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Increasing Knowledge, Skills, and Empathy Among Direct Care Workers in Elder Care: A Preliminary Study of an Active-Learning Model

Correspondence: Address correspondence to Kathryn L. Braun, DrPH, Center on Aging, John A. Burns School of Medicine, University of Hawaii, 1960 East-West Road, Biomed C-106, Honolulu, HI 96822. E-mail: kbraun{at}hawaii.edu

	Abstract

TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 
Purpose: We describe the development of a 24-hr curriculum for nonclinical direct care workers in elder care that features active-learning strategies and consumer-directed approaches. Design and Methods: Our curricular design was based on adult education theory and a survey of 70% of the community's service providers. Training was completed by 88 participants, 90% of whom had no prior formal training in elder care. Questionnaires measured participant knowledge, attitudes, and perceived improvements in understanding, empathy, and skills. A subgroup of participants and employers provided additional feedback through focus groups. Results: Participants significantly improved their scores on knowledge and attitude measures. In addition, direct care workers and employers gave the training high marks and identified ways in which the course helped increase workers' competence, empathy toward elders, and self-esteem. Lack of time and funds for training were two major barriers to broader participation. Implications: This active-learning curriculum represents a frugal yet effective way to train current and future direct care workers.

Key Words: Direct care workers • Adult learners • Curricula • Elder care • Geriatrics • Nurse aides • Work-force development

Although providing direct care to vulnerable elders is a demanding job, research shows that medium wages are low ($7.50/hr for personal care attendants and $8.23/hr for home health aides); many direct care workers are employed part time or as independent providers (increasing their need for multiple jobs and reducing options for health care coverage); job turnover is high (40–60% in home care and 70–100% in nursing homes); workers have low educational attainment; and training and licensure requirements are inadequate (Direct Care Alliance, 2004). Although direct care workers who provide services through the auspices of Medicare are required to have 75 hr of formal training and 16 hr of supervised practice, few states have training standards for other direct care workers, including workers providing services through the Administration on Aging (AoA)-funded aging network (Direct Care Alliance; Hewitt, Larson, & O'Nell, 1996). Instead, direct care workers in the aging network most often are trained on the job, and this training may not include basic information on aging. In contrast, many U.S. states require training, internships, and licensure for workers primarily serving nonvulnerable people. For example, barbers need 1,500 hr of training and 2,500 hr of apprenticeship in Maine, cosmetologists need 1,600 hr of training in California, and manicurists need 200 hr of training in Ohio (BeautyTech, 2003).

Increasing standards for direct care workers training is one of five major requirements (along with improved recruitment, retention, wages, and benefits) in ensuring a quality elder care work force (Direct Care Alliance, 2004). Although the literature on educational interventions for nurse aides and other nursing home personnel is expanding (Aylward, Stolee, Keat, & Johncox, 2003), we found no reports of training designed for direct care workers in the AoA aging network. Training programs in nursing homes often emphasize safety and clinical-practice issues and are geared to fit 30- to 60-min inservice blocks (Aylward et al.); however, evaluation studies suggest that these programs often are lecture based, which direct care workers are reported to find boring, repetitious, or irrelevant (Hurd, Joslin, Nakhnikian, & Wilner, 2002; Mercer, Heacock, & Beck, 1993).

In this article we describe the development of the Paraprofessionals in Aging Project (PAP), a 24-hr curriculum designed to improve the knowledge, skills, and empathy among direct care workers providing home- and community-based care to older adults through the AoA aging network. In line with adult learning theory, the curriculum is based on active learning strategies and emancipatory approaches (Cranton, 1994; Freire, 1970; Gardner, 1983; Kolb, 1984). Our work also was informed by a survey of community elder care providers and by literature on interventions with family caregivers, specifically those that have been found to reduce caregiver burden by actively engaging caregivers to learn stress management and coping skills (Schulz et al., 2003).

	The Project

TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 
The development and refinement of the PAP curriculum was undertaken by Hawaii County's Area Agency on Aging (AAA) in partnership with the University of Hawaii Center on Aging with funding from the Workforce Development Division of the Hawaii Department of Labor. This island-county (population 152,000) is predominantly rural. Its two major population centers—Hilo in the east and Kona in the west—are separated by 13,000-ft (3.96 km) mountains.

We were guided in the design and content of the curriculum by findings from a 2001 survey of 70 of 100 service providers operating in Hawaii County, which identified needs for training the broad spectrum of elder care direct care workers in specific topics (e.g., healthy aging, common disease processes), skills (e.g., assessing problems, reporting observations to supervisors), and behaviors (e.g., treating elders with respect). The literature on training direct care workers in long-term care and on reducing burden in family caregivers also supported our inclusion of modules on communication; interpersonal relations, such as dealing with differences and resolving conflict; and self-care, such as managing stress and balancing work and family (Hoffman, 2003; Juleff, 1995; Schulz et al., 2003). Because several, albeit expensive, 80- to 120-hr training programs for certified nurse aides existed in the state, our PAP curriculum did not include clinical-skills training. Our goals were to provide a foundation for nonclinical direct care workers by imparting a basic knowledge of aging, improving assessment and reporting skills, increasing empathy for older adults, teaching strategies to manage stress, and validating the importance of direct care workers.

Survey findings suggested that employers could only give workers a limited amount of paid time off to attend training. Thus, we limited the course to 24 hr of class time, provided through six, 4-hr, stand-alone modules: (a) What is Aging? How Old is Old?; (b) Getting Healthy, Staying Healthy; (c) Understanding Disease and Disability; (d) Being a Successful Caregiver; (e) Death and Dying; and (f) Putting it all Together—Assessing and Reporting (Cheang & Braun, 2003). Funds were provided to offer training in two communities—Hilo and Kona—during 2002 and 2003. Class size averaged 15 direct care workers. In the initial training, our sessions ran for six consecutive Fridays. Because employers complained that participants spent too much time away from their jobs, we ensured that subsequent training was delivered over three consecutive sessions from Friday afternoon to Saturday morning. Each participant received a manual that included session material and a certificate of completion that was recognized by local employers. Employers paid $15 per employee to the AAA to offset duplicating costs. Invited to attend were nonclinical direct care workers—home aides, bath attendants, chore workers, adult day care workers, activities coordinators, meal deliverers, and elder transport drivers—although certified nurse aides and family members were not excluded from participating.

Essential Features of the Curriculum
The curriculum was replete with active-learning activities, including experiential exercises, role playing, debate, self-assessment inventories, video viewing, demonstrations, short writing assignments, case studies, small group work, storytelling, and discussion. We included these activities to accommodate variations in learning style (e.g., experiential, reflective, conceptual, and experimental) and intelligence (e.g., visual–spatial, verbal–linguistic, interpersonal, and body kinesthetic) and to recognize that effective teaching must allow for the expression of intuition, feeling, sensing, and imagination, as well as cognition (Gardner, 1983; Kolb, 1984). Examples of active-learning activities for selected learning objectives are provided in Table 1.

For example, a direct care worker shared her annoyance with a client who asked the same question over and over again. The trainer took this opportunity to talk about separating the person from the disease (dementia), emphasizing that it was a disease that caused the behavior and that the elder was not trying to be annoying. Other participants related similar experiences, and a discussion ensued about how they could reframe their frustration and interact with the elder in new ways, such as by distracting them with an activity. As elementary as this example sounds, this discussion produced an "aha" moment, and the idea of "separating the person from the disease" was listed by about 20% of participants as a significant gain from the program.

	Refining the Curriculum: Methods

TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 
After the initial offering, 16 of the 29 participants in the initial training and 11 employers attended 90-min focus groups to discuss perceived benefits of the course, ways it could be improved, and barriers to training more paraprofessionals. Interviewers asked direct care workers who had attended PAP training to identify ways in which they felt the training helped them in their jobs and how PAP could be improved. They asked employers (including a director of an assisted living facility and supervisors from chore services, friendly visiting, personal care, and day care programs) to describe any observed changes in knowledge, attitudes, or performance of those who attended training and to offer suggestions for improving PAP's delivery.

Findings
The 16 trainees gave PAP high marks and were particularly enthusiastic about its interactive nature. Several of these individuals provided examples of how they had applied new knowledge and skills. For example, one participant used new strategies to help a resistant elder take regular showers, another used new knowledge to help a picky eater increase her intake of nutritious foods, and another used materials from the Death and Dying section to help her terminally ill father prepare an advance directive and explore hospice. Regarding delivery, participants liked that the training was in another facility and that they spent 24 hr getting to know cohort members and the instructor, which helped create a safe environment for sharing. They did not feel that any changes were needed to the content or delivery of PAP as a 24-hr training tool.

In the employer focus group, the 11 participating employers gave the training high marks, gave examples of differences they noticed in employee performance (e.g., "I've noticed that the staff I sent are more creative in handling challenges that come up for them"), and felt others would benefit from it (e.g., "I want all my staff to take this training"). An assisted living provider noted that, "Many of my workers have absolutely no exposure to gerontology ... we were able to do some rearranging of work schedules to let them attend." However, several smaller employers explained that they were bare-bones operations. In Hawaii, AoA providers are reimbursed by unit of service provided. Sending workers to training means serving fewer clients, and this not only inconveniences or puts at risk the elderly clients but it also reduces the amount of reimbursement the provider receives, which could force the provider to cut staff. Work scheduling conflict also was the leading reason for participant dropout. Thus, the only significant refinement of PAP was in its delivery—from six consecutive Fridays to the three consecutive Friday-afternoon to Saturday-morning sessions.

	Assessing Effectiveness: Methods

TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 
We used a nonexperimental design to obtain a preliminary look at program effectiveness and to provide immediate results to the sponsors of the training (Weiss, 1972).

Participants
The AAA recruited participants among service provider agencies supported through AoA funds, its newsletter, and general newspaper advertisements. In total, 117 individuals enrolled in the training, 106 attended at least one training class session, 88 completed the course and the postcourse satisfaction and demographic survey, 81 completed pretests and posttests of knowledge and attitudes, and between 60 and 81 completed module posttests. Of the 29 individuals who did not complete the course, 22 (76%) noted scheduling conflicts at work, and the remainder dropped out for unspecified personal reasons.

Among the 88 participants who completed the course, 78% were female, and 94% spoke English as a first language. The mean age was 46 years (range 18–71), and half of the participants had 12 or fewer years of education. Of those who completed the training, 10% of the participants also had completed certified nurse aide training, whereas 90% had no formal training. Nine of the participants, or 10%, were family caregivers; 50% provided home-based chore, respite, personal care, or transport services; 30% provided personal care services and led activities in adult day care settings; and 10% worked in assisted living facilities. Ethnically, 15% were White, 28% were Native Hawaiian, and 57% were Asian. About half learned about the training through print sources and the other half through employers, coworkers, friends, or family. Half wanted to advance their careers and half attended out of general interest; employed direct care workers had employer support to attend.

Measures
Our pretest–posttest measure of knowledge was What's Your Aging IQ, a 20-item, true–false quiz developed by the National Institute on Aging (1991). We initially tested a 7-point semantic differential attitude scale (Rosencranz & McNevin, 1969), which asked participants to mark their perception of elders on a line between opposite adjectives (e.g., healthy–frail), with one extreme (e.g., healthy) labeled as more positive than the other (e.g., frail). Regardless of attitude on pretest, however, most spring 2002 participants marked the middle of the line on posttest, explaining that they learned that elders varied so much that the marking of either extreme would be inappropriate. Thus, we constructed a 10-item, Likert-scored attitude scale (e.g., all elders are alike; aging is scary) for use in subsequent training. We constructed 20-item short-answer posttests for the first five modules to test mastery of the day's learning objectives. For the sixth module—assessing and reporting—participants analyzed cases and worked in small groups to document what they observed, what it might mean, and what they would report to a supervisor (Juleff, 1995). An end-of-course survey included close-ended satisfaction items and open-ended questions on significant things they learned, liked, and disliked.

Analysis
We scored the knowledge scale and the module posttests by counting the number of correct items. Because these measures were not changed, knowledge data were available for most of the 88 participants. The 10 attitude items factored into a single domain, but the alpha was relatively low (.67) so we tested items individually; this measure was changed in summer 2002, so attitudinal data were available for only 56 participants. We used paired sample t tests to determine the significance of change. We analyzed open-ended survey items by using Nudist qualitative software.

Findings
Participants made significant improvement on knowledge and attitudes related to aging and achieved high scores on the posttests for the first five modules (Table 2). The majority also demonstrated skills in their discussion and documentation of the complex cases presented in the sixth module (not shown in the table). Participants were very satisfied with the curriculum (M = 9.82) and found it very useful in helping them to understand the aging process (M = 9.73), to gain a more positive view of older adults (M = 9.73), to build empathy toward older adults in need of care (M = 9.8), and to develop skills to more effectively care for older adults (M = 9.71).

	Results

TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 
Direct care workers in this study had relatively few years of education and little knowledge of basic aging processes, differential effects of aging and disease, and good self-care principles. Many conceptualized their jobs as custodial, rather than therapeutic, and did not see the value of their work. This finding confirms those of other long-term-care investigators and underscores the need for upgrading the gerontological knowledge and skills of these important elder care workers (Direct Care Alliance, 2004).

Following the principle that delivery is as important as course content, we used active-learning strategies to accommodate variation in learning style and intelligence (Dixon, Adams, & Cullins, 1997; Gardner, 1983; Kolb, 1984) and emancipatory strategies to allow direct care workers to share their stories and provide the context for the training (Freire, 1970). Qualitative data suggested that, when training participants were able to tell their stories and when the other participants were able to relate to these challenging situations, the experience made their learning real and validated the meaning and purpose of their work. This approach also contributed to improvements in knowledge and to positive attitudes and practices among participating direct care workers.

	Discussion

TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 
Although we did not use a standardized, objective measure of behavior, participants brought examples each week of how they had successfully applied new knowledge and skills from the class when they were working with older adults. It is hoped that these intermediate outcomes will help improve care provided to older adults and reduce worker burnout and turnover. However, participation in the training was not required, and the training likely attracted individuals who were among the most interested and motivated. Thus, the curriculum has to be tested through a randomized control trial design that tracks long-term, as well as intermediate, outcomes.

We believe that a factor that contributed to the relative success of the training was that it was not offered in house as an inservice training. Rather, the training brought together direct care workers of various backgrounds and agencies and was provided at an independent venue. This gave participants a break from routine and the opportunity to meet "others like us." During the 24-hr training, participants established friendships, and participants have taken steps to maintain these networks. Another probable reason for success is that we focused on improving basic knowledge and attitudes that were under the control of the direct care worker, rather than on teaching clinical behaviors that may require concurrent organizational or systems changes (Aylward et al., 2003). These hypotheses should be tested in future research. Also needed are studies as to the appropriate amount of training required by direct care workers in the aging network, as well as workers in the nursing home (Wiener, 2003).

To what extent should AAAs be responsible for the training of direct care workers employed through the aging network? State units on aging and AAAs require contracted service providers to ensure that their workers can provide quality services, but they usually do not hold providers to specific training standards. AAAs can support service provider and direct care worker training through discretionary or grant funds (as was the case in this project), but there is decreasing availability of Title IV funds for this purpose. Unfortunately, the providers that expressed the greatest need for training in the AAA's initial needs assessment did not send their staff to training. Although these employers were willing to pay the $15 fee per participant, they could not afford to provide paid time off for attendees. A train-the-trainer session was held in December 2002 for local gerontology professionals who could continue to offer the PAP curriculum. Of the six individuals who participated, however, none could find the time to cofacilitate the training during spring 2003. As others have found, training is not free, and new training requirements can exacerbate existing staff shortages (Schnelle, Cruise, Rahman, & Ouslander, 1998; Wiener, 2003).

Cost is a major issue in addressing the country's growing crisis in long-term care. Dawson (2003), writing on behalf of the Paraprofessional Healthcare Institute, calls for the development of a national commitment to long-term-care financing. In terms of building a strong direct care work force, funds are needed not only to support worker training but also to increase wages and full-time employment opportunities (with benefits) if we are to attract and retain good elder care workers. Dawson also notes that we need to find ways to broaden the supply of workers in long-term care, suggesting strategies to attract young people, older workers, men, people on public assistance, and new immigrants. All of these individuals will need training, and training and certification standards for direct care workers should be established. In educating direct care workers to distinguish aging from disease, to treat elders with respect, to assess and report problems, to resolve conflict, and to manage stress, the PAP curriculum, which emphasizes active-learning strategies and emancipatory approaches, is a promising and low-cost training model.

	Footnotes

 
This work was supported by grants from the Hawaii County Office of Aging and the Hawaii Department of Labor. Acknowledgments are tendered to Elaine Young, Kathy Mitchell, and Daniel Kinoshita at the Workforce Development Division of the Hawaii Department of Labor and to Alan Parker of the Hawaii County Office of Aging for their support of the project.

¹ Center on Aging, John A. Burns School of Medicine, University of Hawaii, Honolulu.

² Hawaii County Office on Aging, Hilo, HI.

Decision Editor: David E. Biegel, PhD

Received for publication June 4, 2003. Accepted for publication April 13, 2004.

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TOP Abstract The Project Refining the Curriculum: Methods Assessing Effectiveness: Methods Results Discussion References

 

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