Time for Dementia: Quantitative evaluation of a dementia education programme for healthcare students

The future healthcare workforce needs the skills, attitudes, and empathy to better meet the needs of those with dementia. Time for Dementia (TFD) is an educational programme in which healthcare students from a range of professional groups visit a person with dementia and their family carer over a two‐year period. The aim of this study was to evaluate its impact on student attitudes, knowledge and empathy towards dementia.


| INTRODUCTION
The delivery of healthcare to people with dementia is widely recognised as being sub-optimal and a lack of understanding about dementia in the workforce is seen as a contributing factor. 1 The increasing numbers of people with dementia, driven by population ageing, demand a future healthcare workforce with the necessary knowledge, positive attitudes, and skills to deliver effective assessment and support to those living with the condition. To date, dementia education for undergraduate healthcare students has generally failed to meet this aspiration. 2 With its reliance on didactic teaching and emphasis on acute episodes of care, there is a need for undergraduate teaching to adapt to produce a future multiprofessional workforce able to rise to the complex challenges of ageing and dementia for both generalists and specialists.
Educational innovation to meet this challenge has taken place through the involvement of people living with dementia and their carers. Allowing healthcare students at the beginning of training to engage with people with dementia and their carers provides an opportunity to build more positive attitudes towards dementia before more negative and pessimistic attitudes can take hold and become fixed. Newer models of dementia education which directly involve people with dementia include longitudinal approaches and activitybased interventions such as intergenerational art projects. 3 The longitudinal model developed by Mordhardt and colleagues, 4 the Buddy Program, is an elective curricular component, where medical students are paired with a person with dementia and undertake community visits and activities together. The original programme has grown across North America, and the model has been used across a number of different contexts, such as the 'Friend for Rachel' model for pre-medical students (undergraduate and post-baccalaureate students preparing for medical school). 5 The advantages of such longitudinal models are that healthcare students can hear first-hand what it is like to live with dementia and gain an understanding of living with long-term chronic illness, and through continuity of contact build relationships that may foster positive attitudes and person-centred care. 6,7 One programme that builds on this concept, is the TFD programme which was developed in the UK, with support from Health Education England, at Brighton and Sussex Medical School in 2014. 8 Unlike the Buddy Program, which is designed to accommodate only a relatively small number of interested students in any institution, TFD is delivered as a mandatory component of the curriculum. This means that the whole year participates, not just those with an interest in dementia. It was also explicitly developed to be delivered to all healthcare student groups, not just medical students. The learning objectives of TFD are to increase positive attitudes, knowledge, and empathy in students by developing a broader understanding of the impact and experience of dementia.
An initial evaluation of the TFD programme showed that: (a) it was possible to deliver the programme at scale as a mandatory component of the curriculum; and (b) there were improvements in dementia knowledge and attitude change in medical students who undertook the programme compared to students who did not. 9 Qualitative interviews and focus groups with medical, nursing and paramedic students also identified improvements in the depth of dementia understanding, challenging of negative attitudes, and increased confidence in delivering person-centred care in practice. 10,11 Due to these positive preliminary findings, TFD was expanded across the south of England to include a wider range of healthcare students. The aim of the study reported here was to evaluate this wider and more representative expansion of TFD in terms of its impact on student attitudes, knowledge and empathy towards dementia.

| Design
A longitudinal survey was administered to healthcare students before (Baseline) and at the end of the programme (24 months), and at equivalent time points in training for a control group of students who had not taken part in the programme. Measures of knowledge, attitudes, and empathy were completed at both timepoints; demographics and previous experience of dementia were ascertained at baseline. Students then undertake a 2-h preparatory session which makes clear the expectations of the programme, structure and guidelines for visits, and communication with people with dementia. After this, pairs or trios of students visit a person with dementia and their family for 2 h every 3-4 months for a total of 5-6 visits. During the visits, students follow a suggested visit structure linked to core learning objectives. For example, the first visit is focussed on understanding the family's background, events leading up to diagnosis of dementia and the experience of diagnosis, whereas the second visit is focussed on life since the diagnosis, and experiences of services. Further details of the intervention can be found in previous publications. 8,9 In this study, the programme was delivered to nursing, medical, paramedic and allied health professional (AHP; including occupational therapy, physiotherapy, speech and language therapy, radiology) students. Depending on curriculum fit, the programme starts in either the first or second year of training.

| Study setting and participants
The intervention group consisted of healthcare students participating in TFD between 2014 and 2020 at five universities in the south of England: Brighton and Sussex Medical School, University of Surrey, University of Brighton, University of Greenwich, and Canterbury Christ Church University. Participation in TFD was mandatory for students where TFD was included in the curriculum, but participation in the evaluation was not. The control group included cohorts of equivalent healthcare students who did not take part in TFD at these five universities as well as Norwich Medical School. In total 24 intervention and 8 control student cohorts were invited to take part in the study. All students were invited to take part in the evaluation within scheduled lectures. They were given an information sheet in advance, and written consent was obtained. The study was approved

| Outcomes measures
All students completed the same battery of instruments at baseline and 24 months later. For all outcomes, higher scores indicate a higher, or more positive, level of the attribute.

| Statistical analysis
Demographic and outcome data were summarised by group (intervention or control) using means and standard deviations for normally distributed variables, medians and means for skewed continuous variables and frequencies and percentages in categories for categorical variables.
For the primary analysis, outcomes were modelled using twolevel multilevel linear regression models. Students attended visits in pairs or trios and therefore group membership was included as a random effect. Independent variables included in the models were: the outcome at baseline (continuous), student age (continuous), student gender (female/male), student previous experience of dementia

| Student recruitment and demographics
In the intervention group, 3619 students were eligible 1 to take part and 2700 (74%) consented to participate in the evaluation. In the control group, 863 students were eligible and 562 (65%) consented.
At baseline, 2570 (95%) of the consenting intervention group and 498 (89%) of the consenting control group contributed to the data.     Table 1.

| Intervention group
The scores on the study outcomes for baseline and follow up are presented in Tables 2 and 3. Figure 1   It is interesting to note that there appears to be a 'dose response' relationship, in that student outcomes are higher for students who complete more visits. The importance of longitudinal contact is supported by our qualitative findings 10 which identified the importance of relational learning within TFD. Learning takes place within an authentic meaningful relationship between the person with dementia, their carer and students, which deepens over time. Further research is needed to understand the optimal number of visits, and how the longitudinal nature of the visits underpins the effects observed.

| Number of visits
As in our earlier study of medical students, 9 TFD did not appear to change quantitative measures of empathy, unlike our two qualitative studies 10,21 which identified positive change in terms of empathy towards people with dementia. In terms of potential explanations, first JSE is a generic empathy measure, and its potential limitation in measuring empathy towards people with dementia has been identified in a wider systematic review of empathy interventions for people with dementia. 22 It may be that the measure itself is not sufficiently responsive to change in dementia. Second, there may be issues related to social desirability in students, due to a perception that it may be professionally unacceptable to admit to lower levels of empathy. 23 Third, it is interesting to note that there was a positive change in both intervention and control groups, which challenges the existing body of work that suggests a decline in empathy during healthcare training 24 ; and it may be that other factors such as placement experiences including role models and ward culture might have positive impacts on empathy. Finally, it may be that alternative methods of assessing empathy, for example, patient or carer feedback, might have yielded a more accurate reflection of empathy in practice, 25 which could have been a more meaningful outcome.
There are two main limitations of this study. First, the study was affected by the COVID-19 pandemic through unplanned alterations to the TFD evaluation and programme delivery. Data collection sessions could not take place in person as planned.
Despite active attempts to obtain follow up measures from students, overall this means that the loss to follow up was greater than expected. In terms of the TFD programme and altered delivery, we do not know how the final telephone interactions that took place after March 2020, compared to face-to-face visits. Life for both families and students would have been heavily impacted by the pandemic, and this is likely to have been the focus of the telephone contact, and not wider dementia learning. The impact of the pandemic therefore adds complexity to the interpretation of the research. Second, due to the study design, a number of potential confounders and biases cannot be accounted for in the analyses such as differences in the content of university curriculums, in control groups, and potential responder bias across intervention groups and at follow up. However, this study does have strengths.
First, it is a real-life pragmatic study, which has managed to recruit a high number of participants. Second, the use of comparison groups and controlling for potential confounders (including COVID-19 disruption) within the statistical modelling strengthens the conclusions that can be drawn. Third, the inclusion of a broad range DALEY ET AL.
-7 of 9 of professional groups in training across different universities widens the generalisability of the findings.

| CONCLUSION
There is a pressing global requirement that the future workforce is better equipped to support people living with dementia. Evidence based dementia education programmes, such as TFD illustrate that this aspiration can be met and how it can be met. The size and scope of this evaluation demonstrates that TFD can be delivered across a range of training programmes and universities, and suggests that in doing so, TFD can improve the dementia knowledge and attitudes of future healthcare professionals. The future of care for complex conditions such as dementia is teamwork, and strategies like TFD that enable symmetrical understanding of patient needs and experiences are likely to be of particular value in facilitating effective teamwork. The demonstration that people with dementia and their family carers can be deployed at scale as a teaching resource for healthcare students is also an encouragement to the meaningful involvement of patient groups in healthcare education. Further research is required to more fully understand the mechanisms of action of TFD, as well as differential impacts between student types, the optimal number of sessions, and whether change in knowledge and attitude translates into practice.