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Running Head: INTEGRATIVE LITERATURE REVIEW

Integrative Literature Review

Abagail Boinest

Bon Secours Memorial College of Nursing

NUR 4122: Nursing Research

Christine Turner, PhD

April 8, 2018

I pledge.
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INTEGRATIVE LITERATURE REVIEW

Abstract

Purpose: The purpose of this integrated review is to identify the relationship dementia training

has on acute care staff confidence and knowledge.

Background: The number of persons over the age of 65 is growing, increasing the number of

patients in the acute care setting with dementia and other cognitive impairments. The care of

these patients has not been optimal in many acute care settings, resulting in negative outcomes

for these patients.

Method: This is an integrative review in which research was collected from online databases.

The articles discussed are qualitative and quantitative and were chosen based on relevance and

specific criteria. The information from these articles were used to evaluate the effect of dementia

training on acute care staff and care received by patients.

Limitations: Limitations of this integrative review include the author’s inexperience and lack of

recent articles. Other limitations include the search criteria for the articles chosen as well as full-

text availability.

Results and Findings: Data collected in this integrative review supports the need for education

on the pregraduate level as well as an integral part of orientation of acute care staff as findings

have indicated a lack of training and education.

Implications and Recommendations: The importance of training acute care staff on dementia

patients rises each year as the population ages and life expectancy grows. It is recommended that

further research into the most effective and replicable training programs is performed to confirm

the relationship between training and acute care staff and patients.
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INTEGRATIVE LITERATURE REVIEW

Integrative Literature Review

The purpose of this integrated review is to identify the relationship dementia training has on

acute care staff confidence and knowledge. The world’s population is ageing and as of 2015 the

percentage of persons age 65 and older was 8.5 percent or an estimated 617.1 million (He,

Goodkind & Kowal, 2016). The increase in elderly population led to an increase in percentage of

patients in the acute care setting being over 65 years of age, and with this age cohort specifically

there is a population that suffers from dementia, therefore increasing the number of patients in

acute care settings with dementia.

In the acute care setting, patients over 65 years of age with cognitive impairments, such

as dementia or delirium, have worse outcomes than those without impairments (Griffiths,

Knight, Harwood & Gladman, 2013). The need for dementia training has been identified in

national audits and other published literature as experiences of patients and acute care staff have

been found to be disappointing (Elvish, et al., 2013). The aim of this review is to examine and

discuss data related to the researcher’s PICOT question: In acute care staff, what is the effect of

dementia training on confidence and knowledge compared with staff without training?

Design and Methods

This integrative review is focused on five research articles. The method used by the

researcher began with a search using EBSCO Discovery Service. The search words dementia

training, acute care staff, staff training, and dementia care were used to retrieve 1,191 articles.

Other search engines that were searched but did not yield articles include Academic Search

Complete and CINAHL Complete. The articles were then filtered by publication type, year, peer-

review and relevance to the PICOT question. Articles were limited to the years 2013-2018 and
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did not include articles with settings in long term care or assisted living. Full-text availability

was a significant limiting factor in the research process.

These articles were selected based on relevance to the PICOT question, “In acute care

staff, what is the effect of dementia training on staff confidence and knowledge compared with

staff without training?” The researcher focused on articles with discussions on effects of a

dementia training program and staff knowledge and experiences. Articles that did not include

these criteria were excluded, resulting in five articles, one qualitative (Griffiths, et al., 2013) two

mixed method (Martin, et al., 2016; Teodorczuk, Mukaetova-Ladinska, Corbett, and Welfare,

2014), one quantitative (Elvish, et al., 2013), and one systematic review of literature (Scerri,

Innes and Scerri, 2016).

Findings

The findings and results of the articles included in this review identify a relationship

between dementia training and preparedness and increased confidence and knowledge of staff

(Elvish, et al.,2013; Griffiths, et al., 2013; Martin, et al.,2016; Scerri, et al., 2016; Teodorczuk, et

al., 2014). A summary of the five research articles is located in Table 1- Article Evaluations. The

following is a short synopsis of each articles’ findings.

In a quantitative study conducted by Elvish et al. (2013), the authors seek to correlate a

training program called “Getting to Know Me” to improved confidence and knowledge in

dementia. The participants of this study were staff members at a general hospital in the U.K that

worked on wards where the majority of patients were over the age of 65. This study utilized pre-

test and post-test comprising of CODE and KIDE and a controllability beliefs scale to measure

the effectiveness of the training program. The results showed marked improvement in the CODE

and KIDE results with marginal changes in the controllability scale. The authors of this study
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proved a positive correlation between confidence and knowledge with the attending of a

dementia training program. The authors of this study suggest additional study of the outcomes of

patients of participants to ascertain if training has altered their practice.

Preparedness is a factor that is incorporated in a study done by Griffiths et al. (2013), this

was done by assessing acute care staff’s preparedness to care for older adult patients with

cognitive impairments such as dementia. This study was a qualitative phenomenological study,

that was conducted using interviews with open ended questions of 60 healthcare professionals in

a U.K hospital. The data from the interviews was analyzed using NiVivo8 software and

categories were identified. These categories included knowledge and skills necessary for the job,

interactions with patients and colleagues and effects on staff. The results showed a majority of

the participants felt they were unprepared and those who did feel prepared had previous

experience with patients with cognitive impairments. Other significant findings of this study

include the need for multidisciplinary team meetings, need for education on the pre-graduate

level and the lack of knowledge concerning resources available to the staff and patients. This

study’s findings contribute to the development of training programs and emphasizes the

importance of acknowledging mental and cognitive impairments as equally important as physical

ailments (Griffiths, et al., 2013, p 525).

In a 2016 study, Martin et al. evaluated the effects of a dementia training program had on

self-efficacy of 468 staff members at a hospital in Ontario, Canada. The authors of this study

expected to correlate the increase in Self-Perceived Behavioral Management Self- Efficacy

Profile (SBMSEP) scores to the attending of a dementia specific training program “Gentle

Persuasive Approaches” (GPA). This study included a total of 745 participants with a control

group of 277 and an intervention group of 468, with statistical analysis of the control and
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intervention group demographics to assure that the groups did not differ significantly. Pre-

intervention baseline and 8-week post-intervention evaluations were done using SBMSEP for

both groups as well as an immediately post-intervention SBMSEP and focus groups led with

semi structured questions for the intervention group (Martin, et al. 2016). Quantitative data was

analyzed using x2-tests, 2-way repeated-measures of variance, 1-way repeated-measures

ANOVA, and finally multiple linear regressions using SPSS version 23.0. Qualitative data

collected from 3 open-ended questions on the SBMSEP and focus group transcriptions was

analyzed and grouped into themes and then subjected to a step-by-step thematic approach. The

findings of this study proved a statistically significant increase in the intervention group’s self-

efficacy scores from pre-test to post-test. Additional results from the qualitative portion of this

study reflected positively on the training program and indicated participants comprehension of

purpose of the program as well as a shift towards patient centered care, which was one of the

goals of the program.

Scerri et al. (2016) performed a review of the literature to critically assess the literature

available on the dementia training programs tailored to general hospital staff members using a

narrative synthesis approach. The authors conducted a literature search using specific criteria that

included evaluations of designs, studies carried out in general hospital settings and focused on

dementia training that did not contain other geriatric syndromes. Data from the 14 peer-reviewed

articles were analyzed for a quality assessment using criteria from Kmet, Lee & Cook, and

Kirkpatrick’s Evaluation Framework was used to evaluate effectiveness of each training program

(Scerri, et al., 2016, p 8). The results of the quality assessment conducted by the authors yielded

three studies with high quality and four studies with medium quality. The characteristic of the
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studies that the authors evaluated as most effective include; “interdisciplinary ward based, tailor-

made and short sessions” (Scerri, et al., 2016, p 24).

A mixed methods study was utilized by Teodorczuk et al. (2014) to evaluate confidence

and changes in attitude and behavior of 48 hospital staff members in Northumbria, England

following a 2-day dementia and delirium program. The authors of this study utilized a grounded

theory approach to develop an educational program with the purpose of educating staff members

and then evaluating their confidence using Likert scales and posters created by participants and

free-text evaluations. Quantitative data collected from the Likert scales was evaluated using

Mann–Whitney U–tests. Qualitative data was not evaluated using a specific method, but

comparisons were made between posters and the educational points of the educational program.

The significant findings of this study were that educational programs have a positive effect on

acute care staff’s knowledge and confidence.

Discussion/Implications

The articles selected for review signify a correlation between dementia training and an

increase in confidence and knowledge of acute care staff. The researcher focused the review

based on the following themes; education and teamwork. The following is a discussion on the

implications of the articles, organized by these common themes and relevance to the PICOT

question.

Education

Education of acute care staff varies as to the level of the staff members, but a majority of

staff members that participated in the studies reported that they had never received dementia

specific training (Elvish, et al., 2013; Martin, et al., 2016). Many participants reported that

orientation and their formal education did not prepare them for working with confused older
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adults (Griffiths, et al., 2013).This theme relates to the PICOT question in that without previous

education, acute care staff are at a greater disadvantage when caring for the increasing number of

patients with dementia (Elvish, et al., 2013; Griffiths, et al., 2013; Teodorczuk, et al., 2014)

Intervention.

Implementation of a dementia training program during preparatory education or

orientation would eliminate some of the barriers to implementing and maintaining training

programs such as; difficulties releasing staff from the ward or arranging training for night staff,

high staff turnover, and participant bias (Elvish, et al., 2013; Griffiths, et al., 2013; Scerri, et al.,

2016). The development of a program with “delivery at prequalifying level would open up the

opportunity to shape professional identity formation at an earlier stage “(Teodorczuk, et al.,

2014), would eliminate barriers such as releasing of staff and special considerations for night

shift staff.

Teamwork

The emphasis on teamwork encourages staff members to assist one another, lessening the

stress that is associated with caring for patients with dementia (Griffiths, et al., 2013;

Teodorczuk, et al., 2014). The stress of caring for patients that staff members feel unprepared to

care for leads to high job turnover, burn out, personal biases and worse patient outcomes (Elvish,

et al., 2013; Griffiths, et al., 2013; Martin, et al., 2016; Teodorczuk, et al., 2014). The theme of

teamwork relates to the PICOT question in that without teamwork the confidence level of staff

members would be lower regardless of training (Griffiths, et al., 2013; Scerri, et al., 2016).

Intervention.

The use of multidisciplinary team meetings and implementing training that involves all levels of

staff are implications included in articles by Griffiths et al. (2013) and Martin et al. (2016). By
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implementing team meetings, staff members can share knowledge and experiences and can

receive feedback on methods used when caring for dementia patients. Future research should

focus on the perceived experiences of staff members when participating in training programs

with various levels of other staff and how this affects the staff member’s behavior and practices.

Limitations

This integrative review is limited in areas such as experience of the writer, number of

articles included, and it is not an exhaustive review of the literature. The inexperience of the

researcher in conducting an integrative review, and the lack of knowledge on the subject are an

influencing factor on limitations. The researcher has limited experience in the subject of

dementia training as a nursing student with a history of employment in assisted living, therefore

significantly limiting the insight into the subject of the PICOT question.

The articles used in this review contained a majority of studies that were performed in the

United Kingdom, therefore this review is not comprehensive of global practices. In terms of

study design, none of the articles included were randomized control trials, which limits the

reliability of results (Scerri, et al., 2016). Samples of a majority of the studies did not include all

levels of staff in the acute care setting, samples were limited to medical professionals (Elvish, et

al. 2013; Griffiths, et al., 2013; Martin, et al., 2016).

Conclusion

The results collected for this integrative review supports the positive correlation between

dementia training and acute care staff confidence and knowledge (Elvish, et al.,2013; Griffiths,

et al., 2013; Martin, et al.,2016; Scerri, et al., 2016; Teodorczuk, et al., 2014). This is related to

the themes of education and teamwork. Acute care staff felt more confidence and knowledgeable

in the care of patients with dementia after attending training programs (Elvish, et al., 2013;
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Martin, et al., 2016; Scerri, et al., 2016; Teodorczuk, et al., 2014). Future studies on the effects of

dementia training should include evaluation of practice changes and patient outcomes (Scerri, et

al., 2016). Researchers need to address the lack of inclusion of all staffing levels in acute care

settings in future research, as well as assessing the quality and replicability of the study. The

PICOT question of, “In acute care staff, what is the effect of dementia training on confidence and

knowledge compared with staff without training?” was addressed and the literature reflects the

increase of confidence and knowledge of acute care staff with dementia training compared to

those without training.

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References

Elvish, R., Burrow, S., Cawley, R., Harney, K., Graham, P., Pilling, M., . . . Keady, J. (2013).

‘Getting to Know Me’: The development and evaluation of a training programme for enhancing

skills in the care of people with dementia in general hospital settings. Aging & Mental

Health,18(4), 481-488. doi:10.1080/13607863.2013.856860

Griffiths, A., Knight, A., Harwood, R., & Gladman, J. R. (2013). Preparation to care for confused

older patients in general hospitals: A study of UK health professionals. Age and Ageing,43(4),

521-527. doi:10.1093/ageing/aft171

He, W., Goodkind, D., & Kowal, P. R. (2016, March). (United States of America, U.S Census

Bureau, International Population Reports). Retrieved from

https://www.census.gov/content/dam/Census/library/publications/2016/demo/p95-16-1.pdf

Martin, L. S., Gillies, L., Coker, E., Pizzacalla, A., Montemuro, M., Suva, G., & Mclelland, V.

(2016). An Education Intervention to Enhance Staff Self-Efficacy to Provide Dementia Care in

an Acute Care Hospital in Canada. American Journal of Alzheimers Disease & Other

Dementiasr,31(8), 664-677. doi:10.1177/1533317516668574

Scerri, A., Innes, A., & Scerri, C. (2016). Dementia training programmes for staff working in

general hospital settings – a systematic review of the literature. Aging & Mental Health,21(8),

783-796. doi:10.1080/13607863.2016.1231170

Teodorczuk, A., Mukaetova-Ladinska, E., Corbett, S., & Welfare, M. (2014). Learning about the

Patient: An innovative interprofessional dementia and delirium education programme. The

Clinical Teacher,11(7), 497-502. doi:10.1111/tct.12203


INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
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Table 1- Article Evaluation
Ruth Elvish 2013
Doctorate in clinical psychology, research fellow at the University of Manchester
Effect of dementia training program on the confidence and knowledge of staff members of a general
hospital
Mixed quantitative and qualitative study using the pre-posttest method, as well as semi open-ended
questions. Participants completed the CODE and KIDE scales before and after completing the 6 hour
dementia program “Getting to Know Me”.
Sample of 72 hospital staff members from units with a majority of patients were over 65. This study
was performed in a general hospital in the U.K. Ethical approval was given by Royal Bolton Hospital
NHS Foundation Trust Research and Development Office.
CODE- confidence in dementia scale, a 9-item questionnaire where participants ranked statements
from not confident to very confident.
KIDE- knowledge in dementia scale, a 16-item questionnaire where participants scored items as
agree or disagree.
Data was collected from participants using CODE and KIDE and a controllability of beliefs scale
before and after the “Getting to Know Me” program.
On the CODE and KIDE scales the Wilcoxon signed-rank test was used to analyze the data. On the
Controllability of beliefs scale, paired sample t-test were used for analysis as the results were
normally distributed.
52% of the sample stated that they had not previously received training on dementia. The results of
the pre-test and post-test analysis showed significant changes in confidence (CODE) and knowledge
(KIDE) after the Getting to know me program. The results from the portion relating to beliefs about
challenging behavior showed minimal changes that was determined to be encouraging as this change
was indicative of a shift towards person-centered care.
The results of this study reinforce the need for more research into the effect of dementia training on
patient outcomes and staff behavior as there is a need for improvement in the care of dementia
patients in the hospital setting.
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First Author Amanda Griffiths 2013

(Year)/Qualifications - has a master’s and PhD in psychology and is a professorial fellow at the Institute of Mental Health

Background/Problem Analyze the perceptions of healthcare workers preparedness to care for the confused older adult in a
Statement UK hospital

Conceptual/theoretical Phenomenological study

Framework
Design/ Qualitative study, using interviews with open-ended questions
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical 60 healthcare professionals from a UK hospital. Ethical considerations were made, and responses
Considerations were anonymized and approval for this study was granted by the Bradford research Ethics committee
and informed consent was obtained

Major Variables Studied

(and their definition), if
appropriate
Measurement Tool/Data Interviews with open-ended questions were used to collect the data.
Collection Method

Data Analysis Data analysis was done using NVivo8 software and categories were identified.
These categories included knowledge and skills necessary for the job, Interactions with patients and
colleagues and Effects on staff.

Findings/Discussion Findings of this article support further research and the need for education for all healthcare
providers as pre-graduate education had not prepared providers for the challenges associated with
patients with cognitive impairments.

Appraisal/Worth to practice This study is the first step in designing education for healthcare providers as the results of this study
found areas in which education was lacking.

INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
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Lori Martin 2016.
PhD, RN, Associate professor at Daphne Cockwell School of Nursing and Ryerson University,
Toronto, Ontario, Canada
With the number of people worldwide with dementia projected to double every 20 years, it is
necessary to prepare the healthcare work force as the number of patients in the acute care setting
with dementia increase. Evaluation of an education program called Gentle Persuasive Approaches.
Conceptual framework of the intervention correlates environmental, physical, interpersonal, and
social factors. Quasi-experimental
This study consisted of Self-Perceived Behavioral Management Self- Efficacy Profile (SBMSEP)
completed by participants of the intervention and control groups before the intervention (GPA) and
then 8 weeks after the program, the intervention group completed an addition immediate post-
intervention SBMSEP. Additional focus groups were formed post-intervention and conducted
interviews with semi structured questions.
Philosophical underpinnings of the intervention (GPA) – humanism and personhood
The participants consisted of 745 acute care staff members with 468 participating in the intervention,
all employed at a large teaching hospital in Ontario, Canada
Self-Efficacy
10 item Self-Perceived Behavioral Management Self-Efficacy Profile (SBMSEP) and 3 opened
ended questions.
Data was vigorously analyzed; first demographic data was analyzed and rigor was proven using x2-
tests to determine that the control and intervention groups did not differ significantly in terms of
demographic variables. A 2-way repeated-measures analysis of variance was done on all participants,
then a 1-way repeated-measures ANOVA was done to examine changes in the scores of the
intervention group .
The majority of participants were female, age 40-49. Pre intervention scores showed the control
group having a higher SBMSEP score than the intervention group. Post intervention and Immediate
post intervention scores of the intervention group was significantly elevated compared to the control
group.
This study’s results are reflective of a positive relationship between training and staff confidence,
competence and knowledge.

INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
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Anthony Scerri 2016.
Masters in Geriatrics, master’s in health sciences (HSM), RN
To summarize the literature available that evaluates dementia training programs in the hospital
setting.
Narrative synthesis
Systemic literature review
14 peer review studies
Characteristics of training program
Quality assessment
Effectiveness of training programs according to level of training evaluation
Literature from PubMed, Academic Search Complete, PsychInfo, CINAHL and AgeLine were
retrieved using the search criteria demntia or Alzheimers and hospitals and training and education
and evaluation.
Data analysis was done using Kirkpatrick’s four level training evaluation model.
None of the studies reviewed included Randomized Controlled trials, quality analysis of the studies
revealed variability in quality. Methods of delivery of training programs varied as well as the
learning outcomes expected from the participants
This systemic literature review informs of the lack of research on the changes in staff practices and
patient outcomes after participating in a training program. This review is an important piece in the
continuation of research into dementia training in the hospital setting as it reveals the limitations and
effective components of studies conducted on dementia training.

INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
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Andrew Teodorczuk 2014
-Associate Professor in Psychiatry, Griffith University, Queensland, Australia.
-Old Age Psychiatrist, Doctorate
Evaluation of staff confidence after a 2 day program targeting the management of confused older
adults.
Grounded Theory
Mixed methods study
Biggs’ constructive alignment
48 health professionals from a hospital in Northumbria, England, including nurses, health care assistants,
domestic staff, ward clerks, modern matrons, physiotherapists, occupational therapists, doctors, pharmacists,
and porters. Ethical consideration was sought from the National Research Ethics Service (NRES) North East
Committee, but committee approval was not needed.
Likert scores pre and post intervention
Changes reported by staff after training in free-text evaluations
Mann–Whitney U–test for quantitative data collected during the pre and post-intervention evaluations
Review of posters produced by the participants and examining free-text comments from the
evaluations
Statistically significant improvement in participant Likert scores. The themes touched on during the
course were reflected in the posters created by participants during the post-intervention period
reflected change in attitudes and knowledge. Free-text evaluations in the post-intervention period
included participants ability to apply the information to practice and the feeling of empowerment.
The findings from this article reiterate findings from other studies that also positively associate
dementia training with increased staff knowledge. This study also includes staff members from
varying levels of education and job title, from doctors to porters.