Virtual Reality-Based Training Has Potential to Improve Dementia Knowledge, Attitudes, and Sense of Competence of Physical Therapists and Occupational Therapists

Abstract

Aim

(i) Evaluate the perceived effect of the Enabling EDIE Acute workshop on dementia knowledge, attitudes toward dementia, and sense of competence of physical therapists, occupational therapists, allied health assistants, and physical therapy students. (ii) Determine if a greater perceived effect was observed within subgroups of the study population.

Methods

A pretest–posttest study with a three-month follow-up was conducted with participants who attended a virtual reality-based Enabling EDIE Acute workshop.

Results

Participants (n = 96) predominately had no previous dementia training, were physical therapists (45%), female (70%), and had a mean age of 32.5 (SD 9.7) years. Total scores for dementia knowledge, attitudes, and sense of competence improved immediately post workshop and/or at the three-month follow-up.

Conclusion

Virtual reality-based training, such as the Enabling EDIE Acute workshop, appears to be an effective component of dementia education for allied health professionals. Further research is needed to confirm, and expand on, these findings.

ANZCTR reference number

ACTRN12619001095156

Keywords:

• Dementia
• allied health
• virtual reality
• healthcare education

Introduction

Dementia is one of the major causes of disability and dependency among older adults worldwide, with more than 55 million people currently living with the syndrome.¹ In Australia, in 2020–2021 dementia was recorded as the principal diagnosis in two out of every 1,000 hospitalizations (approximately 25,500 over 12 months) and the average Length of Stay (LoS) (13 days) for people living with dementia was five times higher than the average LoS for all hospitalizations (2.6 days).² Functional decline is one of the key features of dementia and can contribute to the need for hospital admission. Allied Health Professionals (AHPs) such as Physical Therapists (PTs) and Occupational Therapists (OTs) have the required skillset to address functional decline.³ Input by PTs and OTs is supported by the Australian Clinical Practice Guidelines and Principles of Care for People with Dementia, which recommend people living with dementia be encouraged to exercise and those living in the community be offered OT interventions.³

To ensure PTs and OTs can provide effective care to people living with dementia, it is important they participate in dementia-specific training.³ Current research suggests that dementia care and training, particularly in the acute care setting, is suboptimal and does not adequately equip healthcare professionals to be receptive to the needs of people living with dementia.⁴ An Australian study found most rehabilitation-based healthcare professionals considered dementia as a low priority for intervention and were skeptical about the capacity of people living with dementia to participate in rehabilitation, highlighting the need for training to target healthcare professionals’ perceptions of people living with dementia.⁵ Many healthcare professionals and care staff report a lack of dementia knowledge, and do not feel prepared to provide care to people living with dementia despite having traditional education and professional dementia training.^6–9

To provide best practice care, training should go beyond knowledge and skill acquisition, and also support healthcare professionals to develop an empathic understanding of people living with dementia.^8,10,11 One study found when conducting dementia-specific training, a blend of theoretical content alongside interactive and practical activities (including experiential learning) was the most effective method for enhancing empathy and communication with people living with dementia.⁴ Virtual Reality (VR) is a computer-generated simulation with three-dimensional images or environments that can be interacted with in a seemingly real way, and has been gaining popularity as an experiential learning tool in the healthcare setting.^12–14 Over recent years a number of VR interventions have been developed to help people better understand dementia, examples include the Frail Aging Suit,¹⁵ Into D’mentia simulation cabin,¹⁶ Virtual Dementia Experience,¹⁷ and Enabling Educational Dementia Immersive Experience (EDIE) Original and Acute workshops.¹⁸ Studies have shown positive results among doctors, nurses, pharmacists, medical students, and informal carers, suggesting VR is a viable tool in dementia-specific training in healthcare.^14,16,19,20 However, there are a lack of dementia-specific VR training studies involving AHPs.²¹

This study aimed to evaluate the perceived effect of the Enabling EDIE Acute workshop on (i) dementia knowledge, (ii) attitudes toward dementia, and (iii) sense of competence in dementia care of PTs, OTs, Allied Health Assistants (AHAs), and PT students. The secondary aim of this study was to determine if a greater perceived effect was observed within subgroups of the study population (profession, years of experience, previous dementia training, and personal experience with dementia). It was hypothesized that the Enabling EDIE Acute workshop would have a positive impact on dementia knowledge, attitudes, and sense of competence among the study population, with a greater improvement observed in less experienced clinicians and students.

Materials and methods

Study design and setting

A pretest-posttest design with a 3-month follow-up was conducted between January and June 2021. The study took place at hospitals within the South-Eastern Sydney Local Health District (SESLHD) and Macquarie University, New South Wales, Australia. Ethical approval was granted by the SESLHD Human Research Ethics Committee (reference number: ETH12158) and the Macquarie University Human Research Ethics Committee (reference number: 52020790522091). The study was registered on the Australian and New Zealand Clinical Trial Registry (reference number: ACTRN12619001095156).

Participants

Participants were recruited via study posters (that included the contact details of the research team) circulated on noticeboards in relevant wards, allied health offices, and university departments, via work and university emails, and during allied health team meetings. Interested participants contacted the research team for further information and to ensure they met the selection criteria before provided written, informed consent. PTs, OTs and AHPs that worked within the SESLHD, and Doctor of PT students from Macquarie University were included if they had not previously attended an Enabling EDIE Acute workshop, and provided written, informed consent.

Intervention: Enabling EDIE Acute workshop

Enabling EDIE Acute workshop is owned and developed by Dementia Australia in commercial arrangement with Deakin University, Applied Artificial Intelligence Institute.¹⁸ The aims of the workshop are: to enhance knowledge and understanding of dementia, identifying causes of excess disability for people living with dementia and clinician/staff stress in the workplace, how to reduce such impacts, and how to support people living with dementia through communication and environment. The one-hour workshop commences with the multisensory VR component (using a smartphone-app that was developed for use with the Samsung Oculus Go mobile headsets) to provide participants with a perspective of dementia through a virtual experience they navigate through by physical movement of the head.²² The experience simulated cognitive and perceptual difficulties a person living with dementia may encounter whilst trying to access and use the toilet.^18,22 The group discussion component is led by a Dementia Australia facilitator (has nursing, community care or similar background) and includes discussions on spatial awareness and dementia, increased stress, communication approaches, debrief on the VR experience, and self-reflection of the work environment.¹⁸ The aim of this component is designed to help participants in applying the learnings to their practice. Further details on the Enabling EDIE Acute workshop can be found on the EDIE - Educational Dementia Immersive Experience webpage.¹⁸

Data collection and outcome measures

Data were collected via surveys hosted on the Qualtrics online platform at three-time points: One week prior to the workshop (pre-workshop), immediately after the workshop (post-workshop), and three months after the workshop (follow-up). Three validated scales were included in all surveys: Dementia Knowledge Assessment Scale (DKAS), Dementia Attitudes Scale (DAS), and Sense of Competence In Dementia care Staff (SCIDS). The perceived effect of the Enabling EDIE Acute workshop on all three scales was considered for the total study population, as well as by profession (PTs, OTs, PT students and AHAs), years of experience (PT student, <2 years, 2–5 years, 5–10 years, >10 years), previous dementia training (yes/no), and personal experience with dementia (interacted with, supported, or provided informal care for a family member or friend living with dementia) (yes/no). Participant demographics were collected in the pre-workshop survey.

The DKAS is a 25-item scale (four subdomains) used to measure dementia knowledge among healthcare professionals and the general public.²³ Each statement is answered on a modified 5-point Likert scale resulting in a total score between zero and 50, with a higher score indicating greater knowledge.²³ The DKAS is a reliable and valid measure of dementia knowledge with an acceptable level of internal consistency for the overall score (Cronbach’s $\alpha$ = 0.85) and subscales (Cronbach’s $\alpha$ ranged between 0.65 and 0.76).²³

The DAS is a 20-item (two subdomains) scale that measures attitudes toward people living with dementia.²⁴ Each item is scored on a 7-point Likert scale with overall scores ranging from 20 to 140, and a higher score indicates a more positive attitude.²⁴ The DAS has demonstrated good internal validity (Cronbach’s $\alpha$ = 0.83–0.85).²⁴

The SCIDS is a 17-item (four subdomains) scale developed to measure sense of competence among dementia care staff.²⁵ Items are scored using a 4-point Likert scale with overall scores ranging from 17 to 68; a higher score reflects a higher level of confidence.²⁵ The SCDIS has shown good internal consistency for overall score (Cronbach’s α = 0.91), and all subdomain scores (Cronbach’s α ranged between 0.70 and 0.83).²⁵

Statistical analysis

Descriptive statistics were used to detail participants’ demographics and overall and subdomain scores for all three scales (DKAS, DAS, SCIDS). The Friedman test was used to compare scores across the three timepoints for all three scales. The change in scores between timepoints for all three scales were compared between participants based on profession and years of experience using the Kruskal–Wallis test, and previous dementia training and personal experience with dementia using the Mann–Whitney U test. Data analysis was conducted using the SPSS Statistics 28 software package (IBM Corp. in Armonk, NY). The significance level of all tests was set at p value < 0.05. To prevent re-identification of data, variables with counts smaller than 5 were reported as ‘<5’.

Results

Ninety-six participants (across seven Enabling EDIE Acute workshops) completed the pre- and post-workshop surveys, of those 53 (55%) also completed the 3-month follow-up survey. Participants were predominately PTs (45%), female (70%), and had a mean age of 32.5 (SD 9.7) years (Table 1). Majority of the participants had no previous dementia-specific training (73%) and had not provided informal care to person(s) with dementia (83%).

Table 1. Participant demographics (n = 96).

Variable	Mean (SD)
Age	32.5 (9.7)
	n (%)
Gender
Female	67 (70)
Male	29 (30)
Profession
PT student or AHA*	30 (31)
PT	43 (45)
OT	23 (24)
Years of experience
PT student	25 (26)
<2 years	19 (20)
2–5 years	20 (21)
5–10 years	11 (12)
>10 years	21 (22)
Current specialty
PT student	28 (29)
Aged care	25 (26)
Outpatients	7 (7)
Community	6 (6)
Neurology	9 (9)
Respiratory	6 (6)
General medicine	15 (16)
Years worked with people living with dementia
PT student	26 (27)
<2 years	24 (25)
2–5 years	20 (21)
5–10 years	11 (12)
>10 years	15 (16)
Previous dementia-specific training
Nil	70 (73)
Internal in-service training	13 (14)
External organization	11 (12)
Both internal and external training	<5
Unspecified training	<5
Personal experience with dementia
Yes	39 (41)
No	53 (55)
Unsure	<5
Provision of informal care to person(s) with dementia
Currently provide care	<5
Previously provided care	11 (12)
No	80 (83)
Prefer not to answer	<5

* Due to low rate of AHAs recruited and to prevent re-identification, PT students and AHAs combined into one profession group.

SD: Standard Deviation; PT: physical therapist; OT: occupational therapist; AHA: Allied Health Assistant.

Dementia knowledge

Total DKAS score demonstrated a significant improvement post workshop (p < 0.001), which showed further significant improvement at the three-month follow-up (p < 0.001). All subdomains (causes and characteristics, behavior, care considerations, and risk factors) improved across all timepoints, though this improvement was only significant (p < 0.001 for all) at the 3-month follow-up (Table 2).

Table 2. DKAS, DAS and SCIDS scores for total study population at all timepoints (n = 96).

Outcome measure	Pre-workshop median (range)	Post-workshop median (range)	p value^	Follow-up median (range)	p value^^
DKAS (47% missing at follow-up)
Total	20.5 (4–30)	22 (8–30)	*0.012	39 (18–50)	*<0.001
Subdomains:
Causes and characteristics	8 (0–12)	9.5 (0–12)	1.000	12 (3–14)	*<0.001
Behavior	5 (0–9)	6 (0–10)	0.647	10 (3–12)	*<0.001
Care considerations	2.8 (1.9)	3.3 (1.9)	0.544	9.6 (2.5)	*<0.001
Risk factors	3 (0–8)	4 (0–9)	1.000	9 (5–12)	*<0.001
DAS (47% missing at follow-up)
Total	102 (81–123)	104.5 (78–129)	1.000	112 (88–138)	*<0.001
Subdomains:
Dementia knowledge	61 (40–70)	60 (46–70)	0.129	59 (48–70)	0.129
Social comfort	43 (28–55)	44 (30–59)	0.704	56 (24–68)	*<0.001
SCIDS (1% missing at pre, 49% missing at follow-up)
Total	44 (25–63)	48 (31–67)	*<0.001	49 (33–68)	*<0.001
Subdomains:
Professionalism	14 (8–20)	15 (10–20)	0.318	15 (11-20)	*0.002
Relationship	9 (4–16)	11 (7–16)	*<0.001	11 (7-16)	*<0.001
Care challenges	9 (4–14)	10 (6–16)	*0.002	11 (6-16)	*<0.001
Personhood	12 (6–16)	12 (8–16)	0.147	12 (8-16)	*0.001

^Pre- and post-workshop Friedman test.

^^Pre- and follow-up workshop Friedman test.

* p < 0.05.

SD: Standard Deviation; DKAS: Dementia Knowledge Assessment Scale; DAS: Dementia Attitudes Scale; SCIDS: Sense of Competence in Dementia Care Scale.

Attitudes toward people living with dementia

The total DAS and the social comfort subdomain scores improved both post-workshop and at the three-month follow-up; these improvements were only significant at the 3-month follow-up (p < 0.001 for both). The mean knowledge subdomain score trended down (not statistically significant) across all timepoints (Table 2).

Sense of competence in dementia care

Total and the relationship and care challenges subdomain scores for the SCIDS showed significant improvements post-workshop and at 3 months follow-up, p value ranged from 0.002 to <0.001 (Table 2). By the 3-month follow-up, the other subdomains (professionalism and personhood) also showed significant improvement (p 0.002 and 0.001, respectively)

Subgroup analyses

Within the study population subgroup analysis was completed based on key variables: Profession, years of experience, previous dementia training, and personal experience with dementia (Supplemental Table 1). No significant changes in DKAS scores were observed between any subgroups. At the 3-month follow-up, participants who had completed previous dementia training prior to attending the Enabling EDIE Acute workshop showed a significantly greater improvement (p = 0.044) in DAS score in comparison to those who had not. A significantly greater improvement (p = 0.036) in DAS score at the 3-month follow-up was also observed in participants who had personal experience with dementia in comparison to those who had none. However, participants who did not have personal experience with dementia did show a significantly greater improvement in SCIDS score post workshop (p = 0.029). A greater improvement in SCIDS score post workshop was also observed in PT students and AHAs in comparison to PTs and OTs, though it was only significant in comparison to PTs (p = 0.036).

Discussion

This study evaluated the perceived impact of the Enabling EDIE Acute workshop (VR-based dementia training for individuals that work in acute care settings) on dementia knowledge, attitudes, and sense of competence. It also explored if there were greater changes in the primary outcomes within subgroups of the study population (profession, years of experience, previous dementia training, and personal experience with dementia). Previous studies that have considered the utilization of VR in healthcare education (including dementia-specific studies) have predominately been conducted with doctors, nurses, pharmacists, and medical students,^14,16,19,20 with very limited research involving AHPs.²¹ Therefore, this study focused on PTs, OTs, AHAs, and PT students.

This study suggest VR-based training can positively impact dementia knowledge as demonstrated through statistically significant improvements of the DKAS median total score both post-intervention (p = 0.012) and at the 3-month follow-up (p < 0.001). These findings are further supported by another Australian study that evaluated the impact of a multisensory VR and practical discussion workshop developed by Dementia Australia (Virtual Dementia Experience)¹⁷ on dementia knowledge of medical and pharmacy students, which also demonstrated a significant improvement (p < 0.01) though using the DAS knowledge subscale.¹⁴ In contrast to the Gilmartin-Thomas et al.¹⁴ study, the DAS knowledge subscale score in this study (which had been selected to primarily assess attitudes and not knowledge) showed a non-significant reduction (median score reduced from baseline by one point immediately post intervention, and by two points at the 3-month follow-up).

The variation of knowledge scores between outcome measures, and between studies may be due to the difference in quantity and variety of knowledge factors considered in the two outcome measures and the type of study participants. The 25-item DKAS considers four factors of knowledge (causes and characteristics, communication and behavior,’ care considerations, risk and health promotion) and was developed to overcome known issues within other dementia knowledge scales, such as ceiling effects, poor sensitivity, item ambiguity, and limited biomedical focus.²⁶ Whereas the DAS was developed to primarily assess attitudes, and the knowledge subscale consists of 10 items that only focus on cognitive knowledge.²⁴ This may result in a ceiling effect when the DAS is used to assess knowledge: This study primarily included healthcare professionals (69%) that are likely to have more clinical experience and knowledge at baseline then the student participants (midway through their degree) in the Gilmartin-Thomas et al.¹⁴ study. Considering such factors along with the findings from this study, the DKAS appears to be more suitable when assessing dementia knowledge among healthcare professionals.

Attitudes can impact the healthcare professional’s clinical decisions and their interactions and relationships with clients, thus impacting client outcomes.¹⁰ One study found healthcare staff with a positive attitude were more likely to provide holistic care to people living with dementia even in the presence of negative behaviors from the person. Whereas negative attitudes resulted in avoidance or reduced interactions with people with dementia and had the potential to lead to poorer health outcomes.¹¹ Therefore, it was considered important to evaluate the perceived impact of the Enabling EDIE Acute workshop on dementia attitudes and sense of competence. This study demonstrated improvements in both attitudes and sense of competence, supporting the findings of other studies that have shown VR-based training can improve attitudes and sense of competence among healthcare professionals (e.g. doctors, nurses, pharmacists, medical students, and informal carers) in geriatric and dementia care settings.^{14–16,19,20,27,28}

In this study, statistically significant improvements were observed in the SCIDS median score both immediately post workshop (p > 0.001) and at the 3-month follow-up (p > .001). The DAS median score also improved at both timepoints, though the improvement was only statistically significant at the three-month follow-up (p > 0.001). These findings suggest that a single VR-based workshop may be able to impact AHPs’ and PT students’ sense of competence immediately but may not be enough to change attitudes alone, and that actual experiences and time working with people living with dementia are also needed. This is further supported by the trends observed in the subgroup analysis: At the 3-month follow-up participants that had previous dementia experience (either completion of previous dementia training or personal experience) achieved a statistically significant greater DAS score (p = 0.044 and p = 0.036, respectively) than those with no dementia experience. Whereas those who did not have personal experience with dementia achieved a statistically significant greater SCIDS score (p = 0.029). Therefore, future dementia education research should consider, which methods are the most effective in targeting different components of learning (e.g. knowledge, attitude, sense of competence, practical skills),²⁹ as well as methods that motivate healthcare professionals based on degree of (formal and informal) experience. For example, research suggests that as expertise and experience grow so does the need and preference for interactive learning (e.g. VR-based training).³⁰

This study has several strengths, including being one of the first to consider the impact of VR-based dementia training on AHPs and PT students. This study has helped to contributed to the Clinical Practice Guidelines and Principles of Care for People with Dementia Committee identified need for dementia-care training that addresses attitude, knowledge, and skill development as a priority area for research translation.³ It collected data not just on knowledge, but also attitudes and sense of competence, which could be considered more important factors due to their impact on clinical decision making, interactions and relationships with clients, and client outcomes.¹⁰ Using a variety of outcomes (that consist of multiple factors) can help to highlight areas healthcare education (undergraduate and postgraduate) should target to help improve the care of people living with dementia.

The main limitations of this study are associated with the pretest-posttest design and sample size (n = 96). There was no control group or randomization, and by the 3-month follow-up a high attrition rate (almost 50%) resulted in a small sample size for this stage of analysis. Therefore, the findings of this study should be considered with caution as they are based on the perceived impact of the Enabling EDIE Acute workshop on the selected outcomes (knowledge, attitudes, sense of competence) from a relatively small sample (at follow-up) of AHPs. This study only recruited participants from one university and one local health network, so the results may not be generalizable to a wider population of PTs, OTs, AHAs, and PT students. However, the promising findings do warrant further consideration of the Enabling EDIE Acute workshop using a Randomized Controlled Trial (RCT) with participants from multiple sites to determine the true impact. There are ongoing costs associated with the provision of VR training, like the Enabling EDIE Acute workshop, which could be a potential barrier. Therefore, it is important that future studies also consider the cost-effectiveness to help determine the sustainability of VR in healthcare education.

The VR-based dementia training, Enabling EDIE Acute workshop improved perceived dementia knowledge, attitudes, and sense of competence of PTs, OTs, AHAs, and PT students. These findings support the use of VR as a suitable tool in the provision of healthcare (specifically dementia care) education. This type of technology allows training to go beyond knowledge acquisition, also addressing the attitudes and sense of competence of AHPs, which can facilitate more effective and empathetic care of people living with dementia. Further research is needed to confirm and expand on the findings of this study to support the implementation of evidence-based dementia education for AHPs.

Author contributions statement

LB led the conception and design of this study and was involved in data collection, data analysis and interpretation, drafting and revising the paper, and final approval of the version to be published. AK was involved in data collection, data analysis, drafting and revising the paper, and final approval of the version to be published. Both authors agree to be accountable for all aspects of this work.

Acknowledgements

The authors would like to acknowledge the physical therapists, occupational therapists, allied health assistants, and PT students who volunteered to participate in this study, and the Dementia Australia facilitators who conducted the Enabling EDIE Acute workshops.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the POW Hospital Foundation under the Annual Grant Awards 2019; NSW Government under the Health Cross Boundary Grant Program 2019.