that before implementation of competency program, slightly further than half (55%) of the nurses had high confidence score compared with 45% had low confidence score.Immediately post as well as one month later competency program, 93.8% and 90% of the entirely nurses had high confidence level compared with 6.2% and 10% had low level of confidence respectively.Table 6: Illustrated a positive correlation between total nurses, knowledge score as well as total practice score throughout the whole phases of the study (p <0.05) before, immediately post and one month after respectively.In contrast, the was no statistical significance correlation between total knowledge score as well as total confidence score also between total practice score as well as total confidence score before to one month later program application (p>0.05).--------------

Discussion
The third aim of the 2030 sustainable development goals is to achieve health and well-being for all, with a focus on reducing maternal mortality.Strategies for EPMM aim to reduce disparities in access and quality of health care across countries (World Health organization, 2023).CBE is an emerging trend in nursing education which permits nurses to progress besides master skills at their field through concentrating on their performance as well as capabilities.A competent nurse plays critical role in maternity health care and can autonomously manage the care of healthy newborns as well as mothers through child-bearing cycle.Consequently, the expansion of the clinical skilled nurse is precarious as this can donate to their proficient caring skills in addition to reflect positively on well-being and health (El-afandy & Ahmed, 2023).In view of the preceding outline; researchers carried out this research to evaluate the effect of competency based program on nurses' level of performance and confidence level regarding antenatal care.The present research exposed that around two thirds of the entirely nurses had novice competency level compared with about one fifth and nearly one eighth had advance beginner and competent level regarding knowledge of antenatal care respectively.This might be as a result of presence of further than half of the entirely nurses didn't participate in any workshop about antenatal care.Low socio-economic factor and low educational level of nurses are other factors of low level of knowledge, as about two thirds of them hadn't enough income and had only diploma in nursing.However, Immediately post as well as one month later implementing research study; it was found that slightly more than half and further than one third of nurses had proficient knowledge level respectively compared to around one third and one quarter of them had expert level of knowledge respectively with statistical significance difference in total mean knowledge score.This means that competency program helped nurses' positively to increase from novice or advance beginner level before program to proficient and expert level of knowledge immediately post as well as one month later program application.These findings were supported with Naga, Bedier, Salem, Ahmed, & Elhfnawy, (2021) who revealed highly statistical significance enhancements in their knowledge through the research with all phases of competency program application.This is in harmony with a research completed by Muzeya & Julie, (2020).
They measured student midwives' knowledge, skills as well as competency in relative to active management of 3 rd stage of labor; they reported significant increases in total mean of knowledge regard the active management of third stage of labor later program implementation.Similarly, a study done by Hakimi, Kheirkhah, Abolghasemi, Hakimi, & Farshad, (2019)  Poor quality of care delivered to pregnant women is considered one of the crucial causes and predisposing factors of high maternal death and diseases.Hence, there is requisite for nurses to attain and preserve a set of competences/skills that permit them to provide safe maternity care according to global standards (WHO, 2023).Pertaining to nurses' practice level on antenatal competence standards; the current research showed that prior implantation of competency intervention, about two fifths from studied nurses had novice and advanced beginner of practice compared with about one fifth of them had competent practice This revealed the lack of use of competency-based practice as a key component of quality assessment programs in maternity care services.However, immediately post as well as one month later program application; further than half from the entirely nurses had proficient practice level compared with further than one third and about one fifth of them had expert level of practice respectively.The total practice mean scores were improved statistically before program till one month after.This indicates the positive efficiency of program on the nurses' practice.The finding of this research was reinforced by Osman, El Ansary, Mohamady, (2023).
They found noticeable enhancement occurred in the total score of practice immediately post intervention, as well as follow-up evaluations when measured nursing students' performance regard active management of the 3 rd stage of labor following competency program.Also, study made by Gholamian, Alidoosti, Zolala, & Sabzevari, (2022) reported a significant improvement in clinical skills among midwifery students trained using the CBE compared to those trained using Conventional Teaching Methods (CTM).Similarly, a study done by Kimario & Otieno, (2022), which declared the important of competency based curriculum application for self-employment, innovation, besides the acquisition of several competencies for sustainable development.On the same context, a study done by Moon and Cho, (2022), they found that the competency-based triage education application was active in enlightening the nurses' emergency triage competency in addition to performance.Self-confidence is a powerful component that influences quick, appropriate, safe, and correct nursing interventions.Nurses with higher levels of self-confidence demonstrate greater competence in devising suitable and safe intervention; making correct decision; as well as providing patients with a higher quality of care.(Abu Sharour et al., 2022).As regard nurses' level of confidence, the present research hypothesis was that application of competency program will heighten nurses' confidence level.This hypothesis is authenticated by the research findings which displayed a progressive influence of competency program in heightening nurses' confidence level as there was slightly less than half from entire nurses had low confidence score as pre assessment.However, following the competency training immediately, almost all of them demonstrated a high confidence score with statistically improvement in the total confidence mean with in all phases of the study.According to the researcher, this increase in nurses' confidence might be attributed to an increase in nurses' knowledge, abilities, and efficacy of the competency-based program as they grew more conscious of their role in providing prenatal care.This result is in compliance with Boucetta, El Alaoui , Seghir , Ghariz, & Boubih, (2023).They demonstrated that, the critical analysis for competency-based training in nursing as well as midwifery education has its role for enhancing students' practical skills, build their selfconfidence, in addition advance the quality of maternal health-care.Furthermore, Gottlieb, Chan, Zaver, & Ellaway, (2022) who studied the confidence-competence alliance besides the role of self-confidence in medical education, and reported that positive effect of competency on self-confidence from pre-program to post-program application.Also, a longitudinal study conducted via Back & Karlstrom, (2020) revealed that midwifery students trained using the competency based training expressed greater confidence in their clinical skills throughout their training journey.In relation to association between antenatal knowledge and practice, outcomes of the existing research, found a positive correlation amongst total nurses knowledge score as well as total practice score throughout whole phases of the study.From the researchers' point of view, the enhancement made in the theoretical competency for antenatal care could play imperative role in improvement for the antenatal healthcare skills.
This research finding aligned by Bashir, Ansari, & Sultana, (2023); when they investigated the knowledge, attitude, and practice of prenatal care among pregnant women and its relationship with sociodemographic characteristics, they discovered that the level of over-all knowledge had a positive correlation with antenatal care practices.Also, Takon, Mgbekem, Madubuko, Ushie, (2023) instituted positive association amongst knowledge as well as practice among the birth attendants regarding antenatal care in the south river state, Nigeria.This finding contradicts Yaseen, Fatima, Ramzan, Quasar, & Ara, (2021), who investigated nurses' knowledge as well as practices regard active care of 3 rd -stage labor in definite Kashmir hospitals.They decided that there was no relationship between them in the study group.Regarding the correlation among total knowledge score; total practice score; and confidence level, present research found no statistical significance association among total knowledge scores as well as total confidence scores also among total practice scores as well as total confidence scores prior to one month later program application.This could be explained by investigators believes that self-confidence is a subjective and acquired element that can be influenced by several aspects, including role, sense of self, perspective, sense of efficacy, self-esteem, and experiences related to the context or environment.Also, improvement of knowledge and practice may need long time to make improvement in the confidence level so nearby was no correlation among knowledge; practice; as well as confidence in this research (Lindgren et al., 2021).The study findings were along the lines of a study made by Esan et al., (2019); reported that birth attendants' knowledge related to most of the maternal and child health interventions wasn't significantly linked to their selfreported confidence in the requisites competencies.This result was on contrary to a study made by Peinado-Molina, Martínez-Vázquez, Paulano-Martínez, Hernández-Martínez, & Martínez-Galiano (2023).They reported a strong relation and association amongst knowledge, selfconfidence as well as satisfaction among nursing students regarding antenatal care.Additionally, a study made by Tallam et al., (2022) who found positive relation amongst midwives' selfperceived confidence and their knowledge as well as skills.This discrepancy among the existing research and later literatures might be allied with sample inclusion criteria differences, the study setting and the intervention strategies.

Conclusion
This research exhibited that competency based program was effective in enhancing the nurses' knowledge as well as practice concerning antenatal care that was translated into advanced confidence score.The research results and outcomes meet the aim and hypotheses of this study.
Research limitations -Phase III (program implementation phase) was prejudiced by both the nurses' absenteeism from the planned training sessions as well as it was affected by disruption and noise.

Figure ( 1
Figure (1): Nurses' percentage distribution based on total confidence scores before, immediately post and one month later; Table6: Correlation between total nurses , knowledge scores, observational practice scores, and total confidence scores;

Table 1 :
Percent distribution of the nurses according to their socio-

Table 2 :
The percentage distribution of nurses according to their professional history;

Table 3 :
The percentage distribution of the nurses based on their total knowledge scores:

Table 4 :
Mean as well as standard deviation of the entirely nurses pertaining to competency practice domains:

Table 5 :
The percentage distribution of the nurses relating to their total practice scores Consequently, the investigators devoted more time and effort for restating the training sessions several times.