Expectations of nursing personnel and physicians on dementia training

The age of the global population is increasing, leading to an additional increase of multimorbid and frail patients who require care in general hospitals [18]. A subgroup of frail and vulnerable patients in hospitals are people with dementia (PwD) who are more likely to be admitted to general hospitals than people of similar age without dementia, particularly for fall-related accidents, chronic disease complications, urinary tract and respiratory infections [17]. Furthermore, the hospital stay is longer [15] and the outcomes are predominantly negative [8]. Specifically, it is estimated that 12.9–63.0% of people admitted to general hospitals have dementia in addition to the primary diagnosis [16]. A German study showed that at least 40% of hospital inpatients over 65 years of age have cognitive impairment [3]. A very similar proportion was revealed by a Greek study, in which cognitively impaired patients were greatly underestimated during admission to hospitals and 30.5% of older inpatients (>65 years) were diagnosed with cognitive decline [9]. The PwD usually experience poor quality of care in hospitals [21] and staff members are often insufficiently educated to meet the special needs of these patients [15]. The lack of adequate knowledge on dementia has been characterized as one of the main factors that affects care quality in hospital settings [19]. Due to this the number of dementia training programs in hospital settings is steadily increasing also internationally [19, 21, 22]. A number of factors regarding an effective dementia education for hospital staff have already been identified in the literature. Effective training programs appeared to be longer than 8 h duration and were classroom-based. Moreover, training content must be relevant to participants’ work, while practical tools and care strategies must be directly applicable in the workplace [21].

In order to develop a successful training program and enable the effective transfer of theoretical education to practice, an educational needs analysis should be carried out with respect to the target group [13, 19, 24]. Specifically, where trainees are involved and given choices about training processes, the training should influence their motivation to learn. Thus, an increase in trainees’ attention during training might possibly lead to the successful clinical implementation of what they learned [14]. Not much is known about the preferences and expectations regarding future dementia training programs for Greek and German staff members working in general hospitals. Although a number of dementia training programs have already been conducted in Germany, hardly any data were published in scientific journals. To our knowledge, there have been no dementia training courses conducted in the hospital settings in Greece.

The aim of this survey was to explore the current status of nursing staff, head nurses’ and physicians’ training needs relevant to the topic of dementia in general hospital settings in Germany and Greece. Specifically, the study attempted to explore interests and expectations of nursing staff, head nurses and physicians regarding their participation in dementia training programs. This survey is part of a larger research project which supports cross-cultural research, aiming to improve the quality of hospital care for cognitively impaired patients in the abovementioned countries. In a further step, the results of this survey will be used to develop a dementia training program individually for each of the countries.

Each descriptive analysis of the thematic parts was divided into two main sections: a comparison between the countries and a comparison between occupational groups focusing on the key findings and differences whereby the main focus was on the country comparison. Occupational groups were grouped into three categories: nursing staff (nurse assistant and registered nurses), head nurses, and physicians (senior physician, assistant physicians and junior physicians).

Exploring staff preferences about training topics, training design and general expectations is helpful to address the educational needs for future dementia training programs [24]. The responses from the participants of both countries showed interesting differences but also similarities.

Regarding the training design, the majority of the participants from both countries prefer to be trained by way of seminars at any time of the day, during or outside of their regular shift work, for 30–90 min per session. Moreover, German participants preferred short training sessions every half year, while Greek participants preferred more regularly scheduled training sessions and were open to full day sessions. Some of these findings corresponded with the characteristics of effective dementia training analyzed by Surr and Gates [21]. According to their results a duration of at least 1 day, delivered in full-day training sessions or as sessions at least for 1 h leads to positive outcomes. There might be some barriers for health staff to attend regular training sessions, for which an ongoing support via in-service experts should be provided [23]. Face-to-face seminars were more preferable than online training programs, which were hardly in demand according to the responses received, even though they were provided as response option in the utilized questionnaire. It appears that clinical staff members prefer to exchange experiences, take part in discussions and have personal contact during training programs. Some reasons could be that the use of electronic devices is still uncommon for clinic employees, or that the e‑learning method seems inappropriate for this subject area. Whereas classroom-based or face-to-face delivery in small groups are supported by the evidence [21, 23], online materials or e‑learning are discussed controversially in the literature, due to internet access problems in the workplace and difficulties with individual motivation of participants. The evidence recommends not to use e‑learning as an independent study option, e.g. in between training sessions [21].

Dealing with challenging behavior and communication were among the popular topics for both German and Greek participants. According to Dewing and Dijk [8] hospital staff members are frequently confronted by behavior such as aggression, agitation and wandering from PwD. This could possibly explain the interest in these topics. Nevertheless, the majority of the Greek participants said they preferred “general knowledge about dementia” as a topic. This finding may coincide with the fact that there has been no previous dementia training in Greek general hospitals, meaning that the staff members require more general knowledge about this topic at the very first level, whereby the German participants demanded more topic-specific knowledge; however, UK data examined by Chater and Hughes [7] showed that participants consider the imparting of the theoretical knowledge of the disease dementia to be important in order to improve provision of care.

The survey results show that training should be directly relevant to the participants’ workplace and the participants hope to acquire practical knowledge on how to handle this special patient group. Practical tools and care strategies are thus important tools for improving and dealing with PwD. According to Surr and Gates [21] the aforementioned tools and strategies are not only valuable for the learners’ reactions, they also produce positive changes and outcome in practice. The reported specific expectations regarding training methodology and trainers’ skills strengthen the existing evidence, which states that training has to be delivered by a skilled facilitator using interactive methods and practical activities, e.g. group learning, videos, scenario-based exercises and experiential learning alongside theoretical content [21, 23]. It can be emphasized that almost all of the Greek participants expect to enhance clinical skills and self-efficacy, which can probably be attributed to the fact that there has been no previous dementia training in Greek general hospitals and therefore there is an uncertainty in caring PwD. The expectations for future training programs are mostly in line with the international literature about effective training programs [21]. Already existing well-developed and evaluated training programs, such as the “Getting to Know Me” program [10, 11], the “VOICE” training course [12], or the “PCTAH” program [20] can be used as potential examples of good science and practice for Germany and Greece.

To fulfil the gold standard of good care an interprofessional team has to be involved. To provide patient-centered care dementia training programs are required to be interprofessional [4]. Therefore, expectations regarding a dementia training program should not vary too much between occupational groups. The survey results show several perspectives from hospital employees working with PwD. The interest of occupational groups in training topics does not differ greatly; however, training content and the used interactive methods and practical activities have to be directly relevant to the staff’s role and workplace [21]. Different expectations of the training design have been revealed. The authors suggest following the evidence and delivering individual sessions of not less than 1 h and additionally to provide ongoing support via in-service experts to bring the expectations of the occupational groups together.

The German participants seem to have been educated mostly in seminars or conferences conducted within the hospital, while the Greeks had attended seminars or conferences mostly outside the hospital, findings that may reveal the differences in the healthcare organizations of each country. Although both countries seem to provide a wide range of continuous training opportunities either within or outside hospitals, dementia training programs are still lacking. Dementia is a topic that must be considered more seriously in the hospital sector. According to Timmreck et al. [25], caring for PwD and generally geriatric patients will become more and more important in the future.

Dementia awareness and friendliness are two of the targets of the global dementia plan [26], but only 30 governments out of the 194 World Health Organization (WHO) member states have developed national dementia strategies [2]. In Germany a national dementia strategy is being developed at the moment [5, 6]. Greece enacted the national dementia strategy in 2014 and 2 years later, the implementation of 3 basic actions was started [1]. Educating professional caregivers in hospitals is one of the goals of national dementia strategies (Action 2, Axis 7 for the Greek national plan); however, the small number of participants who had already attended a dementia program, as well as the fact that almost all participants expressed the willingness to be trained in the future, may reflect the present lack of dementia trainings in hospital settings for both countries.

It should be noted that the survey was not carried out by one scientist in both countries due to language barriers. A standardized questionnaire is missing due to the exploratory approach. Furthermore, staff preferences in training program designs in general were not assessed. Recall bias should be considered in this survey. Some facts have to be highlighted that reduced the generalizability of the survey results. The data were not statistically compared but only descriptively. The sample size and the number of hospitals are small and not representative for both countries. Additionally, the included professions representing only a specific cohort of staff working in hospitals. The exclusion of psychiatric, geriatric and pediatric wards also lowers the generalizability of the results. In the future, further studies on the interests and expectations of different occupational groups should be carried out.