This study was designed to test the hypothesis that the CARE intervention, a specific intervention aimed at enhancing the confidence of healthcare professionals when making ethical decisions, leads to significant enhancements in ethical self-efficacy among healthcare professionals. Although we found that the overall sample did not exhibit a significant change in mean scores post-intervention within the subgroup of participants with initially low self-efficacy, we observed a statistically significant improvement in their confidence levels that was potentially attributable to the CARE intervention.
Building on the existing literature, our study delves into the critical role of self-efficacy in dementia care. The literature has consistently highlighted the perceived difficulty of ethical decision-making and the moral distress associated with ethical dilemmas in dementia care. However, the inconsistency in the literature regarding the impact of educational programs on self-efficacy underscores the need for targeted interventions [3,4,5]. This inconsistency is notable in light of caregivers continuing to report a lack of confidence in managing the challenging behaviours of people with dementia [6, 7]. In addressing this lack of confidence in managing challenging situations, as reported by certain healthcare professionals in dementia care, the CARE intervention has potential benefits in improving their confidence when making ethical decisions.
While we were unable to document any significant changes in the confidence levels of the complete sample, this may be because our sample of healthcare professionals reported a relatively high level of confidence to begin with (i.e., 28.3 out of a potential maximum of 42). Given the well-documented moral distress among healthcare professionals in dementia care [20], the ethics educational needs in healthcare [34] and the high prevalence of complex ethical issues they regularly encounter [15, 35], it is reasonable to expect that confidence levels would be tempered by these ongoing challenges. It might, therefore, be likely that the frequent ethical dilemmas inherent in dementia care potentially contribute to a somewhat natural ceiling on confidence levels. Alternatively, there may be a decreasing marginal utility associated with the intervention effect as participants approach the potential maximum. However, while we did not expect a high mean for the entire sample, we did expect that we would be unable to make significant changes to the scores of participants with high self-efficacy levels. In fact, we speculated that those with initial high scores would not benefit from the intervention. Their individual self-perceived moral capacity, including their beliefs regarding which ethical decisions were appropriate, may have been challenged during the intervention, thus leading to decreased self-efficacy. Although we cannot assert this is practically the case, the overall sample revealed a minor and statistically insignificant decrease in the participants’ self-efficacy levels.
Exploring the potential mechanisms behind the statistically significant impact of the intervention on the participants who were initially lacking confidence is beyond this paper’s scope. However, it is noteworthy that the elements employed in the CARE intervention align with the approach outlined by Rasmussen, et al. 2023 [36]. They found that interventions in dementia education using classroom teaching contexts combined with practice, behaviour and communication-oriented teaching styles may improve self-efficacy among healthcare professionals. Our study also provides an instance of an intervention in dementia education using person-centred teaching approaches to affect self-efficacy, for which evidence had previously been missing. Our results indicate that such interventions may be able to positively influence self-efficacy in certain healthcare professionals who lack confidence.
Clinical implications
The findings of this study have important clinical implications for dementia care settings. The CARE intervention’s focus on enhancing ethical self-efficacy among healthcare professionals has the potential to address moral distress and improve decision-making confidence, particularly for those with lower initial self-efficacy. Implementing such targeted interventions in clinical practice can support caregivers in navigating complex ethical dilemmas, thereby contributing to improved care outcomes and the overall well-being of healthcare professionals and potentially also people with dementia if high confidence levels are associated with making better ethical decisions. The results of this study underscore the value of identifying and supporting healthcare professionals who may benefit most from these types of interventions, which can be critical in settings with high ethical demands and challenging care scenarios. Integrating similar programs into routine training and professional development could help build a more resilient and confident workforce capable of handling the ethical complexities inherent in dementia care.
Limitations
While this study demonstrates robust methodological rigor, it is essential to address certain specific limitations that warrant careful consideration. First, there are potential limitations regarding possible violations of the assumptions within the tests being used. These would include the assumption of equal variance and of normality in the statistical tests. Second, caution should be applied when interpreting the significant effect of the intervention, given the limited number of intervention participants with initially low scores.
This study accounts for potential errors that may arise due to violating these assumptions before the analysis by testing them accordingly. However, several noteworthy limitations persist in the study design. The lack of random assignment is a major weakness of the non-experimental pre-post evaluation. One major challenge is that such studies only have a single arm and, therefore, lack a comparator arm or control group. The associations identified in such studies may be substantiated by an important requirement of causality, such as the intervention occurring before the measurement of the outcome. However, the absence of a control group makes it challenging to establish a causal relationship between the intervention and the observed changes [37]. Notably, among healthcare professionals with initially low self-efficacy levels, a statistically significant improvement was observed. However, in this respect, it is essential to acknowledge the potential influence of regression towards the mean in interpreting this improvement. Caution should be exercised in attributing this small but statistically significant improvement solely to the intervention process.
Notably, another limitation may arise regarding the question of when to follow up and when the measurement of the dependent variable should occur during the post-intervention stage. While we acknowledge that optimal timing depends highly on the nature of the intervention and the expected length of time for the potential effects to manifest, we are also quite confident that our post-measurement was conducted before the effects of the intervention had manifested. Since we measured the post-intervention self-efficacy immediately after the conclusion of the final module of the intervention, the effects of the intervention may not yet have been measurable. However, it is also highly possible that the intervention only exerted a limited measurable effect and that this effect represents the highest achievable measure. This aligns with prior research illustrating the diminishing impact of educational interventions over time [2]. We were also unable to reject our first null hypothesis and found a significant difference in the mean scores of ethical self-efficacy between the pre-intervention and post-intervention measurements throughout the entire sample. However, this is not to say that this group did not gain anything from participating in the intervention.
There may be certain immeasurable effects on intervention participants with high initial scores that are not accounted for in this study. These may include satisfaction with educational elements, reinforcement of beliefs high in self-efficacy, and satisfaction with peer feedback or discussion as methods of maintaining dialogue regarding ethical decision-making when caring for people with dementia. Given the study’s limitations, especially the relatively small number of intervention participants with low initial scores, future research should focus on expanding the sample size within this subgroup. This would enhance the generalizability of the findings and would provide a more comprehensive understanding of the CARE intervention’s impact on ethical self-efficacy. Exploring the long-term effects and conducting follow-up assessments could also offer insights into the sustainability and, potentially, the development of these improvements over time.
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