Feasibility of Internet Training for Care Staff of Residents with Dementia: The CARES® Program

Abstract

This study evaluated an internet-based training module, CARES,® (Connect with the resident; Assess behavior; Respond appropriately; Evaluate what works; Share with the team;) to determine its feasibility for certified nurse assistants in 3 nursing homes and 1 assisted living facility. Pre- and post-test questionnaires were administered to certified nurse assistants (CNAs; N = 40) to determine improvements in dementia care knowledge and perceptions of competence in dementia care. Dementia care knowledge improved significantly after CARES® training. Over 85% of the sample agreed or strongly agreed that the CARES® protocol improved mastery, care competency, and reduced stress related to dementia resident care. Open-ended feedback indicated that CARES® provided new information and skills to CNAs pertaining to dementia care. The results suggest that internet-based programs such as CARES® represent time- and cost-efficient methods to deliver dementia care training in long-term care settings.

Introduction

As Alzheimer's disease (AD) intensifies and neurological damage spreads, individuals may experience a number of symptoms that are challenging for family or professional caregivers to manage. Symptoms can include wandering, agitation, aggression (verbal or physical), pain, and depressed mood. In NHs nursing assistants make up the majority of staff who work with cognitively impaired residents suffering from these symptoms (Kramer & Smith, 2000; McCabe, Davison, & George, 2007). Kramer and Smith (2000) found that nursing assistants received, on average, 75 hours of training with little focus on issues specific or pertinent to dementia care. While training manuals and similar tools are available to assist nursing assistants in delivering dementia care, the overall effectiveness of such training approaches remains unclear.

The goal of the CARES® (Connect with the resident; Assess behavior; Respond appropriately; Evaluate what works; Share with the team) program is to provide a portable, self-paced, interactive training program to help nursing assistants and other NH staff acquire knowledge about effective treatment and management of dementia in long-term care settings. CARES® is designed to provide a cost-effective multimedia educational training program to nursing home and assisted living staff to improve dementia care practices. The purpose of this pilot study was to evaluate the feasibility and implementation of the CARES® training program, with a specific emphasis on staff perceptions of CARES® and whether use of CARES® resulted in increased dementia care knowledge for staff.

Background

Past reviews of effectiveness suggest that staff training programs to improve quality of dementia care in NHs can have modest, positive benefits (Cohen-Mansfield, 2001). A universal limitation across reviews is the lack of high quality research studies. Many studies failed to include adequate sample sizes, rigorous control in evaluation designs, and consistent measurement of outcomes (McCabe et al., 2007). Most staff training programs for residents with dementia focus on improving staff training, knowledge, and education. Other outcome measures include resident behavior problems and quality of care indicators such as staff performance (Kuske et al., 2007; McCabe et al., 2007). Evaluations that included a control group found that staff training programs reduced behavioral problems among cognitively impaired residents, with less consistent findings on whether such programs enhanced staff skills, knowledge, or turnover. Considerable heterogeneity was present in the number of sessions provided (1 to 10) across training programs. Interventions ranged from in-service educational approaches, to individualized care planning supervision, to skills training protocols. Some of the barriers to implementing these programs included lack of attendance (particularly for nursing assistants, as they are largely part-time employees), lukewarm commitment from administrators to implement training or pay staff for attendance, diverse facility sizes, staff turnover, and lack of objective measurement of behavior problems in NH settings (Kuske et al., 2007; McCabe et al., 2007).

As indicated, most staff training programs tend to occur over multiple, in-person training sessions. While these training approaches may entail group, peer, or one-to-one modes of delivery one commonality is that many staff training interventions involve a considerable time commitment on the part of NH staff. This is problematic for many staff who may only work part-time and is further compounded if administrators are not willing to reimburse staff for time spent in training. There are only a few examples of staff training programs that are asynchronous and not delimited by specific training times. One approach (Parks, Haines, Foreman, McKinstry, & Maxwell, 2005) included take home self-study modules along with five in-service lectures and found that this training program resulted in enhanced staff knowledge and positive attitudes. Another intervention model used computer-based interactive videos that were self-paced; this strategy was compared to a traditional face-to-face lectures training model and a control site (Rosen et al., 2002). Findings suggested that staff satisfaction and staff knowledge were greater in the computer-based, self-paced training program than the face-to-face lecture sessions or control group. These results emphasize that self-paced, asynchronous protocols could avoid common implementation barriers (e.g., compliance, restricted delivery times). It remains unknown if these models can improve other key outcomes as demonstrated in traditional, face-to-face training approaches (such as reductions in behavior problems).

Research Aims

The goal of CARES® is to implement a web-based, interactive, multimedia educational program for professional and paraprofessional caregivers in nursing homes. Of particular interest is to educate these caregivers on issues related to Alzheimer's disease or related dementing disorders that are directly relevant to Center of Medicare and Medicaid Services Quality indicators (http://www.medicare.gov/NHCompare). By providing general training about dementia care to NH staff, the long-term goal of the CARES® program is to improve care practices and outcomes for residents and result in overall improved quality of care. This study presents preliminary data on the ability of CARES® to improve certified nurse assistants' (CNAs) knowledge and perceptions of competency, communication, and gain related to dementia care in two types of residential settings (i.e., nursing homes and assisted living facilities).

Methods

Procedure and Certified Nurse Assistant Sample

Content development of the interactive CARES® program began in 2004. Contributors to CARES® content included a geriatric clinical expert from X (Medical Director Dr. X), senior members of the national office of the Alzheimer's Association, experts in dementia care (Lisa Gwyther, Duke University Medical Center, Durham, NC; and Lynne Morishita, geriatric nurse consultant, Minneapolis, MN), and an additional professional focus group. The feedback and ideas from these experts were incorporated into development of content for the CARES® program. Practices developed as part of the 2004 Alzheimer's Association Quality Care Campaign (whose mission was to bring together care experts, chapters, associations and industry leaders to secure their evidence-based practice) also formed the foundation of content in the CARES® program.

Content was developed for three initial sections of the program which were eventually combined into the opening module of foundational training:

• Opener (necessary to guide users as they began using the prototype);

• Introduction to Dementia (included information on the assessment and staging of dementia);

• Introduction to Behavior Management.

Each of these three sections delivered content via text, graphics, and video. In addition, the specific aim of providing quality care for patients with dementia was met by separating the remaining content into three specific prototype sections (each determined to be an area that could most impact the quality of care for residents with dementia):

• Food and Fluid Intake;

• Pain Management in Residents with Dementia; and

• Communicating with Residents.

The CARES® program was web accessible via an internet connection. HealthCare Interactive, Inc., Edina, MN owns CARES®.

Following the creation of the CARES® program, formative research occurred over a two-month process that involved certified nurse assistants (CNAs) from five separate facilities (four nursing homes and one assisted living facility) in four states: Minnesota; Georgia; Delaware; and Illinois. This protocol received human subjects research approval from the X Institutional Review Board (#0310E53293). The CNA testers initially completed a consent form, a written pre-test of dementia care knowledge, and a demographic information form which were mailed directly to the first author in pre-addressed, stamped envelopes. Testers were then given an access code to the web-based program. Upon completion of the testing, each CNA was requested to complete a paper post-test assessment. The post-test assessment included the dementia care knowledge test, a post-test CARES® evaluation tool, and 4 open-ended questions that offered CNAs the opportunity to identify their most favored and least favored components of CARES®. Again, all testers were asked to mail their information directly to the first author in pre-addressed, stamped envelopes.

Measures

CNAs filled out a pre-test (15 questions) and post-test (15 of the same questions in a different order) measure of dementia care knowledge (N = 40), a post-test CARES® evaluation questionnaire consisting of 19 items (N = 35), and four open-ended questions. Alpha estimates reported below are Cronbach's alphas.

Dementia care knowledge

A test of CNAs' dementia knowledge was administered prior to and following completion of the CARES® online module. The dementia care knowledge test was developed internally by HealthCare Interactive and was subsequently reviewed and modified by the geriatrician and clinical expert in dementia (Dr. X) as well as staff from the national office of the Alzheimer's Association. The dementia care knowledge test included 15 multiple choice items (items and key included in Table 1). The dementia care knowledge test showed good reliability at pre-test (α = .94).

Table 1.

Dementia Knowledge Test

Directions: Circle one answer for each question.
Residents with dementia may have a hard time telling you in words that they are in pain. You can tell when your resident is in pain by watching for the following signs of symptoms such as pacing, calling out, or tearfulness. of memories of past pains from long ago, like memories of being in labor. of infections, pressure ulcers – bedsores, or mouth sores from their dentures. all of the above. By learning about dementia and developing your caregiving skills, you will be able to better understand why residents behave the way they do. will know approaches that will reduce your stress. will make your job easier. all of the above. Mrs. Wong is worried about having to pay the bill for her food (many State laws require dietary slips be placed next to the resident's meal). How would you handle this situation? Be creative and tell Mrs. Wong not to worry, that her family has paid for the meal. Be creative and tell Mrs. Wong that she can charge the meal to her room. Be creative and tell Mrs. Wong that she will have to work after eating to pay off the price of the meal. a. and b. above. At times residents will try to give you feedback and will complain about pain in one body area when the pain is coming for a different area. For example, a resident with hip pain may think the pain is coming from the stomach. If you think a resident is in pain, you should ignore the resident and their behavior will probably stop. report the reasons you think the resident is in pain to the nurse. give the resident a drink of water. let the staff on the next shift deal with the resident. It is important to talk with residents, even if they cannot talk back to you, because it gives you something to do during your shift. it adds value to a resident's life. it builds trust with the residents and they are more likely to connect with you. b. and c. above. When talking with a resident, keep in mind that the resident is not going to understand anything you say. the pitch of your voice may be too high and you need to lower your voice. just because they are from another culture does not mean that their customs are any different than your customs. the resident will never catch on to your mimicking or making fun of his or her behavior. Nonverbal communication is the way we talk. your body language, your gestures, your tone of voice, and the look on your face. the way we walk or stand. b. and c. above. One of your major challenges is to recognize residents who are in pain but cannot communicate that pain to you. Some ways to know if your residents are in pain are physical expressions of pain such as sighing or grimacing. physical expressions of pain such as slow movement or rigid posture. anger during daily care or daily activities. all of the above. Being task oriented, like getting a resident dressed immediately, should be your goal with each resident. will not get you better results, than being warm and caring. makes your day go faster because you can get more done. shows who is really in control. Lack of time in your job is real. But your brief conversations can make a difference in a resident's life. Several ways you can brighten a resident's day in 30 seconds or less include holding the residents hand. giving someone a smile and a hug. singing a song with the resident. all of the above. You can also change a resident's behavior by convincing the resident to change his or her behavior. being creative, flexible and willing to change your behavior. reasoning with the resident in order for them to change their behavior. arguing with the resident in order to change his or her behavior. What are some creative ways you would get residents to drink more fluids throughout the day? Have a happy hour before mealtime where you serve non-alcoholic fun drinks. Offer the resident a glass of water every time you enter a resident's room. Serve popsicles, jello, watermelon, or other treats high in water as a daily activity. all of the above. Helping residents enjoy each day can make your job easier and provide the residents with better care. Enjoying each day can be easy if you hurry through each task as quickly as possible. you only work for you paycheck. you treat each resident the way you would like to be treated. you never talk to anyone on your team and never share information about your residents with your co-workers. There are different types of pain including chronic pain and acute pain. The difference between chronic pain and acute pain are chronic pain is a “sharp, violent” pain, while acute pain is a “constant, ever-present” pain. chronic pain is a “constant, ever-present” pain, while acute pain is new in onset. chronic pain lasts only a couple of days while acute pain lasts for many days. none of the above. The residents with dementia change in their behavior over time as their memory worsens, the solution you found to be the right solution yesterday will work today for the resident. may not work today for the resident. will work the same for every resident. is the right solution.
Answer Key: 1)d 2)d 3)d 4)b 5)d 6)b 7)d 8)d 9)b 10)d 11)b 12)d 13)c 14)b 15)b

CARES® Evaluation

A 19-item measure was administered at post-test that included measures of mastery (e.g., “I am more confident about my skills”); competency (“I am more confident in communicating with demented residents,” “I am more confident in recognizing the signs of pain in residents with dementia”) and caregiver gain (e.g., “This program will make caring for residents with dementia easier”). Each item was scored on a 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”). The CARES® Evaluation tool demonstrated excellent reliability (α = .94).

Open-ended questions

In order to provide CNAs with the opportunity to offer additional feedback to the CARES® team, 4 open-ended questions were administered in the post-test CARES® assessment: 1) “What did you like best about this training program?” 2) “What did you like least about this training program? 3) “How was this training program useful to you in performing your job?” and 4) “What suggestions do you have that would make this training program better?”

Analysis

Data from the 15-item pre-test/post-test dementia care knowledge test were analyzed to determine whether CNA knowledge pertaining to dementia care changed following completion of the CARES® training program. A paired T-Test was used to determine if mean change in knowledge was significantly different from zero (i.e., p < .05). Item frequencies were analyzed to determine what areas of the CARES® training CNAs indicated as most beneficial (e.g., mastery, competency, caregiving gain) on the post-test CARES® Evaluation measure. The comments provided on the 4 open-ended questions were compiled and analyzed to identify CNAs' perceptions of strengths and weaknesses of the CARES® program, particularly as it related to the care CNAs delivered to residents with dementia.

Results

Descriptive data: Certified Nurse Assistants

Forty-nine CNAs were approached and completed the CARES® training, and 40 CNAs completed the pre- and post-test dementia care knowledge test. The average age of CNAs was 43.5 years old (SD = 10.5). Age ranged from 21 to 63 years. Of the 34 CNAs who provided race/ethnicity data, 12 were White, 13 were African-American, 6 were Asian, 2 were of mixed race, and one was Hispanic. Five testers were male and 35 female. Employment data ranged from one month of service to 33.7 years of service with a median of 3.3 years (participants were asked, “How long have you worked for your employer?” in years and months).

An area of particular importance in developing and testing an interactive training program such as CARES® was the computer literacy of CNAs. Eight CNAs had never used a computer prior to completing the CARES® training program. Twenty-nine CNAs said they owned a computer. Twenty-four of the CNAs had never taken a computer class. Each CARES® module included approximately 45-70 minutes of content and took CNAs approximately 60 minutes to complete each module of narrated text, video, and other interactive exercises.

Change in Dementia Care Knowledge

Of the CNAs who completed the pre- and post-tests, 78% showed a gain in knowledge or tested the same. Of the 78% of CNAs who showed a gain or remained the same on dementia care knowledge, xx% remained stable and xx% demonstrated an increase. At pre-test CNAs on average answered 12.4 (SD = 1.9) items as correct. At post-test CNAs answered 13 items correct (SD = 2.0). T-test results indicated that this increase in correct responses was statistically significant (t = -2.6, df = 39, p = .013).

Item Frequency Analysis: CARES® Evaluation

Table 2 presents the item frequency response for each of the 19 evaluation items that were administered following participation in the CARES® program. In terms of mastery, 88% of CNAs agreed or strongly agreed with the statement that they were “more confident about my skills” following completion of the CARES® program. Post-test evaluation questions that examined competency found the following percentages of “agree” or “strongly agree” responses: 94% of CNAs were more confident in communicating with demented residents and 89% were more confident in recognizing the signs of pain in residents with dementia. Post-test evaluation questions examining CNA care gain indicated that 85% of participants responded “agree” or “strongly agree” that the new learning techniques acquired from the CARES® program “will make caring for residents with dementia easier.” Other key findings were that 95% of CNAs indicated “agree” or “strongly” agree to the statement that they now had a “common language” to use when talking with other CNAs, and 91% of CNAs “agreed” or “strongly agreed” with the statement that they would discuss the techniques they learned from CARES® with other CNAs in their workplace.

Table 2.

CARES® Evaluation: Item Frequency (Strongly Agree, Agree, and Total of Strongly Agree and Agree Percent Totals) (N = 35)

Evaluation Item Category	Strongly Agree (5)	Agree (4)	Total (4+5)
1. The CARES® Training Program was an interesting way to learn about dementia compared to learning in a classroom, or by reading.	29%	41%	70%
2. The information presented in this training program was easy to understand.	49%	49%	98%
3. I am more confident about my skills in caring for residents with dementia, after completing this training program.	37%	51%	88%
4. Other nursing home staff (Administrators, Physicians, Nurses, CNAs, food handlers, janitors) will find this training program helpful.	46%	40%	86%
5. I would like to use this type of training program to learn about other topics that will help me better care for residents.	46%	49%	95%
6. The videos helped me learn new ways to care for residents with dementia.	31%	54%	85%
7. It was easy for me to fit the CARES® training Program into my work schedule.	20%	60%	80%
8. In order to complete the CARES® Training Program, it was important to be able to go back and review the training program as often as I wanted.	20%	57%	77%
9. I preferred learning with this Internet-based training program as opposed to sitting in a classroom.	29%	46%	75%
10. I have a better understanding of the changes in thinking that are associated with dementia after completing the training program.	36%	52%	88%
11. I was pleased to learn that I will receive a certificate that shows I have completed each section of this training program.	25%	33%	58%
12. I would prefer that this training program be available in languages other than English.	16%	33%	49%
13. I am more confident in communicating with residents with dementia since completing this training program.	39%	55%	94%
14. I feel more confident in recognizing the signs of pain in residents with dementia since completing this training program.	27%	62%	89%
15. The training program taught me new ways to feed the residents with dementia.	27%	41%	68%
16. The information provided in the training program will help me better communicate with a resident's family members.	42%	49%	91%
17. Since completing the training program, I have learned a “common language” that will make it easier for me to talk to other CNAs that I work with about the care of residents with dementia.	27%	68%	95%
18. I will discuss the CARES® technique that I learned in the training program with the CNAs in my workplace.	35%	56%	91%
19. The CARES® Training Program has helped me to learn techniques that make caring for residents with dementia easier for me.	41%	44%	85%

NOTE: CARES® = (Connect with the resident; Assess behavior; Respond appropriately; Evaluate what works; Share with the team); CNAs = certified nurse assistants

Open-Ended Item Analysis

As suggested by the lack of familiarity some CNAs had with computer use, CARES® participants had to overcome a certain amount of trepidation about learning on the internet. Once the initial fear of learning on the internet/computer was overcome, most reported enjoying the learning experience. For example, on the “What did I like best” open-ended item, responses included:

• “I can use the information I learned”

• “It was easy to understand and very detailed”

• “I was able to learn more about dementia and also, I learn (sic) how to care for the resident with it”

Several barriers were noted with regards to the CARES® training program. Responses often focused on the technical aspects of accessing the CARES® program, lack of specific detail on dementia care (e.g., recognizing pain in the person with dementia), or that the content was too simple and that more information should be included:

• “So slow to load on my computer”

• “The program is okay you should bring more material about dementia”

• “What I like least about this program is it is too time consuming and frustrating but fun once we got on”

Participants appeared to believe that completion of the CARES® program positively influenced how they performed routine care activities for residents with dementia. Most of the comments seemed to emphasize that the CARES® program helped CNAs think differently about dementia care and augmented the care tools that CNAs already implemented in their facilities:

• “It gave me insight into the stages of dementia and how to deal with and think about each stage”

• “The program was useful to me in the sense that it helped me understand the basic communication and behavioral management techniques”

• “It was very useful because it taught me different ways to approach a resident with dementia. It also showed me what resident (sic) may be thinking when different things are happening around them or to them”

Recommendations included a group training component, delivery of the CARES® training modules in a single module, and having families of the person with dementia complete the training with CNAs:

• “I believe that a group training would be great. We could share ideas between us”

• “Getting families of demented patients to attend training section” (sic)

• “I did not see anything about identifying pain in the resident. Could whole program load at once instead of each piece loading separately and in my case slowly”

Discussion

The goal of this pilot project was to test the feasibility of an interactive, computer-based training program for CNAs who care for residents with dementia. As stated in prior reviews of dementia care training programs for NH staff, there is a lack of high quality evidence demonstrating the effectiveness of training protocols in improving staff knowledge or behavioral outcomes (Kuske et al., 2007; McCabe et al., 2007). A key issue is whether the results reported in these research studies can be translated to practice and still retain their positive findings for staff or residents suffering from dementia (Kuske et al., 2007). Translating dementia training programs into routine practice in NHs is difficult, however. Among the many factors that complicate translation include staff burden in completing training, cooperation among the various administrative levels of the NH (e.g., administration, staff, and families), and NH organizational barriers (e.g., staff turnover).

The pilot data collected from this study do offer promising, initial results on the feasibility of the CARES® staff training modules. Participation in CARES® appeared to result in increased dementia care knowledge for NH staff. These findings are encouraging. As prior research has noted, most of the training NH staff receive often do not focus on issues relevant to dementia care (Kramer & Smith, 2000). It is likely that most facilities find it difficult to include quality dementia-specific content in staff training because of time constraints. A program such as CARES® may be able to address this administrative barrier. Specifically, the web-based platform allowed NH staff greater flexibility in terms of when the training was received and completed. The results of this pilot study also suggest that CARES® can go beyond the provision of knowledge and influence NH staff's feelings of mastery, competency, and overall confidence in providing dementia care. In addition to noting how easy it was to learn the information provided in CARES®, CNAs indicated that CARES® training content could be used in actual dementia care. As suggested in the analysis of open-ended items, CARES® not only appears to offer information but also skills that can be applied to daily care of residents with dementia. These are promising findings, in that they suggest that CARES® is more than simple education and may influence direct staff-to-resident care behaviors. Cumulatively, the results suggest that CARES® may have accomplished knowledge transfer related to dementia care in residential settings and increased CNAs' feelings of confidence in managing the more challenging aspects of dementia.

There are several important limitations of this study. A control group was not included, and any conclusions of effectiveness or efficacy of CARES® training modules are inappropriate. The measures used, while tailored to the objectives and content of the CARES® training program, were not validated prior to inclusion in this pilot project. The sample is relatively small and it is unknown at this time whether CARES® could maintain similarly impressive responses among CNAs in multiple NH or assisted living environments. Data were not collected on where CARES® training took place (e.g., on a home or work computer). Similarly, it is not clear whether CARES® is generalizable to other types of staff who care for residents with dementia, and whether it would be received as well as it was for CNAs in this study. The results reported in this study are based solely on self-report data. It is unknown whether CARES® actually changed how CNAs cared for cognitively impaired residents or whether CARES® influenced each facility's overall approach to dementia care.

The open-ended comments raised several additional limitations for CARES® to address when implemented in the future. A significant barrier was computer literacy on the part of staff and basic technological barriers related to viewing CARES® on a home computer that may not have had broadband access. A number of recommendations were also provided, including a group component. This implies that some kind of peer support or guidance when using CARES® modules would be effective (and is in keeping with other quality NH staff training programs that emphasize ongoing feedback following the initial training activity) (Kuske et al., 2007). Another important recommendation was to include family in CARES®. A handful of studies have tested the assertion that family involvement influences and benefits resident outcomes (Gaugler, 2006), and researchers have sought ways to promote family-staff communication to enhance family involvement, reduce staff stress, improve family-staff communication and relationships, and promote residents' psychosocial well-being (Gaugler, 2005; Majerovitz, Mollott, & Rudder, 2009). As suggested by CARES® participants, incorporating family into long-term care staff training efforts may enhance the overall care and well-being of cognitively impaired residents and promote collaboration as well as communication among families and staff during various phases of residents' long-term care stay.

The results of this pilot study imply that CARES® is a promising training approach to enhance dementia training for long-term care staff. CARES® may have particular utility for newly hired CNAs or similar care staff in residential settings. It overcomes the barriers noted in prior evaluations of NH staff training protocols in that it is portable, asynchronous, and cost-efficient to deploy as an alternative to time intensive, face-to-face training protocols. Future applications of CARES©, including current evaluation efforts, will aim to build on these pilot findings to increase educational modules and content (e.g., wandering, falls, and restraints) to demonstrate the efficacy of internet-based training strategies for residential long-term care staff. Related applications of CARES© are currently in development that will focus on family caregiving issues as well as management of the most challenging behavior problems in dementia (e.g., verbal or physical aggression) The results from this pilot study emphasize that utilizing more flexible methods of staff training may help to impart key education, information, and skills to residential long-term care staff that are directly pertinent to the everyday needs of persons suffering from dementia.