The U.S. population is aging. In 2014, 14.5% of the population was 65 years and older, and by 2040 this group will grow to 21.7% (U.S. Department of Health and Human Services, 2016). Aging causes increased risk of chronic conditions, including dementia. Almost six million Americans have Alzheimer's disease, the most common form (Alzheimer's Association, 2018). Because there is no cure and because the Baby Boomer generation is aging, the prevalence of Alzheimer's disease will increase.
Caring for people with dementia is complex. Nurses must understand underlying physiological changes and differentiate memory loss from other conditions such as depression and delirium. Dementia affects an individual's ability to think, communicate, focus, reason, and perform everyday activities (Alzheimer's Association, 2016). Most forms of dementia are progressive, and no two people are alike. Patients' behavior can change from hour to hour; therefore, nurses must understand how the disease might affect the individual and be prepared to provide patient-centered care.
The American Association of Colleges of Nursing (AACN, 2010) recommended 19 aging-specific objectives for baccalaureate nursing curricula. Outcomes include development of professional attitudes and values toward mental aging changes, recognition of complex patient presentations including mental conditions, related treatments, and the ability to plan care accordingly. The AACN Competencies were published in 2010; however, only approximately one third of nursing students reported self-efficacy for dementia care (Baillie, Merritt, Cox, & Crichton, 2015). Furthermore, nursing students reported barriers to dementia care employment, including working conditions, negative perceptions of the age-care culture, lack of task diversity and personal interest, physical and emotional demands, communication challenges, fear for personal safety, and previous or lack of experience (McKenzie & Brown, 2014). The aim of this research was to learn whether receiving the Dementia Care Bootcamp plus a dementia-specific clinical experience had a greater influence on baccalaureate nursing students' attitudes toward dementia, empathy, dementia knowledge, and confidence for dementia care, compared with students who received only the Dementia Care Bootcamp.
CINAHL® and PubMed® were searched using the following terms: dementia, Alzheimer's disease, memory loss, nursing students, attitudes, knowledge, confidence, self-efficacy, empathy, and nursing education. Searches were limited to the past 5 years and English language. Reference lists were reviewed for additional evidence pertinent to nursing education and memory loss. Theories that served as the foundation for intervention studies included Knowles's principles of andragogy (Knowles, 1984), Kolb's experiential learning theory (Kolb, 1984), Mezirow's transformation theory (Mezirow, 2000), and social cognitive theory (Bandura, 1977). The most frequently measured outcomes included attitudes toward people with dementia, dementia knowledge, and self-efficacy for dementia care; tools used were inconsistent across studies and several authors created instruments to assess outcomes. Evidence representing dementia education among diverse health professional disciplines is included in the following review. Note, we recognize the need for consistent terminology and therefore use dementia to refer to a general loss of cognitive function that interferes with memory and daily life. In some cases, Alzheimer's disease is used when reporting diagnosis-specific evidence or measures.
Effect of Dementia Learning Activities
The impact of diverse learning activities on health care students' attitudes toward people with dementia was examined. Nursing students who had dementia-specific clinical experiences reported significantly improved attitudes toward people with dementia, compared with students who completed an online module or received no dementia-specific content (Kimzey, Mastel-Smith, & Alfred, 2016). Nursing students who cared for a standardized patient with memory loss reported better attitudes toward people with dementia compared with those who cared for patients with no cognitive impairment (Maharaj, 2017). A simulation which mimicked cognitive impairment (De Abreu, Hinojosa-Lindsey, & Asghar-Ali, 2017); lecture plus clinical experience (McCaffrey, Tappen, Lichtstein, & Friedland, 2013); TimeSlips, a creative storytelling program (George, Stuckey, & Whitehead, 2014); and a poetry workshop including collaborative poetry writing with people with dementia (Garrie, Goel, & Forsberg, 2016) had a positive and significant effect on students' dementia attitudes. Contrary to these findings, participation in a dementia care workshop plus interviews with people with dementia and family caregivers did not significantly affect students' attitudes (Choi & Park, 2017).
Intervention effects on dementia knowledge were similarly encouraging. Caring for standardized patients (Maharaj, 2017) and clinical experiences (Eccleston et al., 2015; Kimzey et al., 2016; Lea et al., 2015) significantly increased dementia knowledge. Dementia knowledge improved after combined learning activities such as lecture, simulation, and clinical experiences (Lorio, Gore, Warthen, Housley, & Burgess, 2017; Wood, Alushi, & Hammond, 2016), as did an online course (Cobbett et al., 2016).
Studies that examined the effects of learning activities on students' empathy for people with dementia were lacking. Empathy was measured using two Likert scale questions before and after participating in the Virtual Dementia Tour® (VDT), a simulation activity in which students are garbed and instructed to perform activities of daily living, as well as assigned reflection papers (Donahoe, Moon, & VanCleave, 2014). Quantitative and qualitative findings suggested that empathy improved after the simulation. Evidence of empathy was also noted in students' narratives after participating in an online dementia course (Cobbett et al., 2016).
Students' confidence in dementia care improved after various learning opportunities. Workshops (Cockbain, Thompson, Salisbury, Mitter, & Martos, 2015), combined experiences (Lorio et al., 2017; Wood et al., 2016), and sharing an activity with nursing home residents with dementia (Jordan & Church, 2013) significantly improved students' confidence to care for people with dementia.
Virtual Dementia Tour
The VDT was developed to provide greater understanding of what it is like to experience memory loss and ultimately to improve care for people with dementia (Second Wind Dreams, 2018). The simulation uses sensory tools, trained facilitators that guide participants, and debriefing. Evidence suggested that the VDT had positive effects and no effect on students' emotional responses to people with dementia or dementia knowledge. Physical therapy doctoral students who received dementia-specific lecture, video, clinical experiences, and participated in the VDT and a book club had significantly improved attitudes toward people with dementia and knowledge in two areas assessed (Lorio et al., 2017). Health professional students' sensitivity toward and empathy for people with dementia significantly improved after participating in the VDT; they also reported a better understanding of patients' emotional needs (Donahoe et al., 2014). On the other hand, the VDT had no effect on students' interactions with people with dementia or recognition of personhood (Brown, Banks, Henderson, Mclachlan, & Sharp, 2014).
Several dementia-specific educational needs were identified. Some nursing students did not understand causes, prevention, or treatment of dementia (Shin, Seo, Kim, Kim, & Lee, 2015), whereas others demonstrated basic understanding (Kimzey et al., 2016). Reasons for dementia-compromised behavior (Morris, 2014), how to respond when behaviors manifested (Baillie, Cox, & Merritt, 2012; Scerri & Scerri, 2012), and more opportunities to interact with people with dementia and debriefing during clinical postconference were perceived to be beneficial (Kimzey et al., 2016). How to provide patient-centered care, how to involve patients in treatment plans (Scerri & Scerri, 2012), and communication skills (McKenzie & Brown, 2014) were other recognized deficits. Recommendations included supportive clinical placements, mentors prepared to supervise students (Chenoweth, Jeon, Merlyn, & Brodaty, 2009), and scaffolding learning opportunities (Watts & Davies, 2014). Caring for people with dementia must be a priority in undergraduate nursing education and addressed early in the curriculum (Baillie et al., 2012). Learning opportunities in a safe environment prior to clinical experiences (Alushi, Hammond, & Wood, 2015), required clinical placements (Alushi et al., 2015; Chenoweth et al., 2009), and innovative learning methods (Lorio et al., 2017; Watts & Davies, 2014) should be provided.
Although several educational methods were used in an effort to positively impact students' ability to care for increasing numbers of people with dementia, no method consistently demonstrated a significant effect on various outcomes measured. Research recommendations included development and use of standardized instruments (Brown et al., 2014), replication (Donahoe et al., 2014), larger samples, and diverse learning methods (Lorio et al., 2017). The purpose of this study was to examine the effect of dementia-specific learning activities on nursing students' attitudes toward dementia, empathy, dementia knowledge, and confidence for dementia care.
Social cognitive theory (SCT; Bandura, 1977) served as the foundation for this study. SCT suggests that learning can be achieved through observing others within the context of social interactions, experiences, and other influences. Theoretical constructs pertinent to this study include self-efficacy and those that promote self-efficacy—specifically, mastery experience, social modeling, verbal persuasion, vicarious experiences, and behavioral capability. Table 1 presents the theoretical constructs, definitions, variables, and measures.
Theoretical Constructs, Definitions, Variables, and Measures
A quasi-experimental pretest–posttest design was used to examine the impact of the Dementia Care Bootcamp and clinical experience on nursing students' attitudes toward dementia, dementia knowledge, self-confidence for dementia care, and empathy, compared with students who received only the Dementia Care Bootcamp.
Research questions included:
- Is there a significant difference before and after dementia-specific learning activities in nursing students' dementia attitudes, knowledge, self-confidence for dementia care, and empathy?
- Is there a significant difference in dementia knowledge, attitudes, self-confidence for dementia care, and empathy between nursing students who receive the Dementia Care Bootcamp plus dementia clinical experience and those who receive only the Bootcamp?
A total of 100 undergraduate nursing students enrolled in the course NURS3513, Psychiatric Mental Health Nursing, during the spring of 2018 participated in this study. Based on an a priori power analysis and findings from Elvish et al. (2014), this sample provided sufficient statistical power at .8, using a significance of .05, and reported effect sizes of r = −0.56 for confidence in dementia care (large effect) and r = −0.44 for dementia knowledge (medium to large effect).
The study was set in the southern United States. Due to the large class size, two Bootcamps were delivered each to half of the class. The first Bootcamp was held at a dementia day center. Because parking was limited at the day center, the second Boot-camp was moved to an on-campus location.
Ethical Considerations, Recruitment and Data Collection
The study was approved by the university's Institutional Review Board. To reduce potential bias, the purpose of the study was explained and informed consent was acquired at the time the postquestionnaire data were collected.
The 10-hour Dementia Care Bootcamp counted toward clinical requirements. Half of the students were assigned by clinical group to receive a 1-day clinical experience at a dementia day center offered by a local nongovernmental organization. The other half of the class had no dementia-specific clinical experiences. Prior to Bootcamp, students were sent reading materials and a link to questionnaires via the course learning management system. During Bootcamp, students were assigned to a team and worked in groups to analyze case studies, take quizzes, and participate in experiential exercises. Bootcamp topics included dementia basics, the need-driven dementia compromised behavior model, how to respond to behaviors, communication challenges, how to promote successful interactions, safety, and wandering. Videos provided additional opportunities for students to observe appropriate responses to need-driven behaviors and communication competencies. Family caregivers shared their experiences of caring for a person with dementia and a social worker presented information on community resources. Students participated in the VDT.
Following the Bootcamp, half the class, based on nonrandomized clinical group assignment, interacted with people with dementia at the dementia day center and turned in a journal summarizing communication techniques used and the effects on interactions. During the clinical experience, students were assigned a person with dementia and helped facilitate planned activities such as reminiscence, a craft activity, and exercise. After the Bootcamp, students were sent a link to the follow-up survey and offered a chance to win one of five $20 gift cards.
Students responded to demographic questions including age, gender, race, and dementia-specific questions focused on the frequency with which they encountered people with dementia. On the Dementia Knowledge Assessment Tool Version 2 (Toye et al., 2014), students answered 21 questions that assess dementia knowledge and dementia care. Response options are yes (score = 1), no (score = 0), and don't know (score = 0), for a range of 0 to 21. Of the 21 statements, 13 are correct and eight are incorrect. The Cronbach's alpha is .79.
On the Dementia Attitudes Scale (O'Connor & McFadden, 2010), students answer twenty 7-point Likert scale questions about general perceptions of people with dementia and feelings toward this population. Responses are totaled; possible scores range from 20 to 140. Higher scores indicate more positive attitudes. The total-scale Cronbach's alphas ranged from .83 to .85.
On the Interpersonal Reactivity Index (IRI; Davis, 1983), students respond to twenty-eight 5-point Likert scale questions. Seven questions comprise each of four subscales: (a) perspective taking or assuming another person's point of view; (b) fantasy or the tendency to feel and act like movie or book characters; (c) empathetic concern, feelings toward other people less fortunate; and (d) personal distress, anxiety, and discomfort in tense situations. Answers are scored 0 = does not describe me well to 4 = describes me very well, for a range of 0 to 28 for each subscale. The Cronbach's alpha of the subscales ranged .71 to .77.
On the Confidence in Dementia Scale (Elvish et al., 2014), students answer nine 5-point Likert scale questions about their confidence in working with people with dementia. The range of scores is 9 to 45; higher scores imply higher confidence in working with people with dementia. Cronbach's alpha is .91.
Data were exported as SPSS® data files from Qualtrics® and screened. Duplicate responses were dropped. The gross number for pretest and posttest responses were 108 and 103, respectively, and decreased to 100 and 87, with duplicates removed. The pre- and posttest data were then matched and merged based on the independent variable created for further analyses. Before proceeding to the main analysis, question responses were reversely coded and scale scores calculated for the Knowledge, Attitudes, and Confidence scales based on the instrument scoring. Subscale scores were calculated instead of a total score for the Empathy (IRI) measure according to Davis (1983).
Internal consistency coefficients were calculated for each scale and the IRI subscales followed by normality examination. Mixed-designs ANOVA were then conducted to investigate the effect of a Dementia Care Bootcamp and clinical experience on students' dementia attitudes and knowledge, self-confidence for dementia care, and empathy (IRI). Pearson's correlation coefficients were also computed to assess the relationships between the outcomes of interest.
The majority of the students were female (n = 83, 81.4%), White (n = 78, 76.5%), and non-Hispanic (n = 83, 81.4%). At the start of the study, one third of the students had family members with dementia (n = 34, 34.3%). Most students had not served as a caregiver for people with dementia (n = 90, 88.2%) or had attended a support group or educational program (n = 97, 95.1%). However, 38 (37.3%) of the students had job or volunteer responsibilities in which they interacted with people with dementia.
The results showed above satisfactory internal consistency reliability for all scales, including the IRI subscales used in this study. All Cronbach's alphas were above .70, ranging from .72 to .95 (Table 2). The normality tests, together with the distribution statistics and graphics, demonstrated normality for all measures except the pre-tests of self-confidence and IRI-emphatic concern and the posttest of knowledge. A closer look at the distribution of these three measures showed similar patterns of increase in student response scores. In addition, no difference was found at baseline in knowledge, attitudes, self-confidence, and empathy between the gender, ethnicity, and intervention groups.
Pretest and Posttest Instrument Internal Consistency (Cronbach's Alphas) for the Sample in This Study
The mixed-designs ANOVA results showed medium to large significant within-subjects main effects in knowledge, F(1, 79) = 8.90, p < .001, partial η2 = .22, power = .996; attitudes, F(1, 77) = 10.82, p = .002, partial η2 = .12, power = .90; and self-confidence, F(1, 71) = 6.01, p = .017, partial η2 = .08, power = .68 (Figure 1). A pattern of increase was observed based on the estimated marginal means (Table 3). No significant difference was found between student pre- and posttest scores for any of the IRI subscales. Nor were significant between-subjects effect or interaction effect found in any of the outcomes.
The within and between effect of the Dementia Care Bootcamp and clinical experience on knowledge, attitude, and self-confidence.
Estimated Marginal Means for the Significant Within-Subjects Effects
The purpose of this theory-based study was to examine the effect of dementia education on nursing students' attitudes toward dementia, dementia knowledge, empathy, and confidence for dementia care. Hypothesis 1 was partially supported—that is, the Dementia Care Bootcamp significantly improved students' attitudes toward dementia, dementia knowledge, and self-confidence for dementia care with medium to large effects. These findings are consistent with previous research that indicated improved attitudes (De Abreu et al., 2017; Garrie et al., 2016; George et al., 2014; Kimzey et al., 2016; Maharaj, 2017; McCaffrey et al., 2013), knowledge (Cobbett et al., 2016; Eccleston et al., 2015; Kimzey et al., 2016; Lea et al., 2015; Lorio et al., 2107; Maharaj, 2017; Wood et al., 2016), and self-confidence for dementia care (Cockbain et al., 2015; Jordan & Church, 2013; Lorio et al., 2017; Wood et al., 2016) following education. Prior research (Cobbett et al., 2016; Donahoe et al., 2014) suggested that empathy improved after dementia education; however, our results do not support these findings. According to social cognitive theory, learning occurs when students' anxiety is low (Bandura, 1977). The primary student learning outcome for the VDT simulation is for students to experience what it is like to have dementia and thus gain empathy for those with the disease. During debriefing after the simulation, it was evident that the experience caused anxiety and stress, which might have had a negative impact on empathy scores. In addition, the IRI does not measure empathy for a particular group. It is possible that using a tool such as the Kiersma-Chen Empathy Scale (Kiersma, Chen, Yehle, & Plake, 2013), which can be tailored to specific populations, will provide a better assessment of students' empathy for people with dementia.
Hypothesis 2—students who experience the Dementia Care Bootcamp plus clinical experience and journal entry will report significantly improved dementia attitudes and knowledge, empathy, and self-confidence for dementia care, compared with students who receive the Bootcamp only—was not supported. This is in contrast to findings of Kimzey et al. (2016), who reported that students who had 12 clinical hours plus debriefing reported significantly improved dementia attitudes compared with those who completed an online module or had no dementia-specific clinical.
Interacting with people with dementia for 1 day was insufficient to affect outcomes, and several explanations exist for this. Wood et al. (2016) examined the effect of an educational program on students' dementia knowledge and confidence for dementia care. Outcomes were measured before (Time 1) and after the educational program (Time 2), after a 12-hour clinical experience (Time 3) and 6 months after baseline (Time 4). Dementia knowledge significantly increased between Times 1 and 2, did not significantly change between Times 2 and 3 or Times 3 and 4; however, knowledge was significantly improved at 6 months compared with baseline. Confidence significantly improved from baseline to Time 2 and between Times 2 and 3. There was no significant change in confidence between Times 3 and 4; however, confidence was significantly improved between baseline and 6 months. These findings suggest that knowledge does not improve with clinical experience; greater experience has a positive impact on dementia care confidence and highlights the need for both theory and practice.
Other factors might have prevented improved dementia care outcomes among students who had dementia clinical experience, compared with those who did not. Access to and review of participant narratives before the clinical experience might help students initiate conversations and facilitate and promote positive interactions. It is possible that students were assigned participants who were uncommunicative, making it difficult for them to practice competencies. Nursing students who had a 3-week clinical experience at an aged-care facility with trained mentors reported improved dementia knowledge and attitude and perceived a sense of staff support (Lea et al., 2015). Role modeling for our students in the clinical setting is unknown and might have been inconsistent. Students who attended dementia clinical did not participate in clinical postconference that provides time for debriefing, discussion, and development of critical thinking; lack of debriefing might have affected dementia care outcomes. As Benner (1982) suggested, direct experience, in this case experience with people with dementia, combined with theoretical knowledge is needed. Experience will help students perceive people with dementia holistically and achieve competency.
Theoretical preparation prior to clinical placements is necessary to promote self-confidence for dementia care (Alushi et al., 2015; Baillie et al., 2015). Knowledge regarding how to interact with people with dementia might not immediately translate to practice. Interactions over time are necessary to practice dementia care competencies and thus develop confidence. More emphasis during the Bootcamp should be dedicated to mastery experience—for example, role-playing communication skills including use of open-ended questions, positive statements, and what to do if the people with dementia does not respond. Students should have opportunities to practice assessment of activity participation, what step in an activity people with dementia are unable to perform, and how to intervene, such as offering verbal cues, demonstration, or guided assistance.
Findings should be considered in light of strengths and limitations. The setting was one state university in the southern United States. Clinical experiences were based on group, not random assignment. Strengths of the research include use of a theory-based intervention, sufficient sample size, and reliable instruments.
As the population ages, dementia prevalence will increase and there is no cure. Caring for people with dementia requires specialized competencies with which nursing students must be equipped. The Dementia Care Bootcamp significantly improved students' dementia knowledge, attitudes, and self-confidence but not their empathy; however, one clinical experience did not improve outcomes beyond theoretical knowledge. Future research should determine the required length of clinical experiences needed to effectively affect outcomes beyond what the classroom provides. In addition, students' application of skills in the clinical setting should be evaluated to learn if knowledge translates to demonstrated competencies. Nurses are the primary providers responsible for care of people with dementia in acute and residential settings. It is imperative that they are prepared to adapt caregiving practices to the special needs of this population.
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Theoretical Constructs, Definitions, Variables, and Measures
|Theoretical Construct||Theoretical Definition||Variable||Measure|
|Mastery experience||Achievement of simple tasks that lead to more complex outcomes||IV: learning will be scaffolded so that students can master basic information and build to more complex thinking and skills||NA|
|Social modeling/vicarious experience||Performance and observation of the behavior to demonstrate processes required to accomplish the action||IV: videos demonstrated experts interacting with people with dementia in ways that promote positive outcomes||NA|
|Verbal persuasion||Encouragement provided in order to complete a task||IV: instructors encouraged student learning through positive and supportive feedback||NA|
|Behavioral capability||Knowledge and skill required to perform a given behavior||IV: learning activities provided knowledge and skills required to promote self-confidence for dementia care||NA|
|Education||The process of giving instruction||IV: a 10-hour Dementia Care Bootcamp||NA|
|Empathy||“A cognitive attribute that involves an understanding of patients' experiences combined with a capacity to communicate this understanding and an intention to provide help to the patient” (Fields et al., 2004)||DV: empathy||Interpersonal Reactivity Index (Davis, 1983)|
|Attitudes||A disposition to respond with some degree of favorableness or unfavorableness to a psychological object (Fishbein & Ajzen, 1975)||DV: attitudes about dementia||Dementia Attitudes Scale (O'Connor & McFadden, 2010)|
|Knowledge||The capacity to attribute meaning to various sensory perceptions, corporeal sensations or vague impressions (Benner, Tanner, & Chesla, 2009)||DV: dementia knowledge||Dementia Knowledge Assessment Tool V2 (Toye et al., 2013)|
|Self-confidence||One's self-worth and probability of being successful (Neill, 2005)||DV: self-confidence for dementia care||CODE (Elvish et al., 2014)|
Pretest and Posttest Instrument Internal Consistency (Cronbach's Alphas) for the Sample in This Study
Estimated Marginal Means for the Significant Within-Subjects Effects