Interactive Tele-Education Applied to a Distant Clinical Microbiology Specialization University Course

Abstract

The microbiology laboratory provides a strategic support for infectious disease diagnosis and also alerts the medical community about bacterial resistance to antibiotics. The microbiologists' training is a challenge in Brazil, a country with an extensive territory, a diverse population, and disparity of resource allocation. The aim of this study was to implement an interactive tele-educational course in clinical microbiology to reach distant laboratory workers and to improve their professional skills. The course scientific content was defined according to competences associated, distributed in 560 h, with laboratory practices (knowledge matrix–contextual education). The 11-module course structure comprised 70% distance learning, 22% on campus (integrated modules), and 8% monographs. The group included 7 physicians and 21 microbiologists from 20 different Brazilian cities. The time flexibility and location were the two main reasons for student participation, thus decreasing absences to the workplace, different from the traditional teaching methodologies. The group performance was measured by monthly evaluations, and 1 year postcourse, the researcher visited their workplace. There was significant improvement in microbiological practices performed before compared with after group participation. Therefore, 76.9% of laboratory practices were modified because of the knowledge acquired in the course. Students showed behavioral changes in relation to performance in infection control as well as on the dissemination of their knowledge. This specialization course using distance education did not compromise the quality. This educational methodology represents an alternative to teach clinical microbiology to laboratory workers from remote hospitals, as a nationwide continuing educational strategy.

Introduction

Bacterial resistance associated to hospital environments is a public health concern and one of the largest challenges in infection control for healthcare services worldwide. The variety of resistance mechanisms is a therapeutic challenge, and the selection of antibiotics should be individualized, based on local antibiograms.^1
–3 Trends in resistance patterns should be monitored from hospital to hospital and city to city, and the differences should be used to determine the need for epidemiological surveillance strategies.^4,5

Within this context the clinical microbiology laboratory (CML) is thus responsible for the diagnosis of infectious diseases, which in turn could provide strategic support to an infection control committee.^6,7 New mechanisms of bacterial resistance and laboratory methods for the detection of new resistant strains demand regular updating from laboratory workers.^8,9

Brazil is a large country with a diverse socioeconomic population and heterogeneity in the regional health infrastructure distribution. The southeast region has the largest number of specialization university courses (4,955; 55.9%). This rate is higher than the sum of all the registered courses in other regions of the country.^10

–13 Telemedicine has become an interesting tool for knowledge dissemination because of the decreasing costs of most communication technologies, thus contributing to the integration of professionals by overcoming the geographical seclusion problem.

In Brazil, there are several experiences in university tele-education. From 2003 to 2006, the courses number increased 571% (52–349) and students number 315% (49,000 in 2003 to 207,000 in 2006).¹⁴

The government recognized the importance of tele-education in healthcare by means of a decree signed by the President of Brazil in December 2010, which established the Open University Health System (UNASUS). Moreover, it addressed the Brazilian Unified Health System (SUS) workers' training and education needs by tele-education.¹⁵

There are other important examples such as the health strategy programs: Telehealth Brazil Project by the Ministry of Health (qualification of family health teams to enhance the service effectiveness for primary care), and the Telemedicine University Network (RUTE) by the Ministry of Science and Technology (improvement of telemedicine infrastructure and connection between university hospitals in the country).^16
–18

In the microbiology area, three publications have reported experiences with telemedicine. These articles are related to image transmission for remote diagnosis and Web site development.^19
–21

In line with this context, the Medical School of São Paulo University (USP) has invested in tele-education with the specialization course proposal to train health professionals.

Objective

The objective of this study was to implement and evaluate a specialization course in e-learning for teaching clinical microbiology through the telemedicine resources for the training of medical personnel from different Brazilian geographical areas.

Methods

The course was planned and implemented by a multidisciplinary group of health professionals (one MD pathologist and microbiologist) and technology (MD with expertise in telemedicine and telehealth) linked to a telemedicine team located at the USP.

Learning environments were constructed and networked. For distance learning, a Web site was designated for the management of theoretical scientific content and the discussion list; for on-campus learning, a theoretical and practical class was held in a classroom, where theoretical concepts were discussed and students presented their research work, complementing the learning process.

Three steps were proposed in all modules: (1) distance learning, (2) additional tasks by the use of the mailing list and by participating in discussions of scientific articles or questionnaires, and (3) the last stage in the classroom clinical training and practice sessions (contextualized educational training). A mean score approval of 7 for each module was established out of a total 10. All activities were to stimulate the literature review.

The course was structured in 11 modules divided into three semesters: 70% distance learning, 22% on campus, and 8% monographs. The number of available seats was limited to 30 because of restricted space for class development in the laboratory. The selection of students was performed by curriculum analysis and they were accepted with a B.S. and practice in microbiology activities.

The scientific content was structured according to the skills associated with laboratory practice (knowledge matrix) and focused on the availability of hospital standard technological resources, so that students could perform their duties. After a 10-year consulting practice, the researcher has recognized criteria for the identification skills needed for laboratory practices implementation. The scientific content was written in Portuguese, with the following main topics: fundamentals of microbiology, quality control, antimicrobial susceptibility tests, bacterial resistance in Gram-positive cocci and Gram-negative bacilli, sexually transmitted diseases, mycology, and mycobacteria. Table 1 shows an example of the bacterioscopy module. A theoretical content was developed for each topic, as well as organized for the practice classroom in order for students to experiment the laboratory routine. The practical lessons were in the microbiology laboratory of the Hospital das Clínicas (USP).

Table 1.

Identification and Correlation of Professional Skills with the Scientific Content of the Course

EXAMPLE: BACTERIOSCOPY
Microbiological routine phase: Analytical
Competencies areas division: Bacterioscopy
Correlation with course module: Bacterioscopy, direct examination methods
Develop the competency to:	Know and practice techniques of preparing smears in accordance with sample characteristics; know and apply the types of staining and their objectives; prepare the staining; read the sample and recognize the morphology of the microorganisms; standardize the reading and interpret the results according to the bacterial normal flora. Detect problems and apply solutions such as quality control.
Scientific content
Theoretical phase	Distance	Course—Bacterioscopies-direct examination methods: Types and objectives of staining; smear preparation; Gram stain: stain preparation and technical procedures; quality control; results and interpretation; morphological classification; application of samples: blood, liquor, respiratory tract, urine, feces, genital tract. Bacterioscopy to bacillus alcohol acid resistance and toluidine blue staining.
	Classroom	Bacterioscopies: practical read; clinical cases discussion and morphologies by photographs. Discussion on the operational procedures.
Practical phase	Distance	Literature review to develop an operating procedure for samples of cerebrospinal fluid, urine, feces and respiratory tract. For the development should be considered the criteria for sample rejection as well as the interpretation of culture results, quality control, and bibliographical references.
	Classroom	In the laboratory: Individual microscopes employed in exercises reading of several clinical materials. Gram, Ziehl-Neelsen, Cryptosporidium, Isospora and Trichomonas methods. Fungi microscopy: wet mount.
	Complementary literature (distributed in class)	IDSA guidelines: Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults; Practice Guidelines for the Management of Bacterial Meningitis; Practice Guidelines for the Management of Infectious Diarrhea; diagnostic value and cost utility analysis for urine Gram stain and urine microscopic examination as screening tests for urinary tract infection
Complementary task		Discussion list

At the course beginning, students were given an indicators list related to the microbiological process according to (College of American Pathologists) regulations: rejection criteria and samples collection; techniques related to bacterioscopy and culture media inoculation (seeding media and incubation methods); bacterial identification; antibiotic susceptibility test with resistance mechanisms research; surveillance; quality management for safe practices; and the students' relationship with the infection control committee. The students used the indicators to report on procedures performed in their laboratory. Based on this report, the researcher categorized where there were improvements or opportunity for improvement. This observation was made in accordance with the procedures described in literature. During the researcher's visit to students' workplace, any modification in the precourse practice performed and related to the course teaching was considered as an improvement. The criterion used was that these procedures allowed the opportunity for students' performance.

One year after the course end, the researcher personally visited each laboratory to assess improvements in microbiological practices and students' attitudes. The researcher interacted with students in several ways: the students heard testimony about the changes made and compared the visit results with the report on workplace routinely written by students at the course start.

For the evaluation of changes in professional attitudes, the researcher carried out a survey of subjective aspects related to behavior, study autonomy, projects development, and job opportunities. The questionnaire was submitted to the pretest in accordance with the methodology used in research for error correction of interpretation and questions formulation.

The researcher followed the entire educational process the students made during the visit and the evaluation implementation.

Students received certificates issued by the USP Dean with permission from the Brazilian Ministry of Education.

Results

The interactive clinical microbiology course was held from March 1, 2006, to June 31, 2007. Fifty-four students enrolled for the course and 28 were initially selected by their curriculum examination. The group comprises 7 physicians and 21 microbiologists, with a mean age of 37.1 (minimum 24 and maximum 72, median of 32.5 years) from 20 Brazilian cities. The two main reasons for enrollment of students were the need for scheduling flexibility and the fact that the course would not require the absence from their work places.

Seventy-five percent of the original group of students were approved (n=21), 18% (n=5) disapproved, and 7% (n=2) withdrew for personal reasons. Ten evaluations were conducted through the Internet (mean score of 8.8, standard deviation [SD] 0.57), complementary tasks were evaluated in 4 reports on the discussion list (mean score of 7.2, SD 1.21), 3 article reviews (mean score of 7.7, SD 1.19), 5 questionnaires (mean score of 7.7, SD 1.53), 3 written evaluations were carried out in the classroom (mean score of 7, SD 1.57), and 21 monographs on bacterial resistance (mean score of 8.2, SD 0.73).

A year after the course end, 19 students from the 21 approved were available to receive the researcher in their laboratory to perform the oral test. Fourteen students (73.6%) scored above 7. The mean score of the group was highest than 7 (7.8, SD 1.38), which was the formal cutoff score to the course approval. Table 2 summarizes these results.

Table 2.

Evaluation Scores Performed During the Course and at 1 Year After the Course End (19 Students)

PHASE	MEAN SCORE	VARIANCE	STANDARD DEVIATION	MINIMUM VALUE	MAXIMUM VALUE	MEDIAN
Assessments made during the course	8.5	0.132	0.36	7.9	9.2	8.4
Postcourse evaluations	7.8	1.90	1.38	4	9.5	8.1

The visit to students' workplace to assess the practical improvement was only possible among 16 students, as 5 of them did not participate (not working at the time). Among evaluated practices, there was improvement in 76.9% of procedures, whereas 23.1% were not modified. Table 3 shows the result distribution.

Table 3.

Postcourse Analysis of Procedures Performed in the Workplace (16 Students)

PROCEDURES EVALUATED	THERE WERE IMPROVEMENTS	%	THERE WAS NO OPPORTUNITY FOR IMPROVEMENT	%	TOTAL NUMBER OF PROCEDURES ANALYZED
Biologic samples—collection	7	63.6	4	36.4	11
Biologic samples—rejection criteria	11	78.6	3	21.4	14
Culture media—selection and applying	6	75.0	2	25.0	8
Cultures—seeding techniques adequation	13	100.0	0	0.0	13
Cultures—techniques, interpretation and reading	15	93.8	1	6.3	16
Organisms identification	8	88.9	1	11.1	9
Bacterioscopy—test result standardization	8	61.5	5	38.5	13
Bacterioscopy—Nugent criteria (vaginal)	4	30.8	9	69.2	13
Bacterioscopy—use as support in the routine microbiological	12	75.0	4	25.0	16
Antibiogram—panel of antimicrobial	13	100.0	0	0.0	13
Antibiogram—research on mechanisms of resistance	14	87.5	2	12.5	16
Antibiogram—cumulative data statistic of sensibility	7	58.3	5	41.7	12
Routine information of the results to the committee infection	8	100.0	0	0.0	8
Committee of infection—integration for discussions about the resistance	14	93.3	1	6.7	15
Operational procedures—documentation	13	81.3	3	18.8	16
Quality control	7	46.7	8	53.3	15
Total	160	76.9	48	23.1	208

Among the changes in professional attitudes, it was found that professionals did more self-study (57%) and showed a greater ability to solve work problems (76%), and some were promoted (33%). Also, they improved their relationship with the group of infection control committees and physicians (100%) and received invitations to teach in their workplace (71%), whereas 57% said they were encouraged to participate in new projects.

All interviewed students approved the model used in this e-learning course and they would recommend it to other professionals. Some adjustments were suggested as follows: dedication of more time to structure the monograph work (58%), change the interaction dynamics of discussed list (38%) and increase the course workload (33%).

Discussion

Microbiologists working in diagnostic laboratories provide strategic support to the infection control committees and to physicians in the management of infectious diseases. The quality of the microbiological practices depends heavily on the microbiologist who manages all stages of the clinical sample testing, from the collection to the release of the final results. The dissemination of current information to the laboratory professionals is critical to keep them informed on indicators associated with nosocomial infections, as bacterial resistance is constantly changing and a new mechanism often emerges.

After 10 years of practice in management consulting at CML in hospitals and 2 years promoting integration among microbiologists, by means of distance learning (via Web sites and courses),²⁰ we conducted this study on the microbiologist education to convey new developments and attitudes that allow this group of professionals to face new challenges. For this purpose, we have developed a microbiology course using tele-education, and this approach also decentralizes the exchange of information from academic centers to distant places. The training of microbiologists is a challenge in Brazil, a country with an extensive territory, a diverse population, and disparity on the resource allocation.

The university coursework proposal resulted in the enrollment of a group of professionals living mainly outside São Paulo city. The two main reasons for the students' participation in this study were the schedule flexibility and not absence from their workplace. These issues showed the need for alternatives to the student-centered learning and not at the university.²²

The content taught was based on identifying the skills and professional knowledge required for the performance of microbiology. For the purpose of this article, we specify competence as ability based on the integration of specific knowledge, skills, and attitudes to perform a professional task at a sufficient level for unsupervised practice.²³ These competences were defined according to the key issues and practical difficulties reported in the microbiology laboratory day-to-day. This approach shows that training should be based on the professional activity and should be incorporated into the work environment.²⁴

In this context, we emphasize the importance of microbiologists training for the detection of bacterial resistance in the laboratory. The theme justifies our goal of devoting five modules (50% of course) exclusively to this subject. The impact of bacterial resistance can be directly measured in the increased morbidity and mortality related to multiresistant pathogens. Several studies have reported that early administration of appropriate treatment and proper antimicrobial management for critically ill patients with bloodstream infections have a positive impact on patient mortality.^25,26

The educational model in this study offered the opportunity to train professionals in various learning environments. On the Internet, as well as distance learning course, there was the incentive to research and read scientific papers to demonstrate the importance of the student autonomy development. In class, learning is encouraged for further discussions on the knowledge application in practical lessons. For practical learning, the environment was addressed to build skill-related techniques used in microbiology laboratory routine.

Seventy-five percent (n=21) of students were approved. This index could not be compared with other courses, because similar experiences were not found in Brazil. The remaining 18% (n=5) not-approved students apparently lacked self-discipline and time to perform the tasks and had difficulties with the English language.

The results of the evaluation showed decrease of student performance after finishing the course. The decrease in knowledge over time can be overcome by offering more updated courses to learning enhancement. The conventional processes of teaching and learning are being increasingly challenged by novel technological innovations such as courses similar to the one in this study. The quality of a course requires an initial time investment and recourses to develop the course content that would match the participants' skills on the specific areas of interest. It is important that the proposals for distance education could impact participants beyond the mere provision of instructional materials by providing dynamic interactive learning between teachers and the students.

There was a significant difference between the improvement rates in microbiological practices conducted in the students' workplace before and after their participation in the course. Seventy-seven percent of the procedures evaluated were improved. These results show a positive influence on the routine practice in microbiological laboratories, but one must consider the variables in this result, such as the difference in complexity level and procedure variety used by participating laboratories.

Brazil is a country with many regional differences, and this study allowed us to see these differences and consider the prospect for further studies. This diversity of national characteristics does not allow the creation of single indicators; thus, there is a need to develop objective parameters in accordance with local rules and their health conditions. To do this investigation, not only the knowledge acquisition but also the training impact on the professional work environment should be considered. The models of training evaluation studies show that the main variable of interest has been the transfer of learning to work, both in depth and in breadth of knowledge (impacts), and its association with the skills at work.^27,28 There is need for further research, so that we can measure the true impact of this result in the hospital environment.

The personal interaction with students at 1 year after the course end was important to assess knowledge retention and personal improvement in the practice implemented. Participation in this course influenced the daily practice of students in the microbiology laboratory, because there was discovery of improvement needs and possible limitations of processes. This interaction also showed changes in the students' behavior regarding the dissemination of knowledge acquired. Students were in scientific discussions with hospital doctors and they taught microbiology at their workplace. The expansion of this educational model associated with information multiplier-students showed an opportunity to spread quality information through a Brazilian microbiology network.

There are limitations in the study that must be discussed, for example, the absence of postgraduate course in e-learning prevented a comparison of results. However, a comparison should consider the quality and professional training desired. The main focus of this study was to structure a model involving specific content used in tele-education for the dissemination of quality continuing education. To this approach is essential considering the difficulties of access to information by Brazilian professionals, because there are no other courses that offer with similar models.

The advantage of this project was evident on the participants' flexibility to take classes and the evaluation opportunity at their own space. This course feature allows the participation of professionals from different Brazilian geographic regions without loss of educational quality and the possibility of participating in the RUTE (Brazilian Ministry of Science and Technology) and SUS (Brazilian Ministry of Health) graduate programs. In addition, the access to educational material in Portuguese would be of importance to transfer scientific knowledge and skills to Brazilian professionals. Moreover, the identification of competence areas and their correlation with scientific content offer the possibility of addressing practices for better laboratory tests performance and accurate results communication in a timely manner.

Conclusions

The implementation of a mixed model based on physical attendance and distance education could be used to train microbiologists without compromising educational quality. The use of telemedicine in this course to disseminate pedagogical strategies allowed professionals from different country regions to be updated in microbiological techniques, which represent an alternative way for innovation in teaching clinical microbiology. This model promoted the application of educational strategies that could impact behavioral changes in the participants' work routine. This study shows the necessities for a continuing educational plan and a progressive upgrading of the transmitted knowledge. The creation of a network of continuing education for those involved in previous courses is suggested.

Footnotes

Acknowledgments

The authors acknowledge the support of the Telemedicine Project of Institutos do Milênio Program, CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico–Brazilian Council for Scientific and Technological Research), and Brazilian Ministry of Science and Technology.

Disclosure Statement

This study was implemented as part of a thesis, and the authors have no conflicts of interest in connection with the manuscript.

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