Abstract
Background
An increasing number of people with dementia (PwD) are being hospitalized due to acute conditions. The surrounding conditions and procedures in acute hospitals are not oriented to the special needs of this vulnerable patient group. The behavior of PwD poses particular challenges and burdens for nursing staff.
Objective
The aim of this pilot study was to evaluate the effectiveness of a 2-day dementia training program with a self-reflection component compared to a standard 1.5‑h training of nursing staff caring for PwD in acute hospitals.
Methods
A nonrandomized pretest-posttest study with a control group was conducted in three German acute hospitals. Through a questionnaire, nursing staff caring for PwD were examined for potential changes in attitude, strain and confidence levels. The intervention group (n = 32) received a 2-day training program, “EduKation demenz® Nursing”, the control group (n = 36) participated in a short,1.5‑h dementia training.
Results
Compared to the control group, the intervention group demonstrated statistically significant improvement in perceived strain (p = 0.007) and in confidence in caring for PwD (p < 0.001). There were positive but not significant changes in attitude (p = 0.176).
Conclusion
“EduKation demenz® Nursing”, a 2-day training program with a self-reflection component, could provide more effective support for nursing staff in acute hospitals caring for PwD than a 1.5‑h training. Results indicate, however, that general conditions in acute hospitals should be changed to allow nursing staff to apply the knowledge gained.
Zusammenfassung
Hintergrund
Immer mehr Menschen mit Demenz (PwD) werden aufgrund einer akuten Erkrankung ins Krankenhaus eingeliefert. Die Rahmenbedingungen und Abläufe in Akutkrankenhäusern sind jedoch nicht auf die besonderen Bedürfnisse dieser vulnerablen Patientengruppe ausgerichtet. Das Verhalten von PwD stellt insbesondere Pflegekräfte vor besondere Herausforderungen und Belastungen.
Ziel
Das Ziel dieser Studie war es, die Auswirkungen eines zweitägigen Demenz-Schulungsprogramms mit einer Komponente der Selbstreflexion im Vergleich zu einer 1,5-stündigen Schulung, wie sie für Pflegekräfte im Akutkrankenhaus eher üblich ist, zu untersuchen.
Methode
Die Studie wurde als explorative Pilotstudie unter Verwendung eines Prä- und Posttestdesigns mit einer Interventionsgruppe und einer Kontrollgruppe in drei deutschen Akutkrankenhäusern durchgeführt. Mittels einer schriftlichen Befragung wurden mögliche Veränderungen in der Einstellung, der Belastung und der Handlungssicherheit der Pflegekräfte im Umgang von PwD untersucht. Die Intervention bestand aus dem zweitägigen Trainingsprogramm „EduKation demenz® Pflege“ im Akutkrankenhaus (n = 32) und einer 1,5-stündigen Fortbildung zum Thema Demenz der Kontrollgruppe (n = 36).
Ergebnisse
Im Vergleich zur Kontrollgruppe zeigte die Interventionsgruppe eine statistisch signifikante Verbesserung der wahrgenommenen Belastung (p = 0,007) und der Handlungssicherheit in der Betreuung von PwD (p < 0,001). Auch die Einstellung veränderte sich positiv, war aber im Verglich zur Kontrollgruppe nicht signifikant (p = 0,176).
Schlussfolgerung
Das zweitägige Trainingsprogramm „EduKation demenz® Pflege“ im Akutkrankenhaus mit einer Komponente der Selbstreflexion ist eine effektivere Unterstützung für Pflegekräfte im Umgang mit PwD als eine 1,5-stündige Schulung. Darüber hinaus müssen die Rahmenbedingungen in Akutkrankenhäusern verändert werden, damit Pflegekräfte die gewonnenen Erkenntnisse in der täglichen Arbeit anwenden können.
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Introduction
There are currently 1.7 million people with dementia (PwD) living in Germany [6]. Previous studies have shown 3.4–43.3% of patients in acute hospitals (AH) with dementia syndromes or disease [22]. In a recent cross-sectional study in German hospitals approximately 40% of all patients over the age of 65 years had a cognitive impairment or were diagnosed with dementia [3].
The PwD in AH have a higher complication rate, particularly for delirium. Furthermore, they require more hours of nursing care and have a higher risk for functional decline and for continued institutionalization after hospitalization than older peers without dementia [19, 23]. In most cases, the physical environment, the organizational culture of an AH, and its associated knowledge and skills, are not adapted to the care of PwD [16, 17, 26]. Patient and staff experiences show that PwD are often perceived as troublemakers who disrupt the normal routine and challenge the medical care process. Risk management often has priority over the dignity of the patient and patient needs are often neglected because of the high nursing workload. Furthermore, the job satisfaction of nurses in dealing with PwD has been described as poor [7].
Nursing staff experience high workload and psychological stress from the patients’ challenging behavior among patients, such as aggression, irritability, nighttime disturbances, aberrant motor behavior, and disinhibition [13]. In their metasynthesis of qualitative literature, Turner et al. [27] reported a general lack of knowledge about dementia among hospital staff. Additionally, a lack of experience in communicating and coping with the challenging behavior of PwD reportedly caused disruption to the medical care process. Furthermore, organizational restrictions in wards with high workloads resulted in low self-confidence, negative attitudes, and an inability to provide person-centered care for PwD. Nurses expressed the opinion that more education about the different types of dementia, the symptoms of dementia and delirium, and how to manage patients with challenging behavior would be helpful for their daily practice [5, 15].
In the last decade a number of training programs have been developed and evaluated for healthcare professionals in hospital settings. The evaluated training programs have all been conducted in English speaking countries and varied in terms of duration and mode of delivery [22, 24]. Most programs were of half to full-day duration and consisted of face-to-face classroom sessions based on a training manual. Most of the studies examined the effects of the training program immediately afterwards and only a few provided a follow-up after 3 months or longer [25]. Surr and Gates [25] have stressed the moderated sharing of experiences under a facilitator as an important factor in increasing knowledge, confidence, and self-efficacy in healthcare professionals coping with PwD. The process of self-reflection has also been reported as encouraging professional caregivers to apply their new knowledge, thus enhancing the quality of care [2].
Most of the studies to date have assessed the training effectiveness in terms of staff knowledge, confidence, self-efficacy, and attitude. The majority of educational programs had a multidisciplinary field of participants from a wide range of health care professions: predominantly nurses but including doctors, therapists, social workers, pharmacists, and psychologists [22, 24]. In order to form any conclusions about dementia training programs and their effectiveness on hospital staff, Elvish et al. [8] recommended future studies include a control group.
To the authors’ understanding, there are currently no published studies from German-speaking countries that have evaluated a training program for nurses working with PwD in AHs and compared two different training programs for hospital staff.
Aims
This study aimed to compare the perceived effects of two educational training programs for nurses in acute hospitals in Germany. The two programs differed in length (1.5 h vs. 2 days) and the component of self-reflection. The conclusions of previous studies led the hypothesis that a training offering educational and self-reflective support (intervention group = IG) would lead to a greater positive change in participants attitudes, perceived strain and confidence when caring for PwD compared to a purely educational (control group = CG) training.
Design and method
Study design and setting
The presented pilot study used a pretest-posttest design with a nonrandomized CG. The IG attended a 2-day program “EduKation demenz® Nursing” (Private Institute for Gerontological Intervention and EduKation at Dementia, Buckenhof, Germany), while the CG participated in a 1.5‑h dementia training. Both the CG and the IG were conducted in acute hospital settings. Because the short educational training is common in many German AHs, this group was labeled the CG. All participants were asked to complete a questionnaire 2 weeks before and 2 weeks after the respective training. A 3-year apprenticeship in a nursing profession and a minimum 6‑month employment on the current ward were inclusion criteria for participation.
In this study five institutions were contacted, three of which showed interest. The intervention study was carried out from March to July 2017 in 3 Bavarian AHs, each with 300–400 beds. Two institutions were privately run; one was a non-profit organization. Two AHs had a separate vocational school for health and nursing care. None of the participating institutions had a dementia care specialist or a consultation liaison service for geriatric psychiatry.
In preliminary meetings with the AH nursing managers, the organization and contents of the two training measures as well as the expectations of the institution were discussed. Both training measures were provided free of charge to the three AHs. To find participants, ward managers typically posted a sign-up sheet on the ward notice board for those interested in a training regarding dementia. Participation in the pre-survey and post-survey was desired, but not a necessary condition for attending the training. After scheduling the training, the head of the ward assigned the interested staff to either the 2‑day or the 1.5‑h training. Randomization was not possible and only a limited number of employees could be recruited due to extenuating circumstances, such as annual leave, the variation in time schedules, and the high workload. A total of 39 nurses participated in the 2‑day training; 56 nurses participated in the short-term training. The short training took place in each clinic before the 2‑day training.
Design of the training programs
“EduKation dementia® Nursing” is a 2-day training program for nursing staff in long-term care facilities, nursing homes, hospitals, and outpatient assisted living communities. The concept is based on the already evaluated psycho-educational training program, “EduKation demenz®”, for family caring for a person with dementia living at home [10]. In addition to imparting knowledge and skills, sharing the participants’ own experiences and encouraging self-reflection were core components. We followed the approach of Miraglia and Asselin, in which reflection was used as “a deliberate process of critically thinking about a clinical experience to develop new insights and transform clinical practice” [21].
To adapt and fine-tune the training program for the AH setting, three nurses in responsible position at the participating AHs were interviewed prior to the study. Issues raised during the interviews included, in addition to the epidemiological and medical basics of dementia, the importance of differential diagnosis in relation to symptoms, such as delirium, prevention, responses to causes, handling of challenging behaviors and the increased risk of falls in PwD. Further topics mentioned in relation to the specific AH settings, included communication, relationship building and biography-based care, and interaction with family caregivers. Regarding the latter topics special emphasis was placed on the concepts of perception and communication. The findings were taken into account in the preparation and implementation of the dementia training program “EduKation demenz® Nursing” in an AH setting (Table 1).
The aims of the training were to increase staff knowledge about geronto-psychiatric disorders and symptoms among PwD, and to strengthen empathetic communication skills and foster person-centered care in AH setting. Additionally, the training aimed to improve staff understanding for family caregivers of PwD and to develop cooperative communication and constructive conflict resolution skills with relatives of patients. To stimulate self-reflection, methods such as contributing one’s own clinical experience, reflective questions, group work, facilitated discussions and case studies, analysis of film scenes, and role play were used.
The trainer of the educational programs had expertise in nursing and gerontology and had received a 7-day train-the-trainer course in the application of the “EduKation dementia® Nursing” program.
The CG attended a 1.5‑h training covering the following topics:
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Diagnosis, forms and signs of dementia
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Symptoms and progression of the disease
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Disease experience from the point of view of PwD
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Communication and dealing with PwD
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Challenging behavior
Data collection instruments
Participants received a questionnaire 2 weeks prior to start of the training and were asked to return it to a research staff member. Participation in the study was voluntary and the return of the questionnaires was anonymous. Demographic information and clinical practice characteristics (pretest) of the participants were also collected. The following scales were used:
Modified Nursing Care Assessment Scale (M-NCAS).
Nursing care burden associated with care of PwD was measured by the 28-item M‑NCAS with a 4-level Likert scale [18]. The nursing staff were asked about certain behaviors or characteristics presented by the PwD (attitude) and the extent to which they are burden to them (strain). Using a factor and reliability analysis, the M‑NCAS was transformed into German and adapted for the use in the AH setting. It demonstrated sufficient to good reliability and construct validity [14]. Higher scores on the scale indicate more severe symptoms and a heavier burden.
Confidence in Dementia Scale (CODE).
Confidence in working with PwD was measured using CODE, a nine-item self-report questionnaire. The CODE scale was developed by Elvish et al. and suggested that the CODE scale has a high internal consistency [8, 9]. Participants were asked to rate their answers on a 5-point Likert scale ranging from “not able” to “very able”. The total score can be calculated within in the following ranges: 0–18 points for “not confident”; 19–35 points for “somewhat confident”; and 36–45 points for “very confident” in dealing with PwD [9]. The CODE scale has been translated into German [20].
Rating the training effectiveness.
To assess the perceived effectiveness of the training, participants were asked to rate on a 10-level scale the importance of the topic “PwD in an AH” to their own work (1 = unimportant to 10 = very important). In the posttest measurement, participants were additionally asked to rate on a 4-point Likert-scale (very helpful to not helpful), how helpful the training was for their work with PwD.
Data analysis
The data evaluation was carried out both descriptive and using interference statistical methods. All calculations were performed using the Statistical Package for Social Science for Windows (SPSSVersion 24, IBM SPSS Statistics, Chicago, IL, USA), with p < 0.05 chosen to indicate inferential statistical significance.
Statistical methods were used to check whether there were statistically significant differences between participants of the IG and the CG at t0 in terms of sociodemographic data. After running normality and homogeneity of variance tests, the repeated measures ANOVA (analysis of variance) were used to determine differences on nurses’ attitudes, perceived strain and confidence of nurses in caring for PwD pretest to posttest between and within the two groups. The group (intervention vs. control) was defined as a between-subjects factor and time point (t0; t1) as a within-subjects factor. Effect sizes were assessed using partial eta squared (η2) and defined by Cohens values of small (0.01), moderate (0.06) and large effects (≥0.14) [4].
Results
Participants
In total, 39 nurses participated in the 2‑day training and 56 in the 1.5‑h training. In the IG, three participants took solely the pretest survey, two took solely the posttest survey, and two did not participate in either of the two surveys. In the CG, 10 participants took solely the pretest survey, 2 took solely the posttest survey and 8 did not participate in either of the 2 surveys. Only those who took part in both surveys were eligible for the predata and postdata analysis. The IG sample thus consisted of 32 (82.1%) participants and the CG sample of 36 (64.3%) participants. We did not find any significant differences regarding sociodemographic or outcome data between the completers and the non-completers.
Table 2 demonstrates the characteristics and baseline data from the participants. The majority of nurses in both groups were female (IG: 90.6%; CG: 86.1%). The CG nurses were older and more experienced than those in the IG. The mean age was 38.8 years in the IG and 43.5 years in the CG. The mean years of overall work experience was 16.3 years (IG) and 21.0 years (CG). The average duration of employment in the current ward was a little over 9 years for both groups. The largest number of participants worked in internal medicine, general surgery or trauma surgery/orthopedics. 9.4% in the IG and 11.1% in the CG had a short training on dementia within the last 2 years. The percentage of PwD on their own ward was estimated to be 39.0% (IG) and 38.3% (CG). On a Likert scale of 1–10, the topic was given a rather high relevance for their own work with values of 7.5 (IG) and 7.9 (CG). In all variables, there were no significant differences at baseline between the two groups regarding sociodemographic data.
Attitude and strain relating to dementia-specific behavior and skill confidence
The ANOVA results of the IG and CG on the outcome measures are presented in Table 3. There were no significant baseline differences between the groups in attitude, strain or confidence in working with PwD.
The total pretraining score for the M‑NCAS scale “attitude” about dementia-specific behavior showed an intermediate value range both in the IG (M = 2.63; SD = 0.29) and in the CG (M = 2.62; SD = 0.28). Within both groups, there was a significant positive change from pretest to posttest on the nurses’ attitude towards PwD (p = 0.026). The change in the IG was larger than in the CG; however, the change over time differs between the two groups (Group X Time interaction) was not significant (p = 0.176) and the effect size small (η2 partial = 0.028).
The total pretraining score for the M‑NCAS scale “strain” in relation to dementia-specific behavior showed an intermediate value range in the IG (M = 2.70; SD = 0.33) and in the CG (M = 2.62; SD = 0.40). The posttest level in the CG remained constant (M = 2.62; SD = 0.30), while an improvement could be observed in the IG (M = 2.46; SD = 32). A significant Group X Time interaction (p = 0.007) with a moderate effect size was shown (η2 partial = 0.104).
The CODE scale was used to examine confidence in working with PwD by the nursing staff both before and after the training. The average value of the CODE scale in the IG increased from 31.41 (SD = 4.01) to 35.41 (SD = 3.75) and in the CG from 32.69 to (SD = 4.46) to 32.94 (SD = 4.13). The participants of the IG assessed their confidence in working with PwD much higher than the participants of the CG. The analyses revealed a significant Group X Time interaction (p = <0.001), moreover the effect size was high (η2 partial = 0.215).
The CODE scale also offers a categorical evaluation in order to classify the confidence in dealing with PwD. Before the training, the majority of participants in both groups reported feeling “somewhat confident” (IG: 84.4%; CG: 80.6%); 15.6% of the IG and 19.4% of the CG reported feeling “very confident”; and none reported feeling “not confident” in working with PwD. After the 2‑day training, 12 more participants in the IG reported feeling “very confident” in working with PwD. In comparison, two more participants in the CG marked “very confident” after the training. Overall, the posttest revealed 53.1% of the IG and 25.0% of the CG reported feeling “very confident”.
Participant rating of the training effectiveness
The participants were asked to rate on a scale from 1 (unimportant) to 10 (very important) how relevant they valued the topic “PwD in an AH” for their own work. The topic “People with dementia in an AH” was rated more important by the IG after the training than before the training. On a scale from 1 (unimportant) to 10 (very important), the mean increased from 7.47 to 8.16. In the CG, however, the assessment of importance of “People with dementia in an AH” remained almost constant (pretest: 7.86; posttest: 7.83).
To the question, “Did you find the training helpful in dealing with PwD?” 81.3% (n = 26) of the IG stated that the 2‑day further training was “very helpful” and 18.8% (n = 6) rated it as “rather helpful”. The 1.5‑h training with the CG was rated “very helpful” by 36.1% (n = 13), “rather helpful” by 52.8% (n = 19) and “less helpful” by 11.1% (n = 4). The evaluation differences between groups were significant as seen in Fig. 1.
Discussion
This pilot study evaluated two different training programs for nurses in terms of reported strain, attitude towards and confidence in working with PwD in AHs. The aim was to investigate the effectiveness of a 2-day dementia training program with a self-reflection component, “EduKation demenz® Nursing” (IG), in comparison to a standard 1.5‑h training of nursing staff (CG). The intervention training sought to increase staff knowledge about geronto-psychiatric disorders and symptoms among PwD, to strengthen empathetic communication skills, and foster person-centered care in AHs. Additionally, the training aimed to improve staff understanding for family caregivers of PwD and to promote cooperative communication and constructive conflict resolution skills with relatives of patients.
After attending “EduKation demenz® Nursing” in the acute hospital setting, participants reported a more positive attitude towards PwD, even if the change in attitude as compared to the CG was not significant. This is consistent with the findings of Hrncir [14], who found that trained nurses assigned more constructive than challenging behavior to PwD. A previous study by Elvish et al. [9] reported that the “Getting to know me” training concept, comprising six teaching units, significantly improved attitudes among nurses towards challenging behavior in PwD; however, with the “controllability beliefs scale”, they used a different measuring instrument and no CG was used in this study. Our results suggest that a negative stigmatizing view of PwD from nurses can be positively modified by a 2-day training. The sharing of positive experiences and memories by participating nursing staff in working with PwD and their relatives was an important component of our concept.
Using the M‑NCAS, the strain on nursing staff in relation to dementia-specific behavior was investigated. Posttraining, the IG reported a significant change in the total M‑NCAS score for reported strain than the CG. One of the training goals was increasing understanding for the needs of PwD and their behavior. In the 2‑day training the Need-Driven Dementia-Compromised Behavior Model [1] was presented. The participants analyzed specific situations and experiences from their daily work and reflected their own behavior. The 1.5‑h training sessions, however, were not long enough to include time for self-reflection. A helpful method for fostering understanding for PwD was thus missing.
The intervention had the greatest immediate impact on reported confidence in dealing with PwD. This finding is in line with other studies. Elvish et al. [9] published a similar finding in their study with following a 6‑h training. They reported a significantly higher CODE level after the training. Galvin et al. [11] noted an increase in knowledge and trust in working with PwD directly after a 7‑h training and up to 120 days after by two thirds of the participating clinics. To offer dementia sensitive care in different settings and to improve internal clinical practice and workflow, training as many employees as possible in the AHs is recommended. Due to the limited personnel resources, the authors suggest using the 2‑day training to educate 2–3 nurses per ward as experts. Shorter training courses could be additionally offered for a larger number of staff. Further studies should focus on how training concepts for other settings and professions in the healthcare system should be developed in order to be effective and helpful for employees in the emergency department and in the functional services, physicians, assistants, service staff or employees in patient transport.
However, the qualification of hospital staff is only one component in becoming a more dementia-friendly hospital. In order for nurses to apply the gained knowledge in practice and thus achieve sustainable effects, the implementation of a more dementia-friendly hospital requires an overall concept. This includes, for example, the identification of PwD, experts in dementia care, geriatric liaison service, environmental adaptations and special care units [17]. Of central importance is the support of the staff in the implementation of a dementia-sensitive care by the management level [12].
The general conditions, organizational structures and processes in AHs and in the German healthcare system should be accordingly refined, as they represent a considerable barrier to a dementia-sensitive care.
Limitations and strengths
Some limitations must be considered with respect to this pilot study. Partly due to the drop-out rate, the sample size was relatively small. This might have reduced the statistical power to detect more statistically significant changes between the two groups and any larger effects. Due to the quasi experimental design, no randomization for group assignment could take place. As a consequence of the nonrandomized design, several sociodemographic variables were investigated, although no significant differences between the IG and CG could be identified. The presence of additional confounding variables, not taken into account here, is of course possible.
The participating nurses were selected by the ward manager and allocated to the groups according to the annual leave and work schedule which might have caused a bias. The IG training covered 2 days. According to the ward manager in all three AHs, releasing nursing staff for 2 days at a time posed a challenge. The reasons given were a high workload and staff shortage. Therefore, more nurses participated in the training courses of the CG than in the IG. Smythe et al. [24] also reported difficulties regarding personnel resources and ward workloads in releasing employees for training sessions. The current study design was thus a pragmatic approach to dealing with the organizational and personnel challenges in AHs.
The multicenter study was conducted in three medium-sized AHs in Bavaria, representing both urban and rural areas. Nevertheless, our results cannot be generalized to other AHs in Germany. The current study did not assess the direct impact of training on patient care or patient outcomes, such as the observed behavior and experiences of PwD and their relatives during hospital stays.
A major strength of our study was the implementation of a CG, which received a short dementia training. The pretest and posttest surveys did not take place immediately before or after the trainings, being instead conducted at 2‑week intervals. This ensured that the survey was not directly influenced by the trainer. The participants were thus also able to gain initial experience in applying their newly acquired knowledge in dealing with PwD. Nevertheless, no mid-term or long-term effects were investigated. The few studies with subsequent follow-up surveys found that confidence declined again without supporting measures [25].
The study added to the existing knowledge of ongoing education for nursing staff working with PwD and supported the method of self-reflection in the educational process.
Conclusion
The favorable results of this pilot study are encouraging. It suggests that with respect to the examined factors, a 2-day training program with a self-reflection component could have more significant effects on nursing staff than a 1.5‑h training. This indicates that to achieve changes in attitudes, strain, and confidence in working with PwD, a dementia training requires self-reflection and a certain amount of time. A short training program provides information but appears to achieve fewer changes.
Relevance to clinical practice
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Dementia-specific conditions represent a considerable burden for nursing staff in AHs; this can result in aversive attitudes and a corresponding uncertainty in working with PwD.
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A training program such as “EduKation demenz® Nursing” can have a more positive influence on the attitudes, perceived strain and confidence of nursing staff in an AH setting.
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A conventional short training course is less effective and has more of an informative character.
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The component of self-reflection is essential for professional nursing training in dementia care.
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General conditions in acute hospitals need to be changed so that nursing staff can apply the gained knowledge to their everyday work.
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We thank the participating acute hospitals for supporting this study and Ashley Basse-Lüsebrink for tidying up English grammar and expression in this manuscript.
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T.J. Gehr, C.C. Sieber, E. Freiberger and S.A. Engel declare that they have no competing interests.
All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 and its later amendments. Written informed consent was obtained from all individual participants included in the study prior to data collection.
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This paper is submitted in partial fulfilment of the requirements for obtaining the degree Dr. rer. biol. hum. (PhD in human biology) for the primary author.
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Gehr, T.J., Sieber, C.C., Freiberger, E. et al. “EduKation demenz® Nursing” in the acute hospital setting. Z Gerontol Geriat 54, 659–666 (2021). https://doi.org/10.1007/s00391-020-01838-8
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DOI: https://doi.org/10.1007/s00391-020-01838-8