Improving the competence and confidence of care staff

Training for care home staff in dementia care is patchy and sometimes poor, so academic experts tried out a new one-day course. Ana Barbosa, Clare Mason and Lindsey Collins report on the results, which showed that a co-designed face-to-face course can significantly improve staff’s sense of confidence and competence

Estimates suggest that approximately 40% of people with dementia live in care homes and that 70% of all residents have some form of dementia (Prince et al 2014). It was Tom Kitwood who highlighted just how important person-centred care is in this context, much of his work evidencing how staff interactions can either improve a resident’s quality of life or exacerbate disability (Kitwood & Brooker 2019).

Providing person-centred care requires a workforce who are competent and confident to interact with people in a way that improves their quality of life. For this reason, ensuring that care home staff receive appropriate dementia training has been a global concern.

Targets for training staff in dementia care are now included in national dementia plans across the world. In England, for example, the Prime Minister’s Challenge on Dementia 2020 (Department of Health 2015) advocated that all people living with dementia receive high-quality care and emphasised the need for staff training on dementia. As a result, a national framework setting out the expectations regarding content and learning outcomes for training courses was launched in 2015.

Yet, evidence has demonstrated that uptake and quality of dementia training is still low (Smith et al 2019). When training is available it tends to target specific groups, for example care assistants or nurses (Scerri & Scerri 2019; Zimmerman 2010) and its impact on staff outcomes is variable (Kuske et al 2007). While participants’ knowledge seems to consistently improve (Kuske et al 2007) there is still no clear evidence on the impact of training on staff levels of competence and confidence.

We wanted to build up the evidence base on the impact of training. Dementia specialist charity Methodist Homes (MHA) commissioned the development, implementation and evaluation of a foundation dementia care training course for all of their care home staff with the broad aim of increasing competence and confidence in providing person-centred dementia care. Here, we report on the implementation and findings from the evaluation undertaken by the authors.

Evaluation

Design and setting

This study employed a pre and post-test design. Measures were completed at baseline, which was immediately prior to commencing the training course, and repeated after completion of the training course. Both qualitative and quantitative data were collected.

The training course took place in nine MHA care homes situated in the north of England between October 2018 and March 2019. The capacity for these homes ranged from 47 to 91 beds and most had both residential and dementia care units.

Participants

Participants were a convenience sample recruited from the nine care homes. The aim was to target a cross section of roles within the care team; participants included care assistants, domestic staff, housekeeping staff, activity co-ordinators, chaplains and managers.

Each care home manager nominated potential participants, who were then invited to take part. A total of 148 care home staff completed the training and were involved in its evaluation. The majority of the participants were female (n=128) and care assistants (n=91) (see graph 1, left).

Training course

The design of the training was informed by the findings from the What Works project, a large research project focused on factors that affect dementia training (Surr et al 2017). Its findings suggest that the most effective dementia training is likely to be characterised by the following:
face to face, small group delivery using interactive methods, activities and discussion; focused rather than broad in content; tailored to the role and service setting of the staff attending; and supported by commitment from the top.
Experts by experience (ie, people living with dementia), family carers and professionals were also consulted about the training content, activities and material.

A one-day face-to-face training course was designed by Centre for Applied Dementia Studies training consultants. The aims of the training were to provide care staff with a foundational level of knowledge about dementia and person-centred care, and to help them feel more confident and competent about supporting people with dementia.

Topics covered included: person-centred dementia care and its importance; what dementia is and how it impacts upon individuals; differences between dementia, depression and delirium; the social and emotional needs of people with dementia and how to support these; positive and effective communication strategies when working with people with dementia and how to apply these in practice; and the impact of the physical environment on the individual. The training encompassed a variety of learning approaches, including case studies, group activities, individual activities, quizzes and scenarios.

Measurements

Two validated measures were used to assess sense of competence and confidence in dementia care:

• The Sense of Competence in Dementia Care Staff (SCIDS) (Schepers et al 2012) – a four-point Likert scale of 17 items. Scores range from “not at all” (1) to “very much” (4) and higher scores represent a higher sense of competence.

• The Confidence in Dementia Scale (CODE) (Elvish et al 2014) – a nine-item self-report questionnaire scored on a five-point Likert scale ranging from “not confident” (1) to “very ‰
‰confident” (5). Higher scores represent a higher level of confidence in working with people with dementia.

Scores from the SCIDS and CODE were compared across baseline and post-training using standard statistical tests. At the end of the training, participants were also asked to complete a feedback form with open questions regarding their opinion about the training. Responses were analysed by categorising comments into themes.

Results

Competence and confidence

While the baseline values were high, a significant improvement between baseline and post-training was reported for staff sense of competence and confidence (table 1, right).

All items in both scales significantly improved after training (graphs 2 and 3). The largest differences between baseline and post-training were observed for: “understand the way a person with dementia interacts with the people and things around them” (SCIDS, item 2), “offer stimulation to a person with dementia in my daily work” (SCIDS, item 15) and “I feel able to understand the needs of a person when they can communicate well verbally” (CODE, item 2).

A moderate, positive statistical correlation between confidence and competence was found, meaning that as the value of one variable goes up, the value of the other also tends to do so.

Qualitative data

The anonymous free-text comments in the feedback forms fell into three main categories: opinion about the training, key lessons learned, and impact on practice. Training was considered informative, enjoyable, and relevant to participants’ work. Staff who took part valued the learning activities throughout the course and mentioned how relevant the facilitator’s skills were to its success.

Comments included:

  • The training was delivered well and easy to understand. Good scenarios used. The trainer got everyone in the group involved. I enjoyed the whole course.

The fact that training sessions included a wide range of different staff was also considered a highlight of the course:

  • Allowed everyone to know a bit more about dementia.

In terms of key lessons learned, participants felt that the course had enhanced their understanding of dementia and of the person’s experience. In particular, the training allowed participants to become more aware of the importance that factors such as the history, health, and personality may have for the individuals’ wellbeing:

  • How important it is to get to know the person with dementia. Find out their history, what they like and do not like, to be able to meet their needs.

Some participants mentioned being more aware of the significance of person-centred care and of their own communication in fostering this approach:

  • I learned that person-centred care is not a task. It is an attitude; it’s an approach to people.

Several participants reported feeling more confident in working with people with dementia, which further supports the results obtained in the questionnaires.

A number of participants had reflected on ways to provide more sensitive and thoughtful care, indicating an impact on practice. They recognised that it was beneficial to invest time in getting to know residents, and commented that they would be more willing to engage with people with dementia and use a calmer approach:

  • I will try to put myself in their shoes, be more aware and observant and have a good approach.

Implications for practice

These results suggest that a co-designed, one-day face-to-face training course can significantly improve confidence and competence in dementia care. Our data further reinforce the value of providing all care home staff with dementia training and furnishes further evidence of the effectiveness of these courses on staff outcomes.

Both recent research and people affected by dementia gave us the insights we needed to set up the course. People with dementia and their carers provided unique and valuable experiential knowledge about living with the condition and offered different perspectives on the topic. Individuals’ involvement enabled them to have their voices heard and contribute to the development of relevant and meaningful training content and material.

Hearing the voice of people with dementia is an underlying principle of person-centred care. Where once it had to be argued whether the views of people with dementia had legitimacy, the practice of involving them in activities related to their experience is both encouraged (Gove et al 2018) and can have immensely beneficial consequences as our research has shown.

Future plans

A relatively large sample of care home staff – and different groups of staff – took part in our study. In future, we will aim to make comparisons between the different groups, which we did not do this time. Although our findings were positive and encouraging, it should not be expected that a one-day training course on its own will lead to long-term changes.

Other conditions will also have to be met, such as organisational change and leadership support. In future training courses we will collect follow-up data in order to understand changes over time and identify facilitators and barriers to change.

Finally, we will examine whether the training has an impact on people living with dementia and investigate the relationship between staff levels of confidence and competence to care, on the one hand, and residents’ experience on the other.

Points for practice
  • a one-day face-to-face training course for care home staff significantly improved confidence and competence in dementia care
  • training was delivered to small groups using interactive methods, activities and discussion
  • experts by experience, family carers and professionals were consulted on training content, activities and material
  • hearing the voice of people with dementia is an underlying principle of person-centred care.
Graph 1: Participants’ roles
Graph 2: SCIDS – item scores
Graph 3: CODE – item scores

References

Department of Health (2015). Prime Minister’s Challenge on Dementia 2020. London: Department of Health.

Elvish R, Burrow S, Cawley R, Harney K et al (2014) ‘Getting to Know Me’: the development and evaluation of a training programme for enhancing skills in the care of people with dementia in general hospital settings. Aging & Mental Health 18(4) 481-488.

Gove D, Diaz-Ponce A, Georges J, Moniz-Cook E et al (2018) Alzheimer Europe’s position on involving people with dementia in research through PPI (patient and public involvement). Aging & Mental Health 22(6) 723-729.

Kitwood TM, Brooker D (2019) Dementia reconsidered, revisited: the person still comes first. London: Open University Press.

Kuske B, Hanns S, Luck T, Angermeyer MC et al (2007) Nursing home staff training in dementia care: a systematic review of evaluated programs. International Psychogeriatrics 19(5) 818-841.

Prince M, Knapp M, Guerchet M, McCrone P et al (2014) Dementia UK (2nd edition): Overview. London: Alzheimer’s Society.

Scerri A, Scerri C (2019) Outcomes in knowledge, attitudes and confidence of nursing staff working in nursing and residential care homes following a dementia training programme. Aging and Mental Health 23(8) 919-928.

Schepers AK, Orrell M, Shanahan N, Spector A (2012) Sense of competence in dementia care staff (SCIDS) scale: development, reliability, and validity. International Psychogeriatrics 24(7) 1153-1162.

Smith SJ, Parveen S, Sass C, Drury M et al (2019) An audit of dementia education and training in UK health and social care: a comparison with ‰
‰national benchmark standards. BMC Health Service Research 19(1) 711.

Surr CA, Gates C, Irving D, Oyebode J et al (2017) Effective Dementia Education and Training for the Health and Social Care Workforce: A Systematic Review of the Literature. Educational Research Review 87(5) 966-1002.

Zimmerman S, Mitchell CM, Reed D, Preisser JS et al (2010) Outcomes of a dementia care training program for staff in nursing homes and residential care/assisted living settings. Alzheimer’s Care Today 11(2) 83-99.

Ana Barbosa is assistant professor in dementia studies, Clare Mason is dementia care trainer and experts by experience lead, and Lindsey Collins is senior dementia care consultant and trainer, all at the Centre for Applied Dementia Studies, University of Bradford