In 2008, an Institute of Medicine (IOM) report identified the aging population in the United States as a significant trend that requires retooling of the health work-force. This report brought national attention to the importance of the direct care workforce and called for increasing minimum training standards, particularly for a subset referred to as personal care aides (PCAs). Currently, no federal competency or training requirements exist for PCAs and there is little standardization across existing PCA training programs. Since dissemination of the IOM report, health care expenditures for older adults in the home setting continue to increase (Centers for Medicare & Medicaid Services, 2012) and the shortage of qualified workers has grown. There are approximately 1.8 million PCAs in the United States currently and projections indicate an expected 26% increase in demand by 2024 (Bureau of Labor Statistics, 2014). It is imperative that this workforce increases in size but also that measures be taken to ensure satisfactory levels of competence.
Direct care workers, primarily PCAs, provide most paid in-home supports and services to older adults (Dawson, 2011). These workers are hired and employed through a provider agency or directly by a client to assist with activities of daily living (ADLs) (e.g., dressing, walking, transferring) as well as instrumental ADLs (e.g., preparing meals, shopping, house cleaning). Adequate training is critical to more than just filling the care gap. By virtue of their proximity and time spent with clients, trained PCAs are in a key position to positively influence the quality and cost of care (IOM, 2008). For example, studies suggest that state programs offering competent personal care services have lower rates of hospitalizations for older adults (Parker, Zimmerman, Rodriguez, & Lee, 2014). However, it is not yet clear what constitutes an ideal training program. Use of web-based learning has proven effective among licensed health care providers and it is a common university practice to offer web-blended coursework, simulation, and group learning activities. Such training holds potential for PCAs but little evidence exists to support its viability or success in terms of knowledge and skill gains. Moreover, these teaching methods are all dependent on access to required technology and the internet. It cannot be assumed that a targeted learner audience has internet access; this must be evaluated before investing financial and human capital into statewide or national training programs that are at least in part delivered online.
Many PCAs comprise what is known as the working poor (Potter, Churilla, & Smith, 2006) and may be less likely to own computers or be facile on the internet (Irvine, Beaty, Seeley, & Bourgeois, 2013), which would severely affect their ability to participate in online education programs. In addition, current research indicates that computer equipment and internet access are determinants of an individual's willingness to participate in web-based learning courses, attitudes toward web-based learning, and computer use (Faul et al., 2010; Yu & Yang, 2006). It is therefore critical to ascertain level of access to the internet among PCAs and their willingness to engage in online coursework prior to investing resources in online training. Little, if any, documentation exists within the literature on these topics as they relate to PCAs. The current article provides initial research findings on issues of internet access, use, and acceptability for PCA training, and has relevance for a significant public health concern: ensuring there is a competent workforce to meet the growing demand for in-home care as a result of an aging population across the United States.
In response to the concerns that no standard training program for PCAs exists, the U.S. Health Resources and Services Administration funded six states in 2010 to develop, implement, and test new PCA training programs as part of the Personal Home Care Aide State Training program (PHCAST). Michigan was one of six states selected for funding. The Michigan PCA training model, Building Training…Building Quality (BTBQ), targeted PCAs who provide in-home, long-term care supports and services to participants enrolled in the Medicare and Medicaid Home and Community-Based waiver program. Through extensive academic–community partnerships, a 77-hour, in-person core curriculum was adapted from the Paraprofessional Healthcare Institute (2009) Personal Care Services curriculum. This curriculum was made possible by the collaborative effort of multidisciplinary regional workgroups comprising individuals from the aging and disability networks across Michigan and through suggestions from those who receive in-home supportive services and their personal caregivers.
The final Michigan BTBQ curriculum included 10 federal competency requirements taught throughout 22, 3.5-hour modules. Each module was taught in-person using adult learner teaching methods composed of short lectures, group work, and skill demonstrations. Concepts of person-centered thinking and delivery of supports and services were infused throughout all modules. The training program was implemented in five regions across Michigan and approximately 400 individuals completed the 77-hour core curriculum. One goal of the BTBQ project was to determine the key components of a gold standard PCA training program. BTBQ was designed based on the premise that the ideal delivery method is entirely in-person, but this assumption needs more extensive testing. Web-based learning holds promise for portions of PCA skills training. However, the extent to which hands-on PCA competencies, such as bathing, can successfully be taught online is still in question.
According to Rice and McKendree (2014), one of the challenges in developing a web-blended learning curriculum is determining which skills are best taught using an online method and which require a face-to-face teaching method. For example, teaching a PCA to bathe a participant using a video is not ideal, as nothing can replace the value of simulation and hands-on practice with real individuals to prepare the PCA for different bathing conditions (e.g., transferring out of a tub onto a wet floor or holding the patient while adjusting the water temperature). It is important to evaluate skills and confidence levels using return demonstrations to increase the odds of participant and PCA safety. In contrast, using a video module to review participant and worker rights or background information on different types of dementia may be appropriate. In these latter cases, employers may be able to use computerized training tools or incorporate video programs into ongoing in-service education.
Determining which BTBQ modules are most conducive to video format was not within the scope of the current study, but is one of the primary aims in an upcoming funded study to determine ways to increase the likelihood and feasibility of BTBQ being adopted in real-world settings. Online programs maximize efficiency but may come at a cost to competency levels and participant safety. However, moving to blended models is inevitable. It is necessary to determine which BTBQ modules should be converted to online, and web access and acceptability must be taken into consideration. Therefore, BTBQ data collection included questions specifically related to (a) whether learners had access to a computer and internet, and (b) their preferences for curriculum delivery (i.e., in-person, online, or a blended model).
Findings are guiding development of modified BTBQ curricula and delivery methods. Although there was general consensus among the BTBQ workgroup members that many of the skills needed to become a PCA, such as ADLs (including transfers, use of assistive device, personal care, bathing, showering and grooming, assisting with meals, use of the bathroom, and dressing), require hands-on practice with an experienced trainer, the possibility of transforming modules that do not include ADL skills in a web-blended learning format are now being considered. Web-blended learning refers to the merging of text-based, asynchronous internet technology combined with face-to-face classroom teaching (Garrison & Kanuka, 2004). A growing evidence base in the scientific literature suggests web-blended learning can be as equally effective as traditional educational methods (Campbell, Gibson, Hall, Richards, & Callery, 2008; McCutcheon, Lohan, Traynor, & Martin, 2015; Rowe, Frantz, & Bozalek, 2012). Implementing web-blended courses offers adult learners flexibility to study when and where they want, and the ability to create personalized educational schedules around previous commitments. This flexibility allows for a greater ability to scale up a program and include learners who are hard to reach due to geographic location or other constraints, such as lack of transportation. In addition, it can be more cost effective as instructors can engage a larger class size and provide learners with the opportunity to share ideas and work together across geographic boundaries (Campbell et al., 2008).
The Michigan PHCAST program included a robust research component using a prospective, mixed-methods design with a randomized control group to determine program impact and key elements of a gold standard PCA training program. Primary outcomes of interest included PCA knowledge, skills, attitudes, and job status. Secondary outcomes included initial inquiry about internet access and desirability of web-based learning (i.e., the basis for the current article). The study was approved by the Michigan State University Institutional Review Board. As part of the evaluation, all enrollees (N = 595) completed a comprehensive Learner Information Form distributed by instructors at the beginning of the first day of class. Data were collected on demographics, work history, job status and conditions, and other enrollee characteristics. In addition, two questions related to internet access were taken from the U.S. Census Bureau and PEW research trust that were recently used to assess internet use and accessibility (Cheeseman Day, Janus, & Davis, 2005; Fox & Rainie, 2014): (a) do you ever use a computer at your workplace, at school, at home, or anywhere else?, and (b) do you have access to a high-speed internet connection?
In addition, two questions specific to the BTBQ program and PCA perception of ease of use and usefulness of web-based programs were asked: (a) would you be interested in using the internet for parts of PCA training if it was available?, and (b) what method of learning do you think would be most effective for the PCA training? A series of options were provided, including in-person instruction only, online interactive classes only, online materials for self-study, and a combination of in-person and online. Respondents were instructed to select all that apply and provide additional explanations if needed. Finally, two questions were included related to participants' reading level. All survey questions were designed at no higher than a sixth-grade reading level, as measured by the Flesch-Kincaid Grade Level score and Flesch Reading Ease score (calculated via tools in Microsoft Word® 2007). The survey was piloted for readability and ease of use.
Descriptive statistics and frequencies were generated for all data sources using SPSS version 22. Cross-tab and multiple regression analyses were conducted using R statistical software version 2.15.1. Specific variables of interest in terms of possible impact on internet access, usability, and acceptance included household annual income, education level, employment, reading level, and gender. Logistic regression was conducted to determine these associations.
Three hundred ninety-three learners completed all 77 hours of training. However, findings related to the internet research questions are based on data from all registered learners, regardless of whether they completed the program. All learners who attended the first day of class completed the Learner Information Form for a 100% return rate (N = 595).
The sample was primarily female (90%), born in the United States (98%), Caucasian (71%), high school graduates (37.6%) or had completed some college (34.5%), ages 20 to 59 (82%) (mode = 20 to 29, 22%), and had low incomes (<$22,981, 67%). Table 1 lists demographic characteristics that are most relevant to the research questions.
Participant Characteristics (N = 595)
Most respondents (n = 521, 87.6%) used a computer at their workplace, school, home, or another place, and most (n = 472, 79.3%) had access to a high-speed internet connection, which is consistent with national averages.
Acceptability of Use of Internet for Personal Care Aide Training
Most respondents (n = 486, 81.7%) stated that they would be interested in using the internet for parts of PCA training. Table 2 provides more detail in terms of learner perceptions about the extent to which internet PCA training would be effective. As respondents were instructed to select all that apply, total percentages exceed 100%. It is notable that most respondents stated they would prefer a combination of in-person and online instruction, whereas only 3.5% stated they would prefer online only.
Perceptions of Most Effective Personal Care Aide Training Delivery Method
Further analyses revealed important statistically significant distinctions in demographic characteristics associated with preferred method of instruction (i.e., coefficients of regression). Individuals with higher household incomes had higher preferences for learning through the use of videotapes/movies, skills practice, and interactive presentations, and had a higher likelihood of believing the most effective method of learning is online only (p = 0.036, 95% confidence interval [CI] [0.012, 0.371]) or a combination of in-person and online (p = 0.011, 95% CI [0.033, 0.263]). Respondents with a higher education level were more likely to have access to a computer at their work-place, school, home, or elsewhere (p = 0.001, 95% CI [0.16, 0.712]), as well as a high-speed internet connection (p = 0.001, 95% CI [0.132, 0.565]). Further, they were less likely to think that in-person instruction only is the best method (p = 0.006, 95% CI [−0.387, 0.063]) and more likely to think that the most effective method is a combination of in-person and online (p < 0.001, 95% CI [0.261, 0.617]). Respondents who were currently employed were less likely to think that in-person only (p = 0.004, 95% CI [−0.811, −0.152]) or online only (p = 0.026, 95% CI [−2.173, −0.139]) is the most effective method. Similar to respondents who were more highly educated, they were more likely to think that a combination is the most effective method for PCA training (p = 0.004, 95% CI [0.156, 0.83]). Respondents with poorer reading skills were the least likely to use a computer at their work-place, school, home, or elsewhere (p < 0.001, 95% CI [−0.822, −0.363]), or have access to high-speed internet (p < 0.001, 95% CI [−0.604, −0.219]). Understandably, they had less interest in using the internet for PCA training (p < 0.001, 95% CI [−0.568, −0.155]), were less likely to think that the most effective method for PCA training is a combination of in-person and online (p < 0.001, 95% CI [−0.591, −0.249]), and were more likely to think that the most effective method is in-person only (p < 0.001, 95% CI [0.174, 0.509]).
The current study focused on PCAs who provide in-home supportive services, adding preliminary evidence to guide use of online courses for training PCAs. Notably, only 3% of the sample believed online-only trainings would be effective; 42% believed in-person only would be the most effective way to learn PCA skills. However, most respondents (62%) preferred a blended program. They valued in-person practice with an experienced instructor for hands-on tasks, such as bathing and transferring. However, they also believed some of the curriculum could be taught online, which would have several advantages, including allowing greater flexibility in terms of ability to fit coursework around other obligations (including paid work) and minimizing challenges (e.g., lack of transportation, child care). Moreover, it would provide a resource that would facilitate additional practice at home or to have as a reference for refreshing skills when necessary.
Of equal importance are study findings that underscore the limits of web-based learning. First, not all potential learners have access to a computer or high-speed internet. Twenty-one percent of the BTBQ learners had no access to high-speed internet. Even if an outstanding web-blended training program is developed, it is useless if learners are not connected. Second, even if learners have access to a computer with high-speed internet, other variables affect their acceptability of using a computer for online training—specifically, employment status and ability to read. Individuals who were currentlyemployedwerelessinclined to accept in-person only training, presumably because it would require time away from their job and potentially lost wages. Respondents with poorer reading skills were less likely to have access to a computer with high-speed internet, but were also less interested in online classes for instruction and more likely to prefer in-person only classes. This finding was confirmed throughout the study, in which learners with difficulty reading were provided additional one-on-one instructor attention and benefited from substantial opportunities to work with instructors and their peers in competency demonstrations, practice sessions, and hands-on learning with medical supplies, mannequins, and live individuals who could simulate being a client.
Program planners must know if the targeted group of learners has access to computers and the internet, the location of the computers, if learners are able to use them for educational purposes, and the learners' reading levels.
These findings underscore the need to think carefully about the use of online teaching materials and methods for training PCAs before investing resources into widespread program development, and suggest that a gold standard PCA training program may be one that uses multiple methods of learning, including portions that are online while also taking into account a range of abilities and resources among the target audience. According to Fox and Rainie (2014), researchers from the PEW Research Center reported that 13% of adults in 2014 were without internet access, which is associated with lower income and education, and racial and cultural minorities. This association reflects the digital divide, a term denoting a well-recognized gap between individuals with and without access to computers and the internet (Kind, Huang, Farr, & Pomerantz, 2005). For PCAs without access to computers or the internet, ability to participate in online education is limited.
Providing computers with internet at training sites is one option for alleviating barriers to access, but may not be feasible or cost-effective, and defeats the purpose of minimizing challenges to training (e.g., geographic distribution, lack of transportation). Other recommendations for consideration include provision of training materials that do not require a computer or the internet, such as providing DVDs that can be viewed multiple times at home, supplemented with in-person, interactive sessions. Prospective learners could be screened for reading levels and access to computers and the internet, and offered individualized plans that are compatible with their resources. However, there is a more fundamental issue. The extent to which hands-on PCA competencies can be taught online is still in question and needs further testing. Prior to taking measures to increase access to technology, it is of critical importance that further research be conducted to determine what types of in-service education are appropriate for online instruction, the impact of online training on knowledge and skills in specific topic areas, and what education should/should not be conducted online. Only then should agencies wrestle with how to configure training programs in such a way as to address the technology challenges highlighted in the current study.
The current study identifies current use of technology and accessibility at one point in time with a specific study population: the direct care worker. The study population and technology component are rapidly expanding. Changes in the current characteristics of the direct care worker and in accessibility or development of new technology may impede the generalizability of the study's results. A second limitation is associated with the questions “do you ever use a computer at your workplace, at school, at home, or anywhere else?” and “do you have access to a high-speed internet connection?” Although these questions mirror those used by the PEW Research Center, neither provide enough specificity to determine the location of respondents' access, which would presumably have an impact on their ability and willingness to take online courses. For example, respondents may be using a computer at work but not have access to that same computer for personal use, in which case the study may be overestimating the degree to which the population has access. Generalizability is also limited by the fact that the sample's demographic profile is not comparable to that of other geographic locations. Although similar in that they were predominantly middle-aged women, there may be higher proportions of foreign-born, less educated PCAs in other regions of the country. Finally, although most participants indicated a preference for a blended delivery model, this finding does not equate to the effectiveness of a blended model. Further research is needed to determine what portions of the curriculum would be appropriate to deliver in-person versus online to have the most positive impact on PCA knowledge and skills, and ultimately client outcomes.
The current findings indicate that online-only comprehensive PCA training programs are not ideal, as they are not accessible to individuals without computers or internet connections nor are they learner-friendly for those who have difficulty reading. There is a trend toward online trainings because in-person–only programs can be costly and present difficulties in terms of scale and flexibility for accommodating challenges such as work schedules, transportation, and childcare. Most participants in the current study preferred a blended model; they valued in-person training for hands-on tasks in particular, with experienced instructors guiding real-life practice. Additional research is needed to determine which topics are conducive to online versus in-person instruction, based on acceptable standards for PCA knowledge and skills. Program planners who want high-caliber PCAs and opt for online training must be mindful of technology access and reading levels among their target audience, as well as building in opportunities for hands-on learning and skills demonstration.
- Bureau of Labor Statistics. (2014). Fastest growing occupations. Retrieved from http://www.bls.gov/emp/ep_table_103.htm
- Campbell, M., Gibson, W., Hall, A., Richards, D. & Callery, P. (2008). Online vs. face-to-face discussion in a web-based research methods course for postgraduate nursing students: A quasi-experimental study. International Journal of Nursing Studies, 45, 750–759. doi:10.1016/j.ijnurstu.2006.12.011 [CrossRef]
- Centers for Medicare & Medicaid Services. (2012). National health expenditure projections 2012–2022. Retrieved from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2012.pdf
- Cheeseman Day, J., Janus, A. & Davis, J. (2005). Computer and internet use in the United States: 2003. Retrieved from http://www.census.gov/prod/2005pubs/p23-208.pdf
- Dawson, S. (2011). Improving jobs and care: A national sector strategy. Retrieved from http://www.directcareclearinghouse.org/download/dawson-phistrategy.pdf
- Faul, A.C., Schapmire, T.J., D'Ambrosio, J., Feaster, D., Oak, C.S. & Farley, A. (2010). Promoting sustainability in front-line home care aides: Understanding factors affecting job retention in the home care workforce. Home Health Care Management & Practice, 22, 408–416. doi:10.1177/1084822309348896 [CrossRef]
- Fox, S. & Rainie, L. (2014). Part 1: How the internet has woven itself into American life. Retrieved from http://www.pewinternet.org/2014/02/27/part-1-how-the-internet-has-woven-itself-into-american-life
- Garrison, R.D. & Kanuka, H. (2004). Blended learning: Uncovering its transformative potential in higher education. Internet and Higher Education, 7, 95–105. doi:10.1016/j.iheduc.2004.02.001 [CrossRef]
- Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press.
- Irvine, A.B., Beaty, J.A., Seeley, J.R. & Bourgeois, M. (2013). Use of a dementia training designed for nurse aides to train other staff. Journal of Applied Gerontology, 32, 936–951. doi:10.1177/0733464812446021 [CrossRef]
- Kind, T., Huang, Z.J., Farr, D. & Pomerantz, K.L. (2005). Internet and computer access and use for health information in an underserved community. Ambulatory Pediatrics, 5, 117–121. doi:10.1367/A04-107R.1 [CrossRef]
- McCutcheon, K., Lohan, M., Traynor, M. & Martin, D. (2015). A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. Journal of Advanced Nursing, 71, 255–270. doi:10.1111/jan.12509 [CrossRef]
- Paraprofessional Healthcare Institute. (2009). Providing personal care services to elders and people with disabilities: A model curriculum for direct-care workers. Retrieved from http://phinational.org/workforce/resources/phi-curricula/personal-care-services-curriculum
- Parker, E., Zimmerman, S., Rodriguez, S. & Lee, T. (2014). Exploring best practices in home health care: A review of available evidence on select innovations. Home Health Care Management & Practice, 26, 17–33. doi:10.1177/1084822313499916 [CrossRef]
- Potter, S.J., Churilla, A. & Smith, K. (2006). An examination of full-time employment in the direct-care workforce. Journal of Applied Gerontology, 25, 356–374. doi:10.1177/0733464806292227 [CrossRef]
- Rice, S. & McKendree, J. (2014). Teaching and learning in medical education: How theory can inform practice. In Swanwick, T. (Ed.), Understanding medical education: Evidence, theory and practice (pp. 164–166). West Sussex, UK: Wiley Blackwell.
- Rowe, M., Frantz, J. & Bozalek, V. (2012). The role of blended learning in the clinical education of healthcare students: A systematic review. Medical Teacher, 34, e216–e221. doi:10.3109/0142159X.2012.642831 [CrossRef]
- Yu, S. & Yang, K.-F. (2006). Attitudes toward web-based distance learning among public health nurses in Taiwan: A questionnaire survey. International Journal of Nursing Studies, 43, 767–774. doi:10.1016/j.ijnurstu.2005.09.005 [CrossRef]
Participant Characteristics (N = 595)
| Less than high school||56 (9.4)|
| High school graduate or GED||224 (37.6)|
| Some college||205 (34.5)|
| Associate degree or vocational||68 (11.4)|
| College/professional degree||37 (6.2)|
| Licensed practical nurse or RN||5 (0.8)|
| $0 to $22,980||399 (67.1)|
| $22,981 to $31,020||77 (12.9)|
| $31,021 to $39,060||28 (4.7)|
| $39,061 to $47,100||21 (3.5)|
| $47,101 to $55,140||18 (3.0)|
| $55,141 to $63,180||9 (1.5)|
| $63,181 to $71,220||5 (0.8)|
| $71,221 to $79,260||8 (1.3)|
| ≥$79,261||10 (1.7)|
| Unemployed||304 (51.1)|
| Employed||288 (48.4)|
Perceptions of Most Effective Personal Care Aide Training Delivery Method
|Combination of in-person and online||368 (61.8)|
|In-person instruction only||252 (42.4)|
|Online interactive classes only||21 (3.5)|
|Online materials for self-study only||31 (5.2)|