With increases in life expectancy, chronic health conditions associated with aging have become more prevalent, which has led to an increase in the need for shared care among family members, health professionals, and institutions, particularly nursing homes (Creutzberg et al., 2007; Estabrooks et al., 2015). Quality of care provided to institutionalized older adults depends on the qualifications of nursing home staff, especially those involved in the daily care of residents (World Health Organization [WHO], 2015). Individuals who lack adequate training tend to disregard the subjectivity and potential of dependent older adults, which further diminishes their independence and autonomy (Allen, 2016). Moreover, lack of knowledge and poor attitudes toward older adults have been associated with ageism, which is linked with poor quality of care and negative health outcomes for older adults (Allen, 2016; Rababa et al., 2020).
Education is important for the promotion of new behaviors, values, and beliefs, as well as expectations regarding old age. Thus, the training of health care professionals in gerontology is an important way of mediating social changes and a determinant of the quality of care (Allen, 2016; Kang et al., 2017; WHO, 2015). Care provided to older adults in nursing homes is wholly dependent on the efficiency of staff. Therefore, bolstering the qualifications of the workforce should be encouraged and supported (WHO, 2015).
Several studies have explored nurses' knowledge, beliefs, and attitudes toward older adult care (Liu et al., 2013; Rush et al., 2017). Findings suggest that gerontological education and positive experience can improve nurses' attitudes toward older adults; however, few studies assess knowledge (Liu et al., 2013; Rush et al., 2017). Less frequent are studies addressing training programs for staff, especially in nursing homes that provide care for older adults with varying health conditions. A systematic review investigated the reproducibility and effectiveness of staff training programs in terms of a reduction in the behavioral and psychological symptoms of dementia (BPSD). The results revealed poor standardization of the interventions and difficulty in obtaining detailed information on the procedures used, which limits the reproducibility of the training programs (Reis et al., 2013). Lamet et al. (2011) conducted a quasi-experimental pilot study to investigate students' attitudes toward older adults, describe self-transcendence, and evaluate students' willingness to care for older adults. The intervention improved attitudes toward older adults, with negative attitudes significantly changed. No significant differences were found on self-transcendence and willingness to serve (Lamet et al., 2011). A recent qualitative study described the use of Clinical Caritas Processes at workshops for nursing home staff and analyzed the perceptions of these professionals regarding the care provided. The workshops contributed to the empowerment of care staff and led to a more humanistic approach (Medeiros et al., 2016). However, changes in beliefs and knowledge about old age were not measured.
The feasibility of interventions is another aspect that has not been explored in these studies. Although necessary, training caregivers remains a difficult task, as institutions deal with shortages of financial resources and labor (Coogle et al., 2007; Damaceno et al., 2019; Roquete et al., 2017). Thus, to be widely implemented, it is essential to consider not only the reproducibility and effectiveness of training programs, but also their feasibility.
The aim of the current study was to analyze the effectiveness and feasibility of a training program for care staff at two nursing homes: one private and one philanthropic. The impact of the training program on staff's beliefs, attitudes, and knowledge about old age was also investigated.
Study Design and Participants
The current quasi-experimental study was conducted between April and August 2017 with care professionals who worked at two nursing homes (one private and one philanthropic) in Belo Horizonte, Brazil. Among individuals who provide care for older adults at nursing homes in Brazil, the most important are formal caregivers and nursing assistants (Roquete et al., 2017). The occupation of formal caregiver in Brazil is accessible to people with at least 2 years' experience in public, private, or nongovernmental caregiving institutions, in supervised functions of caring (Ministério do Trabalho e Emprego, 2010). Access to employment occurs through basic vocational training courses and training concomitantly or after the minimum training that varies from the fourth grade of elementary school to high school (Ministério do Trabalho e Emprego, 2010).
The inclusion criterion was having been hired as a formal caregiver at one of the nursing homes before the start of the study. Nursing assistants were not included as participants. No exclusion criteria were considered. All formal caregivers (32 in the private nursing home and 11 in the philanthropic nursing home) were invited to participate in the study and received detailed information on the objectives and intervention. The final sample comprised 23 formal caregivers at the private institution and 10 at the philanthropic institution who agreed to participate.
This study received approval from the Human Research Ethics Committee of Universidade Federal de Minas Gerais (Comitê de Ética em Pesquisa – CEP-UFMG). All participants signed a statement of informed consent.
Characterization of the sample was performed using a questionnaire to collect data on sex, age, marital status, education, training, experience working with older adults, training received, the reason that led them to become care professionals, and topics of interest for training. The researchers developed the initial version of the questionnaire and the suitability of the questions was evaluated by nursing assistants who had worked at a philanthropic nursing home for more than 10 years. The suggestions were incorporated into the final version, which was administered to formal caregivers.
The Semantic Differential Scale of Attitudes Towards Aging was used to measure beliefs and attitudes regarding aging (Brito, 2018). This scale comprises 30 items grouped into four domains: (a) information processing capacity and problem solving (cognition), which reflects the social adaptation of older adults (10 items); (b) autonomy and instrumentality for achieving goals (six items); (c) social relations, covering affective-motivational aspects reflected in social interactions of older adults (seven items); and (d) social image (persona), reflecting social labels commonly used to designate and discriminate older adults (seven items). Each item is anchored by two opposing adjectives and the intensity of the responses is indicated on a 5-point scale (Cachioni & Aguilar, 2008). Beliefs were grouped into three categories: positive, when the two points closest to the positive adjective were marked; negative, when the two points closest to the negative adjective were marked; and neutral, when the point in the middle of the scale (score of 3) was marked (Brito, 2018). The scale was developed by Neri (1991) and its validation for the Brazilian population has been investigated in different studies (Cachioni, 2002; Resende, 2001; Silva, 1999).
The Palmore-Neri-Cachioni Quiz is a translated and adapted version of the Palmore Aging Quiz 21 (Harris et al., 1996) for use in Brazil. This quiz comprises 25 multiple choice items addressing knowledge of older adults and the aging process in the physical, cognitive, psychological, and social domains. Some questions comprise more than one domain and may be scored more than once for the composition of the total score, the maximum of which is 30 points (Brito, 2018).
All participants answered the semi-structured demographic questionnaire before the training period. The Semantic Differential Scale of Attitudes Towards Aging and the Palmore-Neri-Cachioni Questionnaire were applied before the intervention and 1 week after its completion. All evaluators had undergone training prior to the administration of the instruments.
Satisfaction questionnaires were developed to assess the feasibility of the training program and were answered by formal caregivers and managers 3 months after the end of the intervention. Care professionals reported how much they appreciated the training, level of fatigue, learning, application of the acquired knowledge, changes in professional practice after the course, and the desire to participate in further training programs. Managers reported the occurrence of disturbances in the institutional routine during the intervention, the perceived change in the behavior of staff members after the intervention, and the commitment to implement further training at the institution. Both questionnaires used scales scored from 0 to 10 and provided a space for positive and negative feedback as well as suggestions for improvements. The questionnaires were distributed to participants and managers with the instruction to return the answered form in an envelope left in an easily accessible place at the institution. Participants' attendance during the intervention was recorded using an attendance list at each meeting.
The intervention protocol consisted of five weekly meetings, each lasting 1.5 hours. An expert panel of two occupational therapists, a physiotherapist, and a nurse discussed 15 key issues in the field of aging, which were presented to participants on the evaluation questionnaire. The five topics identified as being of greater interest to care professionals were incorporated into the training. Moreover, requests spontaneously presented by participants during the evaluation process were also incorporated into the training. The following topics were addressed at both institutions: (a) Ageism: uniqueness of the aging process and older people; myths and prejudices against older people; encouraging protagonism, autonomy, and independence; encouraging self-care; (b) Aging Process: understanding demographic, biological, physiological, functional, psychological, social, behavioral, and sexual aspects of the aging process; (c) Older Adult Rights and Public Policies: historical evolution of the legalization of older adult rights; main federal, state, and municipal laws aimed at older people; (d) Violence Against Older People: responsibility in providing care to frail older adults; abandonment and mistreatment; social protection network to combat violence against older adults; (e) Dementia: symptoms, causes, diagnosis, and treatment; management of BPSD; and (f) Communication and Stimulation of Memory: communication strategies; sensory and memory stimulation as a means to care for individuals with dementia in long-term care facilities. Two additional topics could be chosen by nursing home staff. Staff at the private nursing home chose the following topics: “Occupation of formal caregiver, legal aspects, training and responsibilities” and “Self-care of older people, how to stimulate and what is important to know?” At the philanthropic nursing home, staff chose “Life-threatening situations and basic first aid procedures,” and “End-of-life patient care.”
Training was designed to increase staff knowledge regarding the aging process, stimulate the development of skills related to providing care, and offer strategies for improving the care provided to residents. For such, we used recommendations for training and development of skills among workers at health care and social services institutions for older adults in the United Kingdom (Rycroft-Malone et al., 2016; Williams et al., 2016). Table 1 shows the principles of the recommendations and how they were used in the current study.
Principles for Training and Development of Skills Among Workers at Health Care and Social Services Institutions for Older Adults
At each meeting, participants received printed educational material to take home, which included a review of the points raised and reading suggestions. Researchers designed this material to help staff assimilate the content and give them a chance to acquire further knowledge if they wished.
Descriptive statistics were performed with measures of central tendency and dispersion or frequency distribution, depending on the nature of the variables. The Shapiro-Wilk test revealed that the dependent variables exhibited normal distribution. The t test for independent samples (age) was used to compare sociodemographic characteristics of participants at the two institutions. The chi-square test was used to evaluate the association between categorical variables and groups (sex, marital status, education, and income). Repeated measures two- way analysis of variance (ANOVA) was used to compare the quantitative dependent variables (beliefs and general knowledge regarding old age, total and score per domain) before and after training. The level of significance was set to 5% (p < 0.05) and analyses were performed using SPSS version 21.0.0.
Table 2 displays sociodemographic characteristics of participants. No significant differences between groups were found regarding age, sex, marital status, or schooling (p > 0.05). In contrast, a significant difference was found regarding income, which was lower among staff at the philanthropic nursing home (p = 0.028).
All care professionals had some training in health care but on diverse topics (e.g., providing care, technical nursing skills, first aid, prevention and management of skin lesions) and with different total workloads (ranging from 8 to 160 hours of class). Regarding training at the institution, all participants from the private nursing home and 50% of those at the philanthropic nursing home reported receiving some training. Most participants worked with older adults for a period of up to 5 years and chose the profession of formal caregiver due to need or job opportunity.
Attitudes and Beliefs
No significant changes in beliefs or attitudes toward aging were found after the intervention at either institution. Differences between institutions were found for the domains of cognition and agency. Private nursing home staff had higher averages than philanthropic nursing home staff for these domains, indicating more negative beliefs. The frequency of positive, negative, and neutral beliefs before and after the intervention is shown in Table 3.
Knowledge and Beliefs About Aging by Domain Before and After Intervention
Regarding knowledge in gerontology, a statistically significant increase was found in the number of correct answers after training at both nursing homes. This result was observed for the total score as well as in the physical, cognitive, and psychological domains (Figure 1). Significant differences between institutions were found for the total score and social domain score. However, no significant interaction effect was found for any of the domains. These data are displayed in Table 2.
Scoring by domain and total of Palmore-Neri-Cachioni Questionnaire before and after intervention: time × institution. Note. (A) Physical domain (p < 0.05 time comparison; p > 0.05 institution comparison; p > 0.05 interaction time × institution). (B) Psychological domain (p < 0.05 time comparison; p > 0.05 institution comparison; p > 0.05 interaction time × institution). (C) Cognitive domain (p < 0.05 time comparison; p > 0.05 institution comparison; p > 0.05 interaction time × institution). (D) Social domain (p > 0.05 time comparison, p < 0.05 institution comparison, p > 0.05 interaction time × institution). (E) Total score (p < 0.05 time comparison, p < 0.05 institution comparison, p > 0.05 interaction time × institution).
The psychological and social domains had lower success rates before and after training at both institutions when compared to the physical and cognitive domains.
Regarding feasibility of the intervention, attendance was 100% at both nursing homes. Eight staff members left the institutions and did not answer the satisfaction questionnaire. The positive aspects highlighted by participants from both institutions were related to the acquisition of new knowledge as well as improvements in behavior and the accomplishment of the work. No participants raised negative points. Only one private nursing home manager reported concern regarding the care routine while staff were undergoing training. Table 4 displays results of the feasibility analysis.
Participant and Manager Satisfaction With Training
To the best of our knowledge, the current study is the first to evaluate the effect of a training program on attitudes, beliefs, and knowledge about aging among formal caregivers of older adults. The training program improved participants' knowledge about older adults; however, their attitudes and beliefs about old age were not affected. Moreover, results show that the intervention was feasible at the private and philanthropic nursing homes.
The training program included specific content on gerontology that enabled an increase in knowledge about aging. This result is similar to findings described by Placideli and Ruiz (2015) in a study with community health agents, suggesting that a theoretical approach with topics on aging produces positive results, as demonstrated by the better performance on the Palmore-Neri-Cachioni Questionnaire. The training program developed in the current study was based on theoretical principles recommended for in-service training (Rycroft-Malone et al., 2016; Williams et al., 2016). These principles involve considering the actual work routine of staff and understanding their references. The use of such grounding is believed to be essential for these individuals to build knowledge.
Although participants gained knowledge regarding the physical, cognitive, and psychological domains after training, fewer questions were answered correctly in the psychological and social domains during the pre-intervention and post-intervention evaluations at both nursing homes. Ferreira and Ruiz (2012) also found less knowledge on psychological and social topics using the same questionnaire with community health agents. In the current study, the training program included content related to the four domains of the questionnaire: physical, cognitive, psychological, and social. However, previous training programs for formal caregivers seem to have emphasized knowledge on health issues, particularly biological aspects, to the detriment of emotional and social issues (Brito, 2018; Maffioletti et al., 2006). Thus, training programs should seek to involve content that goes beyond biological aspects (WHO, 2015).
Before training, staff at the philanthropic nursing home had less knowledge of gerontology compared to those at the private institution, although all participants had undergone some training related to providing care. Individuals in the current sample went through heterogeneous processes of vocational training both in terms of the scope and duration of training courses. Although the training of formal and informal caregivers is advocated (Ministério da Saúde & Ministério da Previdência e Assistência Social, 1999), courses on providing care for older adults do not have a standardized format regarding scope, content, or workload (Barbosa et al., 2017). Thus, there is a need for clear regulations regarding the minimum workload and the basic content to be addressed in formal caregiver training programs. It is also important to establish specific criteria for the qualification of educational institutions that train these individuals. According to Brazilian Law 4702/2012, which regulates this profession, institutions must be recognized by the federal, state, or municipal public agency with jurisdiction (República Federativa do Brasil Câmara dos Deputado, 2012). However, criteria for such recognition is unclear.
Another difference between the two institutions regarded training at the nursing home itself. One half of participants from the philanthropic nursing home reported having not received this kind of guidance, whereas most at the private nursing home had been trained by the institution. In addition to vocational training, it is important for nursing homes to train newly hired care professionals regarding the development of work functions at the institution. The purpose of such training programs is to minimize variability in the provision of care by helping new employees adapt to norms, routines, and institutional procedures (Bucchi et al., 2011). According to Sapatini et al. (2016), in-service training contributes to the development of the skills and knowledge necessary for a suitable professional performance.
Most formal caregivers invited to participate in the intervention agreed to do so and all who initiated the program participated in all meetings without this causing inconvenience to the institution or the caregivers themselves. Managers and care professionals gave positive evaluations of the training, perceived changes due to the intervention, and were interested in having similar opportunities in the future. The theoretical basis used for the program possibly contributed to the adherence to the intervention, especially the elements that took into account the real-life operations of the staff, favoring the involvement of participants in the development of the training process (Rycroft-Malone et al., 2016; Williams et al., 2016). Nursing homes should perform continuing education activities in gerontology to improve technical skills of employees involved in providing services to older adults (WHO, 2015). Therefore, it is essential for training programs to be made viable for institutions.
Beliefs and attitudes regarding aging did not change at either institution after the intervention. In the literature, it was shown that there is a positive correlation with educational level and positive attitudes toward older adults, as access to scientific information and experience regarding the aging process can contribute to the development of multidimensional views (Pekince et al., 2018; Rababa et al., 2020). However, the provision of information may not be sufficient to change the way society treats its older population. It is also necessary to promote lifelong education for all citizens (Cachioni & Aguilar, 2008; Ryan et al., 2007). Ageism is the stereotyping and discrimination of groups or individuals based on age or a perception that they are “elderly” (Butler, 1969). The persistence of ageism stagnates the cultural evolution of older adults and society itself (Kagan, 2016). The persistence of negative stereotypes about old age may undermine the aging process of individuals immersed in such beliefs—professionals and older people alike (Allen, 2016; Ferreira & Ruiz, 2012; Kagan, 2015).
The domains of cognition and agency were assessed more negatively at the private nursing home compared to the philanthropic nursing home at the pre-intervention and post-intervention evaluations. Such negative attitudes may have been influenced by greater contact with frail and dependent older adults (Rababa et al., 2020) at the private nursing home. Philanthropic long-stay institutions tend to prefer older adults with a more independent functional profile, who are less burdensome and require less care (Camargos, 2014). At the institutions that participated in the current study, it was observed that 90% of older adults at the private nursing home had dementia compared to 65.7% at the philanthropic nursing home. Considering the high prevalence of dementia in nursing home residents, the training program included this topic. However, the discussion focusing dementia as a health condition that can override the natural aging process was not enough to positively impact participants' beliefs and attitudes regarding old age. Dementia impacts the functional ability of older adults performing daily living activities and could increase caregiver burden (Razani et al., 2014). This finding is compatible with other studies that point out that negative attitudes toward older adults could be held for many reasons, including high comorbid burden (Rababa et al., 2020).
The current study has limitations that should be considered. The same researchers who conducted the evaluations were also the ones who performed the training. However, the absence of an effect on attitudes and beliefs may indicate that the influence of the evaluators on participant responses was not significant. Moreover, the study was conducted at only two institutions, one private and one philanthropic, and therefore had a small sample. Further studies should be developed to enable greater generalization of results.
The current study has important implications for individuals involved in the care of older adults. Access to scientific information on aging increases knowledge about aging, which can contribute to a positive change in the care provided to older adults. However, positive learning experiences may not be sufficient to change care professionals' attitudes toward older adults. In this way, longer training programs may be needed to promote changes in beliefs and attitudes. It is also necessary to promote lifelong education for all citizens.
There is a need for clear regulations regarding the minimum workload and the basic content to be addressed during the training of care professionals, as training programs do not have a standardized format in terms of scope, content, and workload. Training programs should emphasize content, with topics that go beyond biological aspects. Possibly, to improve the beliefs and attitudes toward older adults, it is important to include practical experiences (e.g., workshops), which allow individuals to deeply analyze the aging process and its specificities. Such changes in systems for training require a deep understanding of the social contexts in which they are implemented, as the social and attitudinal factors may affect the provision of care.
Nursing homes must perform continuing education activities in gerontology to improve the skills of employees involved in providing care to older adults. An in-service training program is feasible and constitutes an opportunity for staff at nursing homes to improve their clinical skills.
The proposed training program increased care staff knowledge regarding old age and proved to be feasible. However, it was unable to change beliefs and attitudes toward old age. A longer program addressing other topics and/or using other methods may be needed to modify beliefs. Future studies should investigate this issue. The positive results of the current study underscore the importance of the training and continuing education of individuals who work with older adults, especially formal caregivers at nursing homes.
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- Silva, F. P. (1999). Beliefs in relation to old age: Subjective well-being and reasons for attending university for the elderly [Master's dissertation]. State University of Campinas. http://repositorio.unicamp.br/jspui/handle/REPOSIP/251578
- Williams, L., Rycroft-Malone, J., Burton, C. R., Edwards, S., Fisher, D., Hall, B., McCormack, B., Nutley, S. M., Seddon, D. & Williams, R. (2016). Improving skills and care standards in the support workforce for older people: A realist synthesis of workforce development interventions. BMJ Open, 6, e011964 doi:10.1136/bmjopen-2016-011964 [CrossRef] PMID:27566640
- World Health Organization. (2015). World report on ageing and health. https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf;jsessionid=6786ED9E09CAFB352EBD4DD9A1D7B3AA?sequence=1
Principles for Training and Development of Skills Among Workers at Health Care and Social Services Institutions for Older Adults
|Principle||Application in Study|
|1. Making it real to the work of the support worker||Before beginning meetings, professionals involved in the training observed participants' actual work routine to ensure the intervention focused on their work (cognitive proximity)
On the job training
Case discussions, simulations, and sharing experiences|
|2. Where the support worker is coming from||Prior evaluation of participants regarding individual needs and expectations, profile, experience, and previous knowledge and values related to the profession|
|3. Tapping into support workers' motivations||Training carried out with a schedule that facilitated participation
Offer of snacks
One day off for workers completing training|
|4. Joining things up around workforce development||Initial contact with the management team of the institution to discuss the training proposal
Survey of difficulties in participants' work routine and suggestions for improvement for the service
Discussion with managers of the points raised by caregivers|
|5. Codesign||Design of the intervention considering the suggestions of participants
Choice of topics to be addressed in the training of participants based on the options defined previously by the panel of specialists
Topics of participants' interest were incorporated into the training|
|6. “Journeying together”||Training conducted in a group and opened to all employees at the institution; at some moments, residents were also invited to participate
Theoretical training material was prepared with the collaboration of a multi-professional team|
|7. Taking a planned approach in workforce development||Promoting empowerment and emancipatory practices, for example:
Listening to caregivers' experiences and stimulating the recognition of problem-solving skills within the reported experiences
Conducting activities to encourage greater confidence, empathy, self-esteem, and satisfaction with the work performed|
|8. Spreading the impacts of workforce development across organizations||Contact during the intervention was maintained to potentiate the incorporation of training elements in the accomplishment of the work
Follow up with caregivers and managers on the impact of training in work processes
Creation of booklets on the topics studied|
|Private NH (n = 23)||Philanthropic NH (n = 10)|
| Female||23 (100)||9 (90)|
| Male||0 (0)||1 (10)|
| Married||11 (48)||6 (60)|
| Single||8 (35)||2 (20)|
| Widowed/divorced||4 (17)||2 (20)|
| Less than high school||4 (17)||4 (40)|
| High school||19 (83)||6 (60)|
| 1 to 2 times monthly minimum wage||14 (61)||10 (100)|
| 2 to 3 times monthly minimum wage||9 (39)||0 (0)|
|Mean (SD) (Range)|
|Age (years)||45 (10.8) (21 to 59)||43.7 (6.3) (32 to 51)|
Knowledge and Beliefs About Aging by Domain Before and After Intervention
|Domain||Palmore-Neri-Cachioni Quiz||p Value|
|Private Nursing Home||Philanthropic Nursing Home|
|Before Intervention||After Intervention||Before Intervention||After Intervention|
|Correct Answers, %||Mean (SD)||Correct Answers, %||Mean (SD) (Range)||Correct Answers, %||Mean (SD)||Correct Answers, %||Mean (SD)|
|Physical||55.1||4.5 (2)||60.6||5.9 (1.2) (2 to 8)||46.7||4.6 (1.4)||63.3||5.9 (1.1)||0.04a0.9b0.89c|
|Cognitive||51.2||1.3 (1.1)||68.2||2.4 (0.7) (0 to 3)||51.1||1.4 (0.7)||65.6||1.9 (0.6)||0.01a0.49b0.3c|
|Psychological||30.9||2.7 (1.6)||47.5||4.4 (1.8) (1 to 7)||26.7||2.4 (1.2)||46.7||4.2 (0.9)||<0.001a0.54b0.93c|
|Social||33.3||3.2 (0.8)||41.9||4.2 (1.5) (0 to 7)||20||1.8 (1.2)||23.3||2.1 (0.3)||0.07a<0.001b0.21c|
|Total||37.4||10.1 (1.7)||49.7||14.6 (3.2) (7 to 20)||34.4||8.6 (1.8)||51.6||12.9 (1.4)||<0.001a0.05b0.89c|
|Cognition||3.6 (0.6) (2.8 to 5)||3.3 (0.6) (2.1 to 4.3)||2.9 (0.6) (2.1 to 3.8)||3 (0.4) (2.4 to 3.6)||0.63a <0.001b0.25c|
| Positive||31 (14.1)||56 (25.5)||40 (40)||32 (32)|
| Neutral||66 (30)||51 (23.1)||25 (25)||37 (37)|
| Negative||123 (55.9)||113 (51.4)||35 (35)||31 (31)|
|Agency||3.5 (0.6) (2.2 to 4.8)||3.4 (0.8) (1.8 to 5.0)||2.5 (0.4) (1.5 to 3)||2.8 (0.5) (2.3 to 3.8)||0.63a<0.001b0.34c|
| Positive||26 (19.7)||28 (21.4)d||31 (51.7)||24 (40)|
| Neutral||42 (31.8)||42 (32.1)||21 (35)||22 (36.7)|
| Negative||64 (48.5)||61 (46.5)||8 (13.3)||14 (23.3)|
|Social relationship||3.1 (0.5) (2 to 3.9)||3.1 (0.8) (1.9 to 5.0)||3.2 (0.3) (2.6 to 3.6)||3.1 (0.3) (2.3 to 3.6)||0.64a0.73b0.70c|
| Positive||41 (26.6)||51 (33.1)||19 (27.1)||16 (22.8)|
| Neutral||63 (40.9)||47 (30.5)||21 (30)||34 (48.6)|
| Negative||50 (32.5)||56 (36.4)||30 (42.9)||20 (28.6)|
|Persona||3.1 (0.7) (1.9 to 4.4)||3.2 (0.8) (1.7 to 5)||2.9 (0.3) (2.6 to 3.7)||3.1 (0.3) (2.7 to 3.7)||0.46a 0.43b0.65c|
| Positive||39 (25.3)||44 (29.7)e||23 (32.9)||18 (25.7)|
| Neutral||54 (35.1)||40 (27.1)||27 (38.6)||25 (35.7)|
| Negative||61 (39.6)||64 (43.2)||20 (28.5)||27 (38.6)|
Participant and Manager Satisfactiona With Training
|Evaluation Item||Mean (SD) (Range)|
|Private Nursing Home||Philanthropic Nursing Home|
|How much they enjoyed the training||10||9 (1.3) (7 to 10)|
|How tired they felt||0.2 (0.6) (0 to 2)||0|
|How much they learned from the course||9 (1.2) (7 to 10)||8.7 (1.6) (6 to 10)|
|How much do they remember/apply the knowledge acquired in the course||8.6 (1.2) (7 to 10)||9 (1.5) (7 to 10)|
|How much they changed their professional practice after the course||9.2 (0.7) (8 to 10)||8.2 (1.8) (5 to 10)|
|How much they would like to participate in other training||9.8 (0.6) (8 to 10)||9.7 (0.8) (8 to 10)|
|How much disorder did training bring to the routine of the institution||0.4 (0.9) (0 to 2)||0|
|How much improvement did they notice in the conduct of employees after the intervention||7.8 (0.4) (7 to 8)||5 (1) (4 to 6)|
|How much effort would be made to enable other training in the institution||8.6 (1.1) (7 to 10)||10|