Training Trainers in the Management of Older Persons with Dementia during the COVID-19 Pandemic

Abstract

During the COVID-19 pandemic, education activities for the prevention and management of chronic health conditions needed to adapt to meet their learning objectives. Dementia is a chronic disease that is one of the contemporary epidemics in Latin America and the Caribbean (LAC).

Objective: To describe and analyse the impact of the design and results of "The Management of the Elderly with Dementia” Course of the Latin American Academy of Medicine of the Elderly (ALMA) remotely taught to teachers and specialists in geriatrics from various countries of Latin America and the Caribbean (LAC). 

Methodology: A course focused on learning and competencies was designed, including two phases of synchronous and asynchronous activities. An evaluation strategy was designed to assess the level of learning and the teaching strategy itself.

Results: Of the 120 university geriatrics professors who applied, 60 participants were selected, one of whom declined to participate before starting the course. On the course initiation, 89 participants from 20 countries included teachers (6 speakers, 12 advisors, and 12 tutors) and students (59). The participants were professors from 49 universities in LAC and 3 in Europe. A total of 57 (98.25%) students achieved a satisfactory grade, and 17 (29.8%) obtained an excellent grade. Only one student failed. No student dropped out from the course. Self-perception of learning was greater than 70%. The opinions regarding the evaluation of the design, teaching methodology, content quality, quality of teachers, and virtual learning environment were mainly "good and very good".

Conclusions: The virtual course model implemented was successful and efficient and can be used for teaching the topic analysed or adjusted to another issue.

Introduction

Dementia and other memory problems are an epidemic of the 21st century and one of the leading causes of mortality and disability.¹ It has been estimated that the Latin American and Caribbean (LAC) region has 56% of potentially modifiable risk factors attributable to dementia.^2,3 Therefore, empowering human talent to prevent and guide the management of these problems is a key action. ⁴

The Latin American Academy of Medicine for the Elderly (ALMA) was created in 2002 to improve accessibility and the quality of health services for the elderly in LAC. One of its main strategies is strengthening and managing human talent from the region's universities by training geriatric teachers. In addition to the health challenges arising from the COVID-19 pandemic, they suggested others related to maintaining care for people with chronic health problems and teaching innovation to increase healthcare providers' skills in caring for older persons. Older people with dementia were particularly affected by COVID-19. ^5,6

• Program Description

A course for academic geriatricians of LAC was designed to acquire and enhance competencies, using the methodology “Training of trainers” (TOT)”^7–10 aimed at optimising knowledge on the prevention and management of older people with dementia, and emphasising the needs of services, family, and community. At the same time, this course sought to improve learning and virtual teaching capabilities.^11,12 The course was sponsored by the Pan American Health Organization (PAHO/WHO) and the International Association for Gerontology and Geriatrics (IAGG). A massive call was launched through social networks, email, and the ALMA website. The participants were selected according to the academic criteria defined by ALMA (geriatric specialisation degree, academic degree, research, university teaching, scientific publications, and the number of ALMA courses taken previously).

• Description of the trainees:

Students were academic geriatricians that certified that they work as teachers in Faculties of Medicine. They were selected according to their curriculum vitae by the course coordinators.

• Competences proposed for the course

Generic

1. Apply analysis and synthesis, induction and deduction, and the systemic approach as general strategies for knowledge acquisition.

2. Use critical thinking when analyzing different contexts, sources of information, and facts of reality.

3. Effective use of new information and communication technologies.

4. Leading and actively participating in work teams and committed to the tasks and achievements.

5. Respect for the human being, recognition of rights and obligations.

Specific

1. Explain the biomolecular and epidemiological bases that modulate the development of cognitive decline in the elderly.

2. Assess the process of pathophysiological, clinical, and diagnostic approaches to the main dementias affecting the elderly.

3. Explain therapeutic approaches at the pharmacological and non-pharmacological levels to optimise the trajectory of cognitive functioning of older adults, focused on a life lived and human rights.

4. Explain the particularities health services must have to prevent and care for the elderly with dementia seeking healthy and dignified ageing.

5. Use a virtual collaborative work environment with students to deal with the topic learned at different levels of complexity.

The thematic contents according to the specific activities can be seen in Table 2.

• Learning Methodology

The course was developed using different coding methodologies (Fig, 1).

1. Encoding strategies

2. Synchronic masters, individual and team presentations: Real-life cases or examples of problem-based learning were used, which helped to communicate and stimulate discussion of the scientific evidence presented. All the presentations were recorded for posterior review.

3. Asynchronous presentations: Videos or short texts were used to stimulate reflection and enrich learning. All course participants could comment or ask through the corresponding forums/channels.

4. Readings: Readings selected by teachers and others shared by peers were used.

5. Summary of student learning: Participants prepared a PowerPoint presentation of the topic assigned to them and their team. Each group produced an infographic on the given topic.

• Engaging students and drive their attention - top-down and bottom-up strategies

Based on theories of classical and instrumental conditioning and seeking to achieve different types of knowledge and skills, we used two systems of the human mind (implicit and explicit). That is, top-down and bottom-up strategies were used to engage students and drive their attention. ¹³

• Consolidation/retrieval Strategies

Think pair share activities were promoted during synchronous activities by asking students to explain the topic discussed in their own words or present an example (consolidation). The companion partner repeated their understanding and related their experiences or explained how the new knowledge could be translated into daily practice (forums and teamwork). At the end of the course, there was a quiz for a retrieval strategy. The teaching design was carried out considering the hours the students agreed to participate to avoid work overload and promote adequate rest. A cordial and horizontal work environment was always fostered to create the best environment for learning.

• Extrinsic Motivational Strategies

This course is one of three required courses to become a member of ALMA. In addition, documents with publication potential are produced during the course.

• Intrinsic Motivation Strategies

Participants are encouraged to recognize the topic's relevance for their career and public health and reflect on the impact of optimizing their knowledge on the subject for their students and patients.

• Teaching Methodology

The course applied theoretical-practical procedures to discover and incorporate new knowledge for health care and optimal teaching in Geriatrics concerning the subject of the course. Throughout the course, permanent interaction between teachers, tutors, and students is encouraged to guarantee the exchange and acquisition of knowledge. The teaching methodology focuses on the student, promoting autonomous learning and critical thinking, and giving more importance to the management of learning tools and development of study techniques than the accumulation of data. The methodology used is participatory, collaborative, and involves problem-based learning. Learning activities are the axis of the teaching strategy, based on a process of personal construction, mediated by exchanging with classmates, tutors, and teachers.

These learning activities are appropriate to the profile of the participants. They are progressively organized so that in the initial session, students are provided with the knowledge and tools necessary to achieve the objectives of the following sessions. ^14,15 These activities are linked to the practice and the specific scenarios of the students, thereby seeking practical contextualization of learning. ¹⁶

• Learning Activities

1. Lecture strategies

• Expert presentations.

• Masterclasses taught by the invited experts are of 30 minutes in length, followed by 20 minutes of questions. The course has a total of 6 expert master class presentations.

2. Student presentations: "current affairs".

A topic was assigned to 25 students to analyze and then present their conclusions. The student's topic preparation was performed under a tutor's supervision. The presentations were 20 minutes long: 10 min. for their presentation and ten minutes for questions from the other participants. The 10-min. presentations were pre-recorded, and the questions or discussions were conducted live.

3. Teamwork

The groups were made up of 10 participants and a tutor. During the first phase, the group virtually worked on the assigned topic in the related forums. During the second phase, one of the group members made the respective presentation according to the academic program, and the rest actively participated in the discussion. The teachers randomly chose the exhibitor representing the group a few days before the recording. In the plenary session, moderated by a professor, the recorded presentation was presented, and a synchronous debate was held with questions and answers from the attendees that were answered by the participants of the entire group in charge of the topic.

4. Off-learning collaboration/assignments

Students were divided into "learning teams" to perform weekly activities and meet the requested endpoints.

5. General schedule

An academic committee of ALMA members supervised the course's competencies, contents, and activities. The tutors were also members of ALMA. The course had 2 phases. The first phase involved collaborative asynchronous work by groups with one assigned tutor. During this phase, the topics assigned were discussed, and presentations and infographics were prepared. During the second phase, synchronous question-and-answer sessions were held in the plenary session (subjects and development shown in Table 3).

6. Assessments

Continuous evaluation of students, teachers, and teaching strategies was carried out along the course. According to the Kirkpatrick model ¹⁷, the evaluation process included evaluation of the teaching strategy, which consisted of an immediate assessment aimed at students, teachers, and tutors, through a voluntary virtual survey, and the realization of a forum with tutors, professors, and the course coordinators.

7. Grading

The program was graded by a combination of grading of formative and summative assessments. Table 1 shows how the students were evaluated. To pass the course, participants had to obtain a mark of at least 70%. Participants who passed received a certificate of completion with the following criteria: minus 70% = failure, 70–90% pass, and more than 90% pass with excellence. To pass, it is required to attend at least 95% of the sessions of the second phase.

8. Use of Technology

Easy-to-use technological tools that promote interaction and achieve learning objectives were selected. We used the Moodle Platform to implement the phase 1 forums, and zoom was integrated within Moodle for the second phase. Instruction and a video were designed to optimize the use of the virtual environment. WhatsApp groups and google drive spaces were developed to improve collaborative work. The course syllabus describes the cordiality and respect rules for participation in the forums. In addition, there was permanent technical advice for the use of work platforms.

Results

The course was held from September 26 to November 21, 2020 (the first asynchronous phase from September 26 to November 16; and the second synchronous phase from November 17 to 21, 2020) and included a total of 78 credit hours.

Of the 120 university geriatrics professors who applied, 60 participants were selected, one of whom declined to participate before starting the course. On the course initiation, 89 participants from 20 countries included teachers (6 speakers, 12 advisors, and 12 tutors) and students (59). The participants were professors from 49 universities in LAC and 3 in Europe.

A total of 98.31% (58) students passed the course, with no student dropouts after the course had begun. Only 1 (1.69%) student failed, and 17 (28.81%) passed with a grade of excellence (Table 3).

A week after finishing the course, an evaluation of the teaching strategy was carried out through an electronic questionnaire using Microsoft Forms. Of the 59 students, 37 expressed a high level of overall qualification for the course. The performance of teachers and tutors was rated with scores of 4.89 and 4.97, and 4.68, respectively, on a Likert scale of 0 to 5, in which 0 was the lowest possible score and five the highest possible score (Table 3).

Using a Likert scale from 0 to 5, the relevance of the topic proposed and the course program according to the objectives of the same were rated 4.95. Regarding the characteristics of the teaching methodology to achieve the learning objectives, the students reported a good level of perception of quality related to metacognition, motivation, stimulation of critical thinking, collaborative learning, and exchange of experiences (Table 3).

Regarding the stress level during the course, 81% (30) of participants responded that it was adequate (good or very good). Regarding the time available to carry out the activities, 94.59% (35) stated it was good or very good. When asked about the virtual learning environment, 91.9% said that the ease of use was good or very good, and 86.49% said that the program appeal – o – program attractiveness?? was good or very good (Table 3).

Regarding self-perception of self-learning, the students surveyed reported a mean of 70.81% improvement in their abilities in the management of older people with dementia, a mean self-perception of change of knowledge of 53.78%, and a mean self-perception of new knowledge per student of 51.89%. The mean self-perception of improvement in teaching abilities was 78.38%. On evaluating the possibility of behavior change in practice or transfer, it was asked if "with the resources and conditions the student has available in their daily work, rate how many of each could be done differently to optimize the management of older people with dementia", obtaining a mean score of 4.26 in which 0 = nothing and 5 = many changes.

In the qualitative evaluation of the perception of the course quality by the teachers and tutors through forums, there was consensus on the high quality of the strategy. The participants made suggestions for improvement, especially related to the speed of the transmissions of the videos and the participation of the tutors and advisors during the synchronous phase. Each group of students was assigned to build an infographic as a teaching activity based on the given topic, which had already been published. ¹⁸

Concerning the costs of implementing the course, the face-to-face mode was USD 40,000 per course. In contrast, the virtual mode was USD 6500, without considering the transfer expenses that the participants of the first modality usually assume.

Discussion

We present a successful strategy of training 59 geriatric teachers from 20 countries to prevent and manage older people with dementia. The participants (professors, tutors, and students) were teaching geriatricians from 51 different medical schools.

Strengthening human resources is one of the pillars of adapting health services to the particularities of the elderly. ¹⁹ The attitude and aptitude of the persons involved in caring for people with dementia are challenging for health services. Properly trained professionals are less likely to feel powerless when caring for a patient with dementia. ²⁰ At the undergraduate level, it has been described that university medical students benefit from education to prevent and manage dementia, reducing stereotypes towards people living with this condition. ²¹

Due to the COVID-19 pandemic, strategies and recommendations have been proposed to adapt and sustain teaching practices.^22–25 On dementia, a series of courses have been made available during the pandemic to raise community awareness and train caregivers of people with dementia. However, detailed information on teaching experiences, challenges, and opportunities for continuing education presented during the pandemic is scarce.

The strategy presented can be considered successful according to the resulting students' grades, the opinion on the quality of the teaching strategy by the participants, the self-perception of learning, and the absence of drop-outs during the course. Metacognition and a continuous evaluation methodology were promoted with the participation of peers and teachers.

The design of a virtual course is not the same as that of a face-to-face course. It is an opportunity to improve using teaching resources not available in face-to-face courses. Several models have been proposed for the evaluation of the quality of virtual education and these include several dimensions that can be grouped into the following domains: Institutional context (analysis of training needs, infrastructure, human resources, financial situation); students (characteristics of the recipients, factors influencing student satisfaction); teachers (online teacher profile, factors influencing their satisfaction, professional development); technological infrastructure (from the pedagogical and technical point of view); pedagogical aspects (training objectives, teaching materials, and resources, learning activities, learning assessment, teaching strategies, tutoring); and life cycle of a virtual course/program (design, development and evaluation/results).²⁶ The Kirkpatrick model of educational evaluation states that several domains must be taken into account: 1- Reaction (what the learners thought and felt about the training and what they learned); 2.- Learning (the increase in knowledge or capacity as a result of training) 3.- Behavior/transfer (the degree or extent of improvement in behavior, capacity and implementation/application); and 4.-Impact/result (the effects on the socio-community environment, resulting from the actions of the learners).¹⁷ We have included these domains in the presentation of results and evaluation, with a medium- and long-term evaluation of the change in organizations and the final impact on society.

The strength of this study lies in the fact that it presents a strategy of virtual training of geriatric teachers on a topic of great importance to public health, such as the care of people with dementia. It also represents an effort by ALMA to continue its work in LAC. ALMA was created by an interest in developing a project that seeks not only the best training of future academic leaders in Latin American geriatrics but, more importantly, by acting through its members and graduates with a cascade of knowledge that has an impact on health care structure.

The COVID-19 pandemic offered the opportunity to rethink the new digital pedagogical possibilities, the primary purposes of education, and how a renewed vision of education could be harnessed to develop healthier societies. We believe that this course has provided an opportunity for expert geriatric teachers to test these pedagogical possibilities and determine how to take advantage of them in the future in our universities. ²⁷ To demonstrate the option of taking courses with a good quality online format, the perception of the students at the end of the course and the quality of the performance of the activities undertaken along the course were considered. ²⁸

The results of this study demonstrate the effectiveness of innovative teaching models ¹⁴. Collaborative learning has been successfully described for continual medical education.^29,30 The use of peer feedback and other innovative small group techniques is effective by contributing to learning specific topics and has been proposed as strategies to enhance lifelong learning ^31–34. A systematic review reported that peer feedback in a collaborative learning environment might be reliable for assessing professionalism and may aid in developing professional behavior.³² Another systematic review recommended using the findings of teacher research in nursing school curricula and teaching systems, emphasizing that the use of lifelong learning strategies leads to higher quality education, the development of desired competencies, and a higher quality of patient care. ³⁵

Limitations and strengths

While more structured and validated instruments could have been used to evaluate this virtual learning course, the Likert scales and the opinions on the teaching strategy and self-learning given by the participants who are university professors selected for their accreditations in their respective curriculum vitae can be considered reliable.

The second evaluation stage over the medium and long-term will be related to the changes produced in daily practice and the health of the elderly with dementia.

Conclusions

This virtual teaching strategy for training university teachers was effective and efficient, meeting teaching objectives and student expectations and reducing costs concerning the face-to-face strategy. Nonetheless, its impact in the medium and long term must be evaluated.

Declarations

Ethics

Before starting the course, all the participants signed a consent letter with the course procedures for the data collection and use of data from it. Informed consent was obtained from all subjects.

The project was sent, for a post-hoc approval, to the Ethics Committee of the Faculty of Medicine of the University of San Martín de Porres for approval. (Federal Rights Protection Assurance (FWA) Subjects #. FWA00015320 and OHRP - US Department of Health and Human Services. (HHS) - Registration of an Institutional Review Board (IRB) with IRB00003251. All methods were carried out following the relevant guidelines and regulations. During the completion of the course, the collection, analysis and publication of the information have followed the corresponding ethical international standards that guarantee the security and privacy of the participants.

The authors do not report any conflict of interest related to the execution of this work.

Consent to publication NA

Data availability

The data sets used and analyzed during the current study are available, protecting the identity of the participants, through the corresponding request to the study's corresponding author: José F. Parodi [email protected].

Funding

The International Association Of Gerontology and Geriatrics (IAGG) and ALMA funded the course.

Conflict of interest.

The authors of this article do not have specific funding for preparing this work.

Authors contribution

Fernando Runzer-Colmenares, Carlos Cano-Gutiérrez, Sara Aguilar-Navarro and Jose F. Parodi wrote the main text of the manuscript. Jose F. Parodi prepared the figures and tables. Jose F. Parodi, Carlos Cano-Gutierrez and Sara Aguilar-Navarro participated in the design and execution of the course, in addition to collecting and analyzing the information obtained. All authors reviewed the final version of the manuscript.

Acknowledgments

The authors are grateful to Donna Pringle (Universidad Científica del Sur) for reviewing the language and style of the final manuscript.

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