Efficacy of the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification for Hospital Staff

Abstract

The main objective of the current study was to ascertain the efficacy of a newly developed online, video-based dementia training and certification program for hospital staff, the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program. A parallel randomized waitlist control design was utilized. Participants (N=272) completed online pre-evaluation measures. Forty-five days after completion of CARES® (treatment) or pre-evaluation measures (control), participants completed a post-evaluation online assessment. Analyses of variance found that participants in the treatment condition indicated greater and statistically significant (p < .001) increases in sense of competence, approaches to dementia, and patient care. The results implied that the CARES® Dementia 5-Step Method for Hospitals™ program could serve as a dynamic resource for hospitals nationwide to update training and share experiences, perspectives, and resources. The inherent scalability of the program regarding its acceptability, feasibility, and potential to incorporate seamlessly into routine workflows and staff training suggests high implementation potential.

Introduction

The hospital setting is both a common and a potentially problematic setting of care for people living with dementia (PLWD). More than twice as many Medicare beneficiaries with dementia are admitted to hospitals for care than those without dementia.^1–3 People living with dementia experience more extended hospital stays than age-matched counterparts without dementia, have a 7% greater risk of dying during hospitalization, are more likely to be institutionalized upon discharge, account for greater costs, and experience a range of other adverse conditions (e.g., falls, incontinence, pain, agitation/behavioral challenges) more frequently than people without dementia.^1,4–8 Among Medicare beneficiaries living with dementia, approximately one in five are readmitted within 30 days of discharge.^1,9,10 Hospitalization itself is associated with an elevated risk of incident dementia for older people.^1,11–13 Nearly half of hospitalized older adults with dementia have co-occurring delirium, for whom there are more extended hospital stays, more negative cognitive and functional outcomes, and a greater risk for institutionalization nd mortality than for older adults with dementia without delirium.¹⁴ As the number of PLWD who undergo hospitalization rises,¹⁵ dementia care training programs to improve hospital staff competence and implement person-centered care principles are becoming increasingly essential. Training programs for nursing assistants and allied health workers (NA/AHWs) are particularly needed, as these individuals provide most of the frontline care to PLWD in hospital settings.

Dementia-specific training programs for hospital staff are rarely provided, as they are challenging to implement and disseminate due to insufficient resources and the cost and time required to deliver them. Moreover, existing training programs have demonstrated mixed efficacy.^2,3 The main objective of the current study was to ascertain the efficacy of a newly developed online, video-based dementia training and certification program for hospital staff, the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program. The 5-step CARES® Approach is an easy-to-learn and easy-to-remember acronym to improve person-centered care for PLWD (C-Connect with the Person; A-Assess Behavior; R-Respond Appropriately; E-Evaluate What Works; and S-Share with Others). Caring for PLWD from a person-centered perspective involves understanding individuals’ unique needs, preferences, abilities, and goals and recognizing the crucial role of caregivers and families. This approach encourages healthcare professionals, patients, and their families to improve communication and make decisions together.^16,17

Background and Research Focus

Literature reviews suggest that paid and unpaid hospital staff face many challenges when providing care and support to hospitalized PLWD, but they also value person-centered care and indicate a willingness to deliver such care if trained to do so.²¹⁸ Staff training to improve dementia care competence, staff knowledge, and person-centered care principles has demonstrated benefits for hospitalized PLWD,2,19–24. However, adoption and sustainability are persistent issues as many training approaches rely on time-consuming, costly, in-person modalities. A comprehensive, easy-to-access training program geared toward these healthcare workers who care for PLWD in hospitals is critical, as such approaches may reduce administrative burden and serve as cost-effective.²³

The CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program is unique because it is tailored specifically for nursing assistants and other allied health workers such as dietary, housekeeping, transportation, unit secretaries, and X-ray technicians (NA/AHWs). The CARES® program utilizes a web-based platform to provide “real life” (i.e., no actors) videos of scenarios, dementia education, and interactive training exercises that are readily available nationally. The program aims to focus specifically on the needs and preferences of PLWD, with the goals of facilitating a positive impact on the caregiver’s sense of competence, positive approaches to dementia, job satisfaction, communication, and increased person-centered, quality patient care. Although not evaluated in the current study, the program has an ultimate focus on helping reduce adverse events such as delirium, falls, wandering, decreased food and fluid intake, agitation and dementia-related behavior, and the functional decline of the people living with ADRD.

CARES® is potentially cost-effective and can be provided uniformly to NA/AHWs to improve the quality of care during interactions with dementia patients. This approach is uniquely and especially well-suited to an acute-care hospital setting in which patients with dementia are in stressful and unfamiliar environments for a short amount of time, limiting the relationships that can be established, which can elicit fear and exacerbate symptoms. Training NA/AHWs to provide person-centered care even in a short period can also help increase their sense of competence and decrease stress and burnout, positively impacting the worker and the acute-care facility.

A pilot test of the first four modules of the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program³ with NA/AHWs suggested its potential feasibility, acceptability, and perceived utility.³ In addition, the effects of CARES® were evaluated in a separate, multi-year, nonrandomized implementation study in five hospitals in the Southeast with positive changes in staff ratings and a decrease in the average number of stays per patient (under review). While the number of online training programs to enhance the dementia capability of care staff is increasing, few have been studied with rigorously controlled designs to determine efficacy.²⁴ The current study aimed to fill this gap in the literature.

The primary objective of the current trial was to determine the efficacy of the CARES® program in improving healthcare professionals’ sense of competence, positive approaches to dementia, job satisfaction, communication, and perceptions of person-centered, quality patient care. Conceptually, these outcomes are potential mechanisms that could then influence quality of care and patient health outcomes. The scope and resources available to evaluate this iteration of the CARES® program necessitated a focus on mechanisms (or intermediary outcomes) that would eventually result in the desirable, longer-term outcomes of quality of care and the health outcomes of patients themselves. For these reasons, we hypothesized that NA/AHWs who received the CARES® program would report statistically significantly (p < .05) improved sense of competence, positive approaches to dementia, job satisfaction, communication, and perceptions of person-centered, quality patient care when compared to a control group of NA/AHWs who did not view the interactive online modules.

Materials and Methods

This randomized controlled trial adhered to CONSORT reporting guidelines.

Trial Registration and Regulatory Approval

This trial is registered at ClinicalTrials.gov (NCT04182282). The NYU Langone Health Institutional Review Board (S13–00815) approved the study for human subjects review.

Design

A parallel randomized waitlist control design was utilized to evaluate the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program for NA/AHWs. One-to-one random assignment and collection of survey data from participants was completed using an online software platform from Qualtrics, a data analytics firm. Participants were randomly assigned to the training intervention or the wait list control. All participants completed IRB-approved pre-evaluation measures using the Qualtrics online survey tool. Demographic information was collected by Qualtrics and via an IRB-approved online Survey Monkey form. Forty-five days after completion of CARES® (treatment) or pre-evaluation measures (control), participants received a link to the post-evaluation online assessment. Once the post-evaluation assessment was completed, participants were paid a $60 incentive if they completed the post-evaluation assessment. Participants in the intervention condition who did not complete the online training did not receive a link to the post-evaluation measures and were not paid a $60 incentive. Participants in the control condition who did not complete the post-evaluation measures were not paid a $60 incentive. Participants in the control condition received no-cost access to the online training once the study was completed.

Participants

Initially, the trial aimed to enroll 12 hospitals and 300 NA/AHWs in the wait-list randomized controlled protocol. Site recruitment began in late 2018 and continued through the spring of 2020. However, COVID and other difficulties prevented an adequate number of hospitals from participating. In August of 2019, to identify a sufficient sample, recruitment shifted from a hospital-based strategy to an individual/staff-focused strategy across the U.S. Specifically, the research team contracted with Qualtrics, a data analytics firm, and their partner marketing company to identify hospital workers around the country and share information about participation in the study. Two hospitals from a Midwestern state that withdrew during COVID eventually rejoined the study, were of similar size and makeup, and were randomly assigned to intervention and control at the site level. All participants met the following criteria: (a) were employed in a hospital setting at the time of the study; (b) were employed as a nursing assistant or other allied health worker (e.g., dietary staff, housekeeping staff, transportation staff, unit secretaries, or lab/X-ray technician); (c) had access to a computer, laptop, iPad/tablet, or smartphone with access to the Internet; and (d) were comfortable reading and speaking in English.

Interventions: CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program

The online training consists of four courses: 1) Basics of Dementia-Friendly Care; 2) Communication and Behavior; 3) Patient Safety and Comfort; and 4) Personal Care Practices. Within each course are four modules, each taking 10–20 minutes to complete. Table 1 outlines the content of each module; a screenshot of the main menu is provided in the online supplemental material. According to the National Institutes of Health,²⁵ 22.4% of healthcare support workers were immigrants in 2018. To address lower English literacy and comprehension levels of some NA/AHWs, the training was designed at the 6^th to 8th-grade reading level, is audio narrated, contains approximately 50% of all content delivered via “real life” videos (i.e., no actors), and is designed with video closed captioning so that NA/AHWs may follow along while watching video vignettes and instruction.

Table 1.

CARES® Dementia 5-Step Method for Hospitals™ Module Content

Course 1: Basics of Dementia-Friendly Care
	Module	Topics
1	Introduction to Dementia-Friendly Care	• Dementia in Hospitals • How Can You Recognize Dementia? • Alzheimer’s Affects Each Person Differently • Importance of Dementia-Friendly Care
2	Communication and the CARES® Approach	• A Positive Start • The Cares® Approach • The Family
3	Behavior as Communication	• How Does Dementia Affect Communication? • Common Communication Problems • Understanding Behavior as Communication
4	Delirium and Other Adverse Events	• Delirium • Decreasing the Risk of Delirium • Other Adverse Events
Course 2: Communication and Behavior
	Module	Topics
5	Understanding the Patient with Dementia	• Dementia and the Brain • The Hospital Experience • Adjusting Your Care
6	Dementia-Related Behavior	• What Is Dementia-Related Behavior? • Triggers of Dementia-Related Behavior • Responding to Dementia-Related Behavior
7	The CARES® Approach Explained	• Overview of the CARES® Approach • The CARES Approach—Step by Step • Applying the CARES Approach
8	Partnering With Families	• The Family’s Perspective • Learning from the Family • Involving the Family in Care
Course 3: Patient Safety and Comfort
	Module	Topics
9	Recognizing and Managing Pain	• Pain in Patients with Dementia • Recognizing Pain • Managing Pain
10	Maintaining Patient Safety	• Dementia and Patient Safety • Reducing Risks • Elder Abuse
11	Wandering and Falls	• Wandering • Falls • Physical Restraints
12	Mobility, Positioning, and Transfer	• Mobility • Positioning • Transfer
Course 4: Personal Care Practices
	Module	Topics
13	Maintaining the Patient’s Abilities	• Understanding Functional Decline • Helping the Patient Maintain Abilities • Applying the CARES® Approach
14	Eating and Drinking	• How Dementia Affects Eating and Drinking • Helping the Patient Eat and Drink • Mealtime Safety • Applying the CARES® Approach
15	Maintaining Continence	• How Dementia Affects Continence • Helping the Patient Use the Toilet • Applying the CARES® Approach
16	Bathing and Hygiene	• How Dementia Affects Bathing • Helping with Bathing and Hygiene • Applying the CARES® Approach

The training was developed through consultation and collaboration with a national team of subject matter experts to focus on strategies for improved dementia care and reduced costly adverse events. Six hospitals served as filming sites for video content. The hospitals included a diverse range of settings, from small, critical-access hospitals to hospitals in mid-sized cities to large urban settings. Hospitals were also geographically and regionally diverse, with locations in the Northeast, Southeast, South, Midwest, and West. This provided opportunities to film actual patients, families, staff, and patient care scenarios in various settings aligned with the course topics and objectives. With hours of actual video footage and by filming “live” care (i.e., no actors), this provides for rich, high-fidelity scenarios, both with and without the hallmark CARES® Dementia 5-Step method of care. All participants in the video footage and/or their families provided consent.

The asynchronous format provides standardized training for NA/AHWs—including night, weekend, and part-time—and not just day-time staff. The online training can be completed from any computer, tablet, mobile device, or community-based computer access point, such as a public library. Participants were allowed to access the program from work, home, or other community locations and could quickly resume training where they left off. Participants assigned to the intervention group received access to the online training immediately after completing the pre-evaluation measures. They were asked to complete the eight-hour online CARES® Dementia 5-StepMethod for Hospitals™ Online Training and Certification Program within two weeks of enrollment. In efforts to ensure knowledge by participants to further improve care for PLWD, a required certification exam was created and implemented alongside the online training program (30 questions, 6^th to 8th-grade reading level, and an 80% pass rate, consistent with most professional continuing education standards, unlimited attempts to achieve the 80% pass rate).

Measures

Measures were administered immediately after enrollment in the study (i.e., pre-evaluation measures) and again 45 days after completion of the training (i.e., post-evaluation measures). For each measure, a scale score was calculated by computing the mean of the items. Descriptive information for each measure is presented in Table 2. Reliability information is presented below; for information about the validity of the measures, readers are encouraged to review source references.

Table 2.

Means and Standard Deviations, Study Variables

	Pre-evaluation		Post-evaluation
Variable	M	SD	M	SD
Sense of Competence	2.89	0.55	3.23	0.54
Approaches to Dementia	3.81	0.34	3.95	0.40
Job Satisfaction	3.66	0.76	3.80	0.67
Patient Care	3.72	0.62	4.10	0.59
Communication	4.00	0.55	4.20	0.52

Note. N = 272.

Primary outcome: Sense of competence.

Sense of competence was measured using the 17-item scale developed by Scheper, Orrell, Shanahan, and Spector (2012)²⁶ (pre-evaluation α = .90, post-evaluation α = .93). All items were rated on a 4-point Likert-type scale (1 = Not at all, 2 = A little bit, 3 = Quite a lot, 4 = Very much; example items include: How well do you feel you can: Understand the way a person with dementia interacts with the people and things around them? Engage a person with dementia in a conversation? Keep yourself motivated during a working day?).

Secondary outcome: Approaches to dementia.

Approaches to dementia was measured using the 19-item Approaches to Dementia Questionnaire (ADQ).²⁷ The ADQ measures the application of hopefulness and person-centered approaches among care staff towards persons with dementia, and it has been successfully deployed among home care staff in the United Kingdom.²⁸ All items were rated on a 5-point Likert-type scale (1 = Strongly Disagree, 2 = Disagree, 3 = Neither Disagree Nor Agree, 4 = Agree, 5 = Strongly Agree) (pre-evaluation α = .75, post-evaluation α = .81).

Secondary outcome: Job satisfaction.

Job satisfaction was measured with the short-form Minnesota Satisfaction Questionnaire.²⁹ Each item was rated on a 5-point Likert-type scale (1 = Very Dissatisfied, 2 = Dissatisfied, 3 = Neither, 4 = Satisfied, 5 = Very Satisfied) (pre-evaluation α = .85, post-evaluation α = .81).

Secondary outcome: Patient care.

Patient care was assessed using 15 items developed for this study. For exploratory purposes, a principal components factor analysis suggested that only one underlying factor explained the relationships among the items. At the pre- and post-evaluation intervals, the single dimension explained approximately 55% and 63% of the variance in the correlation matrix. All items were rated on a 5-point Likert-type scale (1 = Strongly Disagree, 2 = Disagree, 3 = Neither Disagree Nor Agree, 4 = Agree, 5 = Strongly Agree) (pre-evaluation α = .94, post-evaluation α = .96).

Secondary outcome: Communication.

Relying on other studies of work stress,^e.g.,30 three items assessing communication were developed by the investigators for the purposes of this trial. All items were rated on a 5-point Likert-type scale from 1 = Terrible to 5 = Excellent (pre-evaluation α = .80, post-evaluation α = .81; items include: How would you rank your skills at communicating with patients with dementia?; How would you rank your skills at communicating with family members of patients with dementia?; How would you rank your skills at communicating with other staff about the patients with dementia?).

Sample Size, Randomization, and Concealment

Statistical power was initially based on the design of 12-hospital/300 allied health workers. As noted earlier, the design shifted to an individual participant, randomized controlled design. A power analysis was conducted assuming Type I error rate = .05, power = .80, and, based on Cohen’s³¹ conventions, an effect size between small and medium, f = .26. Using G*Power, the minimum sample size was 119 to detect a significant difference in one outcome.³² Due to the multiple comparisons conducted, a Bonferroni adjustment³³ was administered to the five outcomes analyzed in the current trial, and the statistically significant p values were conservatively adjusted to p < .01 (i.e., .05/5=.01).

All data were collected via the online Qualtrics tool, with additional demographic data collected via an NYU IRB-approved online survey tool. Qualtrics generated random group assignments, and investigators were concealed from random allocation.

Statistical Analyses

The present study involved a 2 (time) × 2 (condition) mixed design.³³ Time was a within-subjects factor with two levels (pre-evaluation vs. post-evaluation), and the condition was a between-subjects factor with two levels (training intervention vs. waitlist control). Table 2 includes descriptive statistics for all outcomes, including means and standard deviations. Table 3 also presents descriptive statistics by condition. The online supplemental material presents Pearson correlation coefficients among all outcomes.

Table 3.

Means and Standard Deviations on Study Variables by Condition and Evaluation Period

	Control (n = 146)				Training (n = 126)
	Pre-evaluation		Post-evaluation		Pre-evaluation		Post-evaluation
Variable	M	SD	M	SD	M	SD	M	SD
Sense of Competence	2.91	0.55	3.04	0.55	2.85	0.54	3.45	0.44
Approaches to Dementia	3.81	0.35	3.87	0.38	3.81	0.32	4.04	0.40
Job Satisfaction	3.58	0.84	3.72	0.71	3.76	0.64	3.89	0.62
Patient Care	3.73	0.64	3.94	0.59	3.69	0.59	4.30	0.53
Communication	3.95	0.56	4.10	0.55	4.04	0.53	4.31	0.47

Note: n = Sample size within condition

A univariate analysis of variance (ANOVA) was conducted.³³ Although the univariate approach for analyzing data from a mixed design requires the sphericity assumption, the assumption is always satisfied when there are only two levels of the within-subjects factor.^34,35 For all analyses, residuals were examined to ensure that the normality and homoscedasticity assumptions were satisfied. Examining q-q and residual plots suggested that the normality and homoscedasticity assumptions were tenable.

Results

Participants

Figure 1 illustrates the participant flow in the trial. The total sample size that included complete data for both assessments (i.e., pre-evaluation and post-evaluation) was 272. One hundred and twenty-six participants completed the online training condition (with 157 lost to follow-up), and 146 completed the pre- and post-evaluations in the control condition (with 128 lost to follow-up). Lab/X-ray/imaging techs comprised most of the sample (91.9%) compared to other NA/AHWs (8.1%). Regarding participant demographics, 83.6% of the sample was white (not of Hispanic origin), 4.8% Black, 1.9% Asian, 0.4% American Indian or Alaskan, 0.7% mixed race, and 8.6% preferred not to answer. Close to 90% (89.5%) of respondents were non-Hispanic, 1.9% Hispanic, and 8.6% preferred not to answer. Over eighty percent (84.4%) of respondents were female, 9.3% were male, and 6.3% preferred not to answer. The average age of participants in the training and control conditions was 41 (SD = 11.41) and 39 (SD = 12.29) years old. The average number of years of work experience as an NA/AHW for those in the training and control conditions, respectively, was 13.9 (SD = 9.69) and 13.4 (SD = 10.18) years. Treatment/control condition assignment was not significantly related to race [𝜒²(1) = 0.16 (p = .691)], gender [𝜒²(1) = 0.601 (p = .438)], age [t(243) = 1.19, (p = .236)], work experience [t(243) = 0.42, (p = .676)], or job position [𝜒²(1) = 1.06 (p = .303)].

Figure 1.

Participant flow

Descriptive Statistics on Study Variables

Table 2 presents the means and standard deviations by assessment (i.e., pre-evaluation, post-evaluation). Table 3 also presents means and standard deviations for study outcomes by assessment and condition.

Univariate ANOVA Results

Table 4 presents the results of the ANOVAs; when considering time by condition effects, the following outcomes were statistically significant: sense of competence (p < .001), approaches to dementia (p < .001), and patient care (p < .001). For each of these outcomes, participants in the treatment condition indicated greater and statistically significant increases from pre- to post-evaluation on each outcome when compared to controls. Although the time by condition interaction for communication was p < .05, this finding was not deemed significant due to the Bonferonni adjustment indicated earlier. See the online supplemental material for graphical representations of each time by condition effect.

Table 4.

Analysis of Variance Results

Outcome	F(1,270)	${\eta }_G^2$	p
Sense of Competence
Time	153.24	.104	<.001
Condition	9.31	.027	.003
Time by condition	66.16	.048	<.001
Approaches to Dementia
Time	43.67	.038	<.001
Condition	5.10	.014	.025
Time by condition	13.87	.013	<.001
Job Satisfaction
Time	8.43	.009	.004
Condition	5.77	.015	.017
Time by condition	.04	<.001	.848
Patient Care
Time	148.94	.105	<.001
Condition	6.14	.018	.014
Time by condition	35.88	.027	<.001
Communication
Time	47.91	.037	<.001
Condition	7.07	.02	.008
Time by condition	4.57	.004	.033

Note: Statistical significance is set at p < .01

Discussion

The present study evaluated the efficacy of an online, video-based training and certification program, the CARES® Dementia 5-Step Method for Hospitals,™ for enhancing the skills of NA/AHWs in caring for the needs of PLWD. The results implied that this online training program has the potential to serve as a dynamic resource for hospitals across the nation to update training and share experiences, perspectives, and resources. In this randomized controlled trial, we found statistically significant improvements in sense of competence, approaches to dementia, and patient care. Overall, the online training and certification program appears to be an effective tool in improving the skills of NA/AHWs in caring for the needs of PLWD. Care needs for PLWD are compounded in the hospital setting, where delirium frequently emerges as a significant challenge for older persons (see above) and the staff who care for them. Study results suggest that the CARES® Dementia 5-Step Method for Hospitals™ program, with its inclusion of actual patients, families, and staff members (i.e., no actors) in its video footage and real-time demonstration of the person-centered CARES® dementia 5-step method, holds value for hospital settings of various sizes and geographical locations.

For healthcare professionals in hospitals who do not have training in dementia and dementia care, the challenges of providing standard or emergency care to cognitively impaired patients can be daunting and, in some instances, demoralizing. Challenges in function, behavior, and communication that often occur when hospital staff care for people with dementia can exacerbate already complex care situations. In addition to providing knowledge, care strategies, and tips to address the various issues that can occur when someone with dementia is admitted to a hospital, innovations such as the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program can instill efficacy and person-centered care principles that likely drive optimal dementia care in such settings. As demonstrated in the current efficacy study, the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program, through its module content, real-person demonstrations via interactive video content, and other engaged learning strategies, has considerable potential to improve the perceived quality of dementia care, staff sense of competence, and other vital mechanisms that ultimately drive positive patient outcomes and care quality.

The CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program represents a convenient, potentially cost-effective, and interactive means by which to improve upon care for PLWD. Many current dementia training curricula have been developed for nurses and to be delivered in person.²² Asynchronous, online training programs are highly accessible; an internet connection is the only requirement to access the materials. The interactive, media-based CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program engages learners and reinforces key concepts to promote knowledge retention; it is easy for staff to learn and remember, making it likely to be utilized by NA/AHWs.

Providing flexible dementia care training experiences is paramount in a fast-paced healthcare environment. CARES® certification serves as a step towards a more competency-based care system. Completing the examination provides hospitals and NA/AHWs with increased confidence that they are adequately equipped to provide the necessary care, thus increasing the credibility of the institutions involved. It may also assist in staff recruitment and retention, ensuring that NA/AHWs committed to ongoing professional development have the means to do so. Since NA/AHWs often have the most frequent contact with PLWDs in hospitals, administering a training program such as CARES® may prove particularly beneficial to achieving practice improvements in dementia care.

Limitations

As with many research projects conducted between 2020 and 2022, the COVID-19 pandemic challenged this study’s progress. The original plan for evaluating the online training program was to conduct a cluster wait-list randomized control trial in 12 hospital sites nationwide with 300 participants, as described earlier. Due to low initial hospital commitment and the subsequent COVID-19 pandemic introducing severe challenges to hospitals around the country, the study design was changed to a combination of site-level and individual-level participant identification.

There are additional limitations to this study. First, the study design did not adopt an intention-to-treat principle, a significant limitation when interpreting efficacy. A substantial number of consented participants in both the intervention and control groups did not complete the study and were excluded from the analysis. Although no statistical difference was identified between X-ray technicians and other NA/AHW participants, this study relied on a volunteer sample of X-ray technicians and may not be generalizable to the many other NA/AHW staff in hospitals challenged by hospitalized PLWD. Additionally, both the pre-evaluation and post-evaluation consisted of only self-reported measures. The use of the Qualtrics system as the primary form of data collection could pose a potential for unintentional participation bias as individuals/staff who are non-technical or technology-averse may have been reluctant to participate. Finally, due to recruitment problems at the hospital level and the impact of COVID-19, participants were identified from a mix of Qualtrics and two participating hospitals, with participant identification and randomization being conducted differently in the latter than in the former. As noted earlier, the scope and resources available in the current study did not allow for sufficient follow-up to thoroughly test whether changes in critical mechanisms/intermediary outcomes, as demonstrated in this analysis, would ultimately lead to improved quality of care or patient health outcomes. Quality of care and patient health outcomes are likely of utmost significance to patients, healthcare professionals, and payers.

Conclusions

Future research should focus on expanding the participant base for training to include NA/AHWs representing more diverse staff positions to confirm findings. Additional research could also examine the sustained effects of the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program on other vital outcomes, particularly those related to reducing any number of adverse events for PWLD covered in this training. A future longitudinal study would also help determine a recertification timeline, as is familiar with other medical certifications. Understanding optimal certification intervals would help to ensure that healthcare providers provide and sustain high-quality dementia care in hospital settings. Future studies might also expand outcomes to include data points such as the impact on the cost of care, days spent in the hospital, and other more objective outcome measures, as noted earlier. In addition, extending self-report measurement to assessment of change in actual care practice is another important consideration.

The inherent scalability of the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program regarding its acceptability, feasibility, and potential to incorporate seamlessly into routine workflows and staff training suggests high benefit for routine clinical practice. Future work that considers the applicability of this online training approach in various sociodemographic contexts and across different types of hospital care and staff will further contribute to the program’s implementation potential.

Highlights.

• Training in dementia-capable care for nursing assistants and allied health workers in hospital settings remains a significant challenge.

• The main objective of the current study was to ascertain the efficacy of a newly developed online dementia training and certification program for hospital staff, the CARES® Dementia 5-Step Method for Hospitals™ Online Training and Certification Program.

• Results found that hospital staff who completed the online training and certification indicated more significant increases in sense of competence, approaches to dementia, and patient care than controls who did not receive the online training.

• The online training and certification program, the CARES® Dementia 5-Step Method for Hospitals,™ has the potential to serve as a dynamic resource for hospitals nationwide to update training and share experiences, perspectives, and resources.