Aging & Mental Health
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20
Positive attitudes and person-centred care predict of sense of competence in dementia care staff Margaret A. Mullan & Karen A. Sullivan To cite this article: Margaret A. Mullan & Karen A. Sullivan (2015): Positive attitudes and person-centred care predict of sense of competence in dementia care staff, Aging & Mental Health, DOI: 10.1080/13607863.2015.1018865 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1018865
Published online: 11 Mar 2015.
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Date: 13 November 2015, At: 12:29
Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1018865
Positive attitudes and person-centred care predict of sense of competence in dementia care staff Margaret A. Mullana and Karen A. Sullivana,b* a
Clinical Neuropsychology Research Group, School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia; bInstitute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
(Received 12 November 2014; accepted 10 February 2015) Objectives: The number of people who will require institutional care for dementia is rapidly rising. This increase raises questions about how the workforce can meet the challenge of providing quality care. A promising psychological concept that could improve staff and care recipient outcomes is staff sense of competence in their capacity to provide dementia care. The purpose of this study was to elucidate the relative importance of staff factors associated with sense of competence. Method: Sixty-one Australian dementia care staff (mostly nurses, 69%; and allied health, 21%) were recruited. Measures included the Sense of Competence in Dementia Care Staff (criterion) and standardised measures of empirically derived predictors: training, knowledge, attitudes and person-centred care strategies. Results: Standard multiple regression revealed that 33.9% of the variance in sense of competence was explained by the combination of the four predictors. Attitudes and person-centred strategies each uniquely explained a moderate amount of variance, while training and knowledge were not significant predictors of sense of competence. Conclusion: A positive attitude towards people with dementia, and stronger intentions to implement person-centred care strategies, predicted a greater sense of competence to provide care, whereas knowledge and training, commonly believed to be important contributors to sense of competence in dementia care, did not predict this outcome. Investing in strategies that address staff attitude and encourage person-centred care could influence sense of competence, and by extension, dementia care. Keywords: dementia; Alzheimer’s disease; sense of competence; self-efficacy; confidence; professional care staff
Introduction Currently, 30% of the 333,000 Australian people with dementia live in residential aged care facilities (RACFs; Australian Institute of Health and Welfare, 2012). The standard of care received by people with dementia in RACFs is regulated, but variable (Alzheimer’s Australia, 2013). Residents and their families rate staff factors in such environments as critical to care quality (Moyle et al., 2013). Staff training has been a focus of efforts to improve dementia care quality, but with mixed results (Kuske et al., 2007). While it seems clear that staff factors are important to the provision of high quality dementia care, it is not yet clear how this relationship works. A potential target for staff interventions to improve care quality is the sense of competence that professional dementia caregivers have in performing their work roles. The definition and theoretical origin of sense of competence has its roots in social cognitive learning theories. It is a concept that is akin to self-efficacy. Self-efficacy relates to an individual’s perception of their ability to perform competently in a specific situation (Bandura, 1997). Sense of competence in dementia care is a belief in one’s capacity to care for people with dementia across a range of dementia-specific roles and responsibilities (Schepers, Orrell, Shanahan, & Spector, 2012). Confidence in providing dementia care appears to be closely related, and
*Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis
importantly, it is malleable attribute (e.g., Elvish et al., 2014). Self-efficacy in dementia care is associated with lower levels of staff burnout (Duffy, Oyebode, & Allen, 2009). In turn, lower levels of burnout are associated with a greater willingness on the part of dementia care staff to help people with dementia, greater optimism that behavioural and psychological symptoms of dementia (BPSD) are modifiable, and less negative emotional responses to BPSD (Todd & Watts, 2005). Therefore, a better understanding of sense of competence in dementia care could reveal new ways of understanding how care quality could be improved. Social cognitive theory suggests that a number of staff attributes may predict sense of competence in dementia care. Specifically, task-related knowledge, skills and effective performance strategies are gained through effective task-related experiences and training, and these factors can increase self-efficacy (Gist & Mitchell, 1992). This possibility has been explored in only a handful of studies (see Table 1). These studies have shown that a combination of these variables account for a low to moderate amount of the variance in dementia staff sense of competence (14%, Hughes, Bagley, Reilly, Burns, & Challis, 2008; 16.1%, Moniz-Cook, Woods, & Gardiner, 2000). These findings are promising, particularly if there is scope to improve the predictive power of the models.
Residential dementia care homes and dementia community care settings Residential homes, nursing homes and duel registered.
Residential care/ assisted living facilities (low care) and nursing homes (high care).
Cross-sectional
Cross-sectional
Cross-sectional
Schepers et al. (2012)
Hughes et al. (2008)
Zimmerman et al. (2005)
Wilcoxon signedrank test or independent between groups t-tests and effect sizes. Bivariate correlations (Spearman’s r, Pearson’s r).
Stepwise multiple regression.
Bivariate correlations (Pearson’s r) and multiple regression (perceived competence was a predictor in this study). For this review only, relevant bivariate correlations are shown.
N D 71 nurses, healthcare assistants, doctors, allied health staff N D 211 nurses and care assistants
N D 254 direct care providers; majority (212) nursing and care assistants.
N D 154 direct care providers; majority (N D 136) certified nursing assistants.
UK
UK
UK
USA
Acute wards in general hospital
Statistical analysis
Sample
County
Setting
Repeated measure, dementia training intervention
Study design
Elvish et al. (2014)
Study
Table 1. Summary of the quality analysis of studies included in the literature review in chronological order.
(1) Perceived adequacy of staff training to assess seven aspects of dementia care. (2) Perceived adequacy of staff training to treat seven aspects of dementia care.
Perceived confidence at managing ‘challenging’ behaviours.
Sense of competence in dementia care (SoC).
Self-confidence in dementia care.
Operationalisation of sense of competence Main findings
Significant relationship between SoC and dementia experience (r D .24), job satisfaction (r D .16) and attitudes towards people with dementia (personhood subscale; r D .13). No relationship between SoC and dementia knowledge. Dementia training (b D 1.55), senior care staff (compared to junior care staff, b D 1.15), formal qualifications (b D .82) and dementia knowledge (b D .27), predicted 14% of the variance in confidence. Home type, resident mix, studying for formal qualifications, age, priority for dementia training and experience not predictive. Significant relationship between perceived adequacy of dementia assessment and training and job satisfaction (r D .58; r D .56). Significant relationship between perceived adequacy of dementia assessment and treatment training and attitudes towards dementia (r D .26; r D .29).
Following dementia training, significant increase in confidence in caring for people with dementia (r D .56), knowledge (r D .44) and decreased beliefs in controllability of challenging behaviours (b D .37).
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
(continued)
26 (65%)
22 (55%)
32 (80%)
34 (85%)
Quality rating
2 M.A. Mullan and K.A. Sullivan
Dementia unit in residential aged care facility.
Repeated measure, dementia training intervention
Cross-sectional
Mackenzie & Peragine (2003)
Moniz-Cook et al. (2000)
Sample
UK
ANCOVA
Statistical analysis
N D 326 direct care Multiple regression using backwards providers; elimination. majority (N D 243) care assistants
Canada Intervention group: N D 28 nurses and nurse aides; Control group: N D 13 nurses and nurse aides.
County
Perceived ease of management of ‘challenging’ behaviours.
Self-efficacy in the provision of dementia care.
Operationalisation of sense of competence Following dementia training, the intervention group demonstrated a statistically significant improvement in self-efficacy in the provision of dementia care compared to baseline, F(1,38) D 8.43, p < .01, while the control group did not improve. The intervention group demonstrated almost significantly greater selfefficacy than the control group immediately post-intervention (p D .06) and significantly greater self-efficacy at three-months follow-up (p < .01). Staff grade [managers (b D .19) and qualified nurses (b D .15)] had greater difficulties managing challenging behaviour that care assistants; resident influence (b D ¡.03), cohesion (b D ¡.04), supervisor support (b D .03) and staff anxiety (b D .02) predicted 16.1% of the variance in perceived difficulty management of challenging behaviours (all significant relationships). Experience, age, hours worked, burnout, depression, somatisation, social disturbance, job satisfaction and dementia knowledge not predictive.
Main findings
26 (65%)
27 (67.5%)
Quality rating
Note: The papers in this table were selected because they explored factors relating to sense of competence (or self-efficacy/confidence) in dementia care staff. The quality rating was calculated using the Crowe Critical Appraisal Tool (Crowe & Sheppard, 2011), whereby each study was assigned a rating based on eight aspects of the study, including preliminaries, introduction, design, sampling, data collection, ethical matters, results and discussion. organisational, environmental or resident attributes (rather than staff attributes that were the focus of this review) so were not considered for further analysis.
Residential and nursing homes
Setting
Study design
Study
Table 1. (Continued )
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
Aging & Mental Health 3
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
4
M.A. Mullan and K.A. Sullivan
Several variables have been used as predictors of sense of competence (see Table 1). The most robust findings suggest that the major contributors to sense of competence are prior training, attitudes and possibly dementia knowledge. Previous studies have shown that prior training (Elvish et al., 2014; Hughes et al., 2008; Mackenzie & Peragine, 2003) and attitudes towards people with dementia (Schepers et al., 2012; Zimmerman et al., 2005) are consistently associated with sense of competence, but knowledge of dementia is inconsistently related to this outcome. Two studies found no relationship between knowledge and either perceived ease of managing ‘challenging’ behaviours (Moniz-Cook et al., 2000) or sense of competence (Schepers et al., 2012), and one study reported that knowledge predicted confidence in managing ‘challenging’ behaviours (Hughes et al., 2008). However, since two of these past studies used knowledge measures without known psychometric properties (Moniz-Cook et al., 2000; Hughes et al., 2008), it is important to clarify the relationship between knowledge and sense of competence using an established measure. Empirical research has not yet examined whether there is a relationship between adopting particular care strategies and sense of competence. Evidence suggests that implementing person-centred dementia care strategies, such as managing pain effectively, employing behavioural strategies to address agitation and offering choices in care, improves both resident and staff outcomes (Chenoweth et al., 2009; Cohen-Mansfield, Thein, Marx, Dakheel-Ali, & Freedman, 2012; Jeon et al., 2012; Sidani, Streiner, & LeClerc, 2012). Therefore, it is plausible that using person-centred dementia care strategies might also increase sense of competence. This study aimed to elucidate the relative contribution of four variables (knowledge of dementia, training, person-centred care strategies and attitudes towards people with dementia) to sense of competence in providing dementia care. As previous research has demonstrated that sense of competence is consistently associated with attitudes towards people with dementia and training, it was hypothesised that both variables would be significant and positive predictors of sense of competence. It was also anticipated that person-centred care strategies would significantly and positively predict sense of competence and that knowledge would positively, but relatively weakly, predict sense of competence.
Methods Participants The participants were 61 dementia care staff. This group included clinical staff and trainees employed within the residential aged care sector in Brisbane, Australia. Most of these participants also took part in a related study exploring the psychometric properties of four knowledge of dementia tools (Mullan & Sullivan, under review). The Participants’ demographic characteristics are displayed in Table 2. Inclusion criteria were caring for at least one person with dementia per shift in a RACF setting. Staff employed in
Table 2. Participant demographic characteristics. Total (n D 61) % Age (in years) M (SD) Gender Female Male Recruitment One RACF One-day BPSD workshop Private allied health service provider Occupation Personal care staff Registered nurse Allied health professional Student nurses Education Bachelor’s degree or higher Lower than bachelor’s degree
40.86 (14.80) 90.2 9.8 63.5 18.5 18.0 50.8 18.0 21.3 8.2 37.5 62.5
Note: N D 61. M D mean; SD D standard deviation.
non-clinical roles such as kitchen staff were excluded from participation.
Materials The Sense of Competence in Dementia Care Staff (SCIDS; Schepers et al., 2012): the SCIDS consists of 17 items pertaining to a broad range of dementia care roles and responsibilities. An example of an item on the SCIDS is: How well do you feel that you can understand the feelings of someone with dementia? Scoring is on a four-point Likert scale from 1 (not at all) to 4 (very much). Summation of items permits a total score between 17 and 68. It demonstrates excellent internal consistency (a D .91), acceptable test retest reliability (intraclass correlation coefficient, ICC D .74) and promising construct validity (Schepers et al., 2012). The Approaches to Dementia Questionnaire (ADQ; Lintern, 2001): the ADQ measures attitudes towards people with dementia. It has two subscales: hope and personcentred attitudes. The total scale consists of 19 items and the two subscales can be summated to form a total score ranging from 19 to 95. An example of an ADQ item is: there is no hope for people with dementia. Items are graded on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The total scale has acceptable internal consistency (a D .78; Schepers et al., 2012) and there is evidence for its construct validity (Lintern, 2001). The Dementia Knowledge Assessment Tool Version Two (DKAT2; Toye et al., 2014): the DKAT2 was designed for use with dementia care staff. It consists of 21 items, with three response options: yes, no, and do not know (Toye et al., 2014). An example of DKAT2 item is: only older adults develop dementia. A total scale score is obtained by summing all correct answers. The range of possible scores is between 0 and 21. This measure has acceptable internal consistency (a D .79) and there are early indications of its construct validity (Toye et al., 2014).
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
Aging & Mental Health The patient pain, behaviour and cognition (PPBC) vignette [non-pharmacological subscale (NPS); Hunter et al., 2013]: this vignette describes a person with dementia who is living in an RACF and is displaying signs of pain and agitation. The NPS consists of eight items querying the likelihood of implementing particular care strategies in response to the situation in the vignette. Items are rated on a six-point Likert scale from 1 (definitely not) to 6 (definitely). An example of an NPS item is: How likely are you to provide an enjoyed activity such as music to distract the patient? An item about occupational therapy was removed because it was not relevant to the Australian RACF context. Items are summed to obtain a total score ranging from 6 to 42. The NPS demonstrates excellent internal consistency (a D .91) and there is evidence of its construct validity (Hunter et al., 2013). Design and procedure The tests were administered as part of a larger test battery, including a separate block of knowledge of dementia measures, the results of which have been published elsewhere (Mullan & Sullivan, under review). A crosssectional survey was employed to investigate the predictors of sense of competence. An a-priori power analysis revealed that to detect medium effect size (R2 D .20) in a standard multiple regression analysis (a D .05, power D .80) with four predictors, a sample size of at least 108 participants was required (Green, 1991). To maximise participation, participants were invited to enter a prize draw to win $200 upon study completion. Results Data were analysed using SPSS 21 (SPSS Inc., Chicago, USA). Data were missing for all items (
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20
Positive attitudes and person-centred care predict of sense of competence in dementia care staff Margaret A. Mullan & Karen A. Sullivan To cite this article: Margaret A. Mullan & Karen A. Sullivan (2015): Positive attitudes and person-centred care predict of sense of competence in dementia care staff, Aging & Mental Health, DOI: 10.1080/13607863.2015.1018865 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1018865
Published online: 11 Mar 2015.
Submit your article to this journal
Article views: 202
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=camh20 Download by: [Washington University in St Louis]
Date: 13 November 2015, At: 12:29
Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1018865
Positive attitudes and person-centred care predict of sense of competence in dementia care staff Margaret A. Mullana and Karen A. Sullivana,b* a
Clinical Neuropsychology Research Group, School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia; bInstitute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
(Received 12 November 2014; accepted 10 February 2015) Objectives: The number of people who will require institutional care for dementia is rapidly rising. This increase raises questions about how the workforce can meet the challenge of providing quality care. A promising psychological concept that could improve staff and care recipient outcomes is staff sense of competence in their capacity to provide dementia care. The purpose of this study was to elucidate the relative importance of staff factors associated with sense of competence. Method: Sixty-one Australian dementia care staff (mostly nurses, 69%; and allied health, 21%) were recruited. Measures included the Sense of Competence in Dementia Care Staff (criterion) and standardised measures of empirically derived predictors: training, knowledge, attitudes and person-centred care strategies. Results: Standard multiple regression revealed that 33.9% of the variance in sense of competence was explained by the combination of the four predictors. Attitudes and person-centred strategies each uniquely explained a moderate amount of variance, while training and knowledge were not significant predictors of sense of competence. Conclusion: A positive attitude towards people with dementia, and stronger intentions to implement person-centred care strategies, predicted a greater sense of competence to provide care, whereas knowledge and training, commonly believed to be important contributors to sense of competence in dementia care, did not predict this outcome. Investing in strategies that address staff attitude and encourage person-centred care could influence sense of competence, and by extension, dementia care. Keywords: dementia; Alzheimer’s disease; sense of competence; self-efficacy; confidence; professional care staff
Introduction Currently, 30% of the 333,000 Australian people with dementia live in residential aged care facilities (RACFs; Australian Institute of Health and Welfare, 2012). The standard of care received by people with dementia in RACFs is regulated, but variable (Alzheimer’s Australia, 2013). Residents and their families rate staff factors in such environments as critical to care quality (Moyle et al., 2013). Staff training has been a focus of efforts to improve dementia care quality, but with mixed results (Kuske et al., 2007). While it seems clear that staff factors are important to the provision of high quality dementia care, it is not yet clear how this relationship works. A potential target for staff interventions to improve care quality is the sense of competence that professional dementia caregivers have in performing their work roles. The definition and theoretical origin of sense of competence has its roots in social cognitive learning theories. It is a concept that is akin to self-efficacy. Self-efficacy relates to an individual’s perception of their ability to perform competently in a specific situation (Bandura, 1997). Sense of competence in dementia care is a belief in one’s capacity to care for people with dementia across a range of dementia-specific roles and responsibilities (Schepers, Orrell, Shanahan, & Spector, 2012). Confidence in providing dementia care appears to be closely related, and
*Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis
importantly, it is malleable attribute (e.g., Elvish et al., 2014). Self-efficacy in dementia care is associated with lower levels of staff burnout (Duffy, Oyebode, & Allen, 2009). In turn, lower levels of burnout are associated with a greater willingness on the part of dementia care staff to help people with dementia, greater optimism that behavioural and psychological symptoms of dementia (BPSD) are modifiable, and less negative emotional responses to BPSD (Todd & Watts, 2005). Therefore, a better understanding of sense of competence in dementia care could reveal new ways of understanding how care quality could be improved. Social cognitive theory suggests that a number of staff attributes may predict sense of competence in dementia care. Specifically, task-related knowledge, skills and effective performance strategies are gained through effective task-related experiences and training, and these factors can increase self-efficacy (Gist & Mitchell, 1992). This possibility has been explored in only a handful of studies (see Table 1). These studies have shown that a combination of these variables account for a low to moderate amount of the variance in dementia staff sense of competence (14%, Hughes, Bagley, Reilly, Burns, & Challis, 2008; 16.1%, Moniz-Cook, Woods, & Gardiner, 2000). These findings are promising, particularly if there is scope to improve the predictive power of the models.
Residential dementia care homes and dementia community care settings Residential homes, nursing homes and duel registered.
Residential care/ assisted living facilities (low care) and nursing homes (high care).
Cross-sectional
Cross-sectional
Cross-sectional
Schepers et al. (2012)
Hughes et al. (2008)
Zimmerman et al. (2005)
Wilcoxon signedrank test or independent between groups t-tests and effect sizes. Bivariate correlations (Spearman’s r, Pearson’s r).
Stepwise multiple regression.
Bivariate correlations (Pearson’s r) and multiple regression (perceived competence was a predictor in this study). For this review only, relevant bivariate correlations are shown.
N D 71 nurses, healthcare assistants, doctors, allied health staff N D 211 nurses and care assistants
N D 254 direct care providers; majority (212) nursing and care assistants.
N D 154 direct care providers; majority (N D 136) certified nursing assistants.
UK
UK
UK
USA
Acute wards in general hospital
Statistical analysis
Sample
County
Setting
Repeated measure, dementia training intervention
Study design
Elvish et al. (2014)
Study
Table 1. Summary of the quality analysis of studies included in the literature review in chronological order.
(1) Perceived adequacy of staff training to assess seven aspects of dementia care. (2) Perceived adequacy of staff training to treat seven aspects of dementia care.
Perceived confidence at managing ‘challenging’ behaviours.
Sense of competence in dementia care (SoC).
Self-confidence in dementia care.
Operationalisation of sense of competence Main findings
Significant relationship between SoC and dementia experience (r D .24), job satisfaction (r D .16) and attitudes towards people with dementia (personhood subscale; r D .13). No relationship between SoC and dementia knowledge. Dementia training (b D 1.55), senior care staff (compared to junior care staff, b D 1.15), formal qualifications (b D .82) and dementia knowledge (b D .27), predicted 14% of the variance in confidence. Home type, resident mix, studying for formal qualifications, age, priority for dementia training and experience not predictive. Significant relationship between perceived adequacy of dementia assessment and training and job satisfaction (r D .58; r D .56). Significant relationship between perceived adequacy of dementia assessment and treatment training and attitudes towards dementia (r D .26; r D .29).
Following dementia training, significant increase in confidence in caring for people with dementia (r D .56), knowledge (r D .44) and decreased beliefs in controllability of challenging behaviours (b D .37).
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
(continued)
26 (65%)
22 (55%)
32 (80%)
34 (85%)
Quality rating
2 M.A. Mullan and K.A. Sullivan
Dementia unit in residential aged care facility.
Repeated measure, dementia training intervention
Cross-sectional
Mackenzie & Peragine (2003)
Moniz-Cook et al. (2000)
Sample
UK
ANCOVA
Statistical analysis
N D 326 direct care Multiple regression using backwards providers; elimination. majority (N D 243) care assistants
Canada Intervention group: N D 28 nurses and nurse aides; Control group: N D 13 nurses and nurse aides.
County
Perceived ease of management of ‘challenging’ behaviours.
Self-efficacy in the provision of dementia care.
Operationalisation of sense of competence Following dementia training, the intervention group demonstrated a statistically significant improvement in self-efficacy in the provision of dementia care compared to baseline, F(1,38) D 8.43, p < .01, while the control group did not improve. The intervention group demonstrated almost significantly greater selfefficacy than the control group immediately post-intervention (p D .06) and significantly greater self-efficacy at three-months follow-up (p < .01). Staff grade [managers (b D .19) and qualified nurses (b D .15)] had greater difficulties managing challenging behaviour that care assistants; resident influence (b D ¡.03), cohesion (b D ¡.04), supervisor support (b D .03) and staff anxiety (b D .02) predicted 16.1% of the variance in perceived difficulty management of challenging behaviours (all significant relationships). Experience, age, hours worked, burnout, depression, somatisation, social disturbance, job satisfaction and dementia knowledge not predictive.
Main findings
26 (65%)
27 (67.5%)
Quality rating
Note: The papers in this table were selected because they explored factors relating to sense of competence (or self-efficacy/confidence) in dementia care staff. The quality rating was calculated using the Crowe Critical Appraisal Tool (Crowe & Sheppard, 2011), whereby each study was assigned a rating based on eight aspects of the study, including preliminaries, introduction, design, sampling, data collection, ethical matters, results and discussion. organisational, environmental or resident attributes (rather than staff attributes that were the focus of this review) so were not considered for further analysis.
Residential and nursing homes
Setting
Study design
Study
Table 1. (Continued )
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
Aging & Mental Health 3
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
4
M.A. Mullan and K.A. Sullivan
Several variables have been used as predictors of sense of competence (see Table 1). The most robust findings suggest that the major contributors to sense of competence are prior training, attitudes and possibly dementia knowledge. Previous studies have shown that prior training (Elvish et al., 2014; Hughes et al., 2008; Mackenzie & Peragine, 2003) and attitudes towards people with dementia (Schepers et al., 2012; Zimmerman et al., 2005) are consistently associated with sense of competence, but knowledge of dementia is inconsistently related to this outcome. Two studies found no relationship between knowledge and either perceived ease of managing ‘challenging’ behaviours (Moniz-Cook et al., 2000) or sense of competence (Schepers et al., 2012), and one study reported that knowledge predicted confidence in managing ‘challenging’ behaviours (Hughes et al., 2008). However, since two of these past studies used knowledge measures without known psychometric properties (Moniz-Cook et al., 2000; Hughes et al., 2008), it is important to clarify the relationship between knowledge and sense of competence using an established measure. Empirical research has not yet examined whether there is a relationship between adopting particular care strategies and sense of competence. Evidence suggests that implementing person-centred dementia care strategies, such as managing pain effectively, employing behavioural strategies to address agitation and offering choices in care, improves both resident and staff outcomes (Chenoweth et al., 2009; Cohen-Mansfield, Thein, Marx, Dakheel-Ali, & Freedman, 2012; Jeon et al., 2012; Sidani, Streiner, & LeClerc, 2012). Therefore, it is plausible that using person-centred dementia care strategies might also increase sense of competence. This study aimed to elucidate the relative contribution of four variables (knowledge of dementia, training, person-centred care strategies and attitudes towards people with dementia) to sense of competence in providing dementia care. As previous research has demonstrated that sense of competence is consistently associated with attitudes towards people with dementia and training, it was hypothesised that both variables would be significant and positive predictors of sense of competence. It was also anticipated that person-centred care strategies would significantly and positively predict sense of competence and that knowledge would positively, but relatively weakly, predict sense of competence.
Methods Participants The participants were 61 dementia care staff. This group included clinical staff and trainees employed within the residential aged care sector in Brisbane, Australia. Most of these participants also took part in a related study exploring the psychometric properties of four knowledge of dementia tools (Mullan & Sullivan, under review). The Participants’ demographic characteristics are displayed in Table 2. Inclusion criteria were caring for at least one person with dementia per shift in a RACF setting. Staff employed in
Table 2. Participant demographic characteristics. Total (n D 61) % Age (in years) M (SD) Gender Female Male Recruitment One RACF One-day BPSD workshop Private allied health service provider Occupation Personal care staff Registered nurse Allied health professional Student nurses Education Bachelor’s degree or higher Lower than bachelor’s degree
40.86 (14.80) 90.2 9.8 63.5 18.5 18.0 50.8 18.0 21.3 8.2 37.5 62.5
Note: N D 61. M D mean; SD D standard deviation.
non-clinical roles such as kitchen staff were excluded from participation.
Materials The Sense of Competence in Dementia Care Staff (SCIDS; Schepers et al., 2012): the SCIDS consists of 17 items pertaining to a broad range of dementia care roles and responsibilities. An example of an item on the SCIDS is: How well do you feel that you can understand the feelings of someone with dementia? Scoring is on a four-point Likert scale from 1 (not at all) to 4 (very much). Summation of items permits a total score between 17 and 68. It demonstrates excellent internal consistency (a D .91), acceptable test retest reliability (intraclass correlation coefficient, ICC D .74) and promising construct validity (Schepers et al., 2012). The Approaches to Dementia Questionnaire (ADQ; Lintern, 2001): the ADQ measures attitudes towards people with dementia. It has two subscales: hope and personcentred attitudes. The total scale consists of 19 items and the two subscales can be summated to form a total score ranging from 19 to 95. An example of an ADQ item is: there is no hope for people with dementia. Items are graded on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The total scale has acceptable internal consistency (a D .78; Schepers et al., 2012) and there is evidence for its construct validity (Lintern, 2001). The Dementia Knowledge Assessment Tool Version Two (DKAT2; Toye et al., 2014): the DKAT2 was designed for use with dementia care staff. It consists of 21 items, with three response options: yes, no, and do not know (Toye et al., 2014). An example of DKAT2 item is: only older adults develop dementia. A total scale score is obtained by summing all correct answers. The range of possible scores is between 0 and 21. This measure has acceptable internal consistency (a D .79) and there are early indications of its construct validity (Toye et al., 2014).
Downloaded by [Washington University in St Louis] at 12:29 13 November 2015
Aging & Mental Health The patient pain, behaviour and cognition (PPBC) vignette [non-pharmacological subscale (NPS); Hunter et al., 2013]: this vignette describes a person with dementia who is living in an RACF and is displaying signs of pain and agitation. The NPS consists of eight items querying the likelihood of implementing particular care strategies in response to the situation in the vignette. Items are rated on a six-point Likert scale from 1 (definitely not) to 6 (definitely). An example of an NPS item is: How likely are you to provide an enjoyed activity such as music to distract the patient? An item about occupational therapy was removed because it was not relevant to the Australian RACF context. Items are summed to obtain a total score ranging from 6 to 42. The NPS demonstrates excellent internal consistency (a D .91) and there is evidence of its construct validity (Hunter et al., 2013). Design and procedure The tests were administered as part of a larger test battery, including a separate block of knowledge of dementia measures, the results of which have been published elsewhere (Mullan & Sullivan, under review). A crosssectional survey was employed to investigate the predictors of sense of competence. An a-priori power analysis revealed that to detect medium effect size (R2 D .20) in a standard multiple regression analysis (a D .05, power D .80) with four predictors, a sample size of at least 108 participants was required (Green, 1991). To maximise participation, participants were invited to enter a prize draw to win $200 upon study completion. Results Data were analysed using SPSS 21 (SPSS Inc., Chicago, USA). Data were missing for all items (
