As a global public health challenge, the prevalence of dementia increases exponentially with age [1]. According to the Global Burden of Disease Study 2016 [2], there were 43.8 million people living with dementia worldwide, and this number is projected to be doubled in 2030 and tripled in 2050 [3]. As a growing number of older adults suffered with dementia have resided in nursing homes, how to ensure the quality of care for people with dementia (PwD) has become a pivotal concern of the public. Taking care of PwD during the pandemic might be more challenging, due to their greater vulnerabilities to the SARS-CoV-2 virus. The high risk of infection also casts a negative impact on healthcare worker’s health and well-being mentally and physically [4]. Given such a background, it is critical to address the protective factors that promote caregivers’ positive reactions.
Caregiver’s experiences and reaction is a response to a myriad of physical, psychological, emotional, social and financial stressors, and the majority of existing literature has focused on caregiving burden. However, caregiving burden is not the only outcome of caregiving, and increased research has found that in the adaptation process of caregiving, both positive and negative experiences could co-exist. For example, recent evidence showed that taking care of PwD can lead to unexpected benefits, such as recognizing one’s own strength of resilience, patience, and fortitude, as well as gratification of interpersonal connections [5]. Overlooking the positive aspects may lead to biased understanding about dementia caregiving experiences. The positive aspects of caregiving (PAC) were characterized as uplift, gratification, reward, growth, and satisfaction among the caregivers [6]. Prior research has found that there are three groups of factors that would determine nursing home staffs’ satisfaction about work: staff characteristics, patient’s characteristics, and contextual factors [7]. Care staffs with more experiences of working [8], greater knowledge about PwDs [9], and more positive attitude [10] usually are more satisfied with caregiving. Adjusting perspective, attitude and behaviors to make meaning is also associated with more PAC during the pandemic [11]. A recent review has suggested that the emergence of PAC could be promoted by the individual factors such as greater self-efficacy [12]. Yu et al. proposed an integrated theoretical model predicting PAC [13], which called for more attention on how to generate the enriching and meaningful aspects of caregiving, and caregiver factors such as knowledge and management skills, self-efficacy should be considered.
Factors predicting PAC
Existing literature has identified that factors such as knowledge, attitude, and self-efficacy could affect caregiving experiences such as burden or PAC [14, 15]. One of the most challenging factors that influences caregiving experiences is handling PwD’s behavioral and psychological symptoms related with dementia (BPSD), and how increasing knowledge helps with handling BPSD is not clear. In a recent review [16] on formal caregiver’s burden, PwD’s need-driven and emotional behaviors both contribute to greater caregiver burden [17]. The negative impact of disruptive behaviors affecting others (e.g., aggressions, screaming, and repetitions) on staff’s burden could even exceed that of cognitive symptoms [18]. Nevertheless, recent research has viewed BPSD as responsive or need-driven behaviors that serve as PwD’s means of communication [19], and in-depth understandings and knowledge about BPSD would improve caregiver’s competence of handling behavioral symptoms [20], develop adaptive expectations, and result in more positive caregiving experiences. A recent review on caregiver’s competence of handling BPSD has defined this competence as “the aggregation of knowledge, skills, and attitudes as well as the synergies between them” [20]. The authors proposed a conceptual model including four key attributes: judging, empathizing, adjusting, and reflecting. Among them, judging mainly refers to “understanding BPSD incidents”, which was very similar to the BPSD knowledge in our study, and it is the precondition for the other three. Empathizing refers to the warm attitude and the ability to recognize PwD’s emotions behind BPSD. With empathy, the carers could understand and respond to PwD’s needs in a better way. However, how the four attributes interplay with each other in predicting caregiving outcomes still needs more empirical studies.
The moderating role of self-efficacy
The majority of the research on dementia knowledge has focused on the overall knowledge, and little evidence could be found on knowledge about BPSD and care staff’s PAC. Previous studies showed that the majority of general practitioners reported lacking self-confidence in managing BPSD [21], and it is not clear whether limited knowledge about BPSD is related with low self-efficacy [22]. Further studies are warranted to clarify the role and pathways of BPSD knowledge in caregiving experiences. In addition, the moderating role of self-efficacy would also be investigated in the current study. Self-efficacy, defined as a cognitive construct to which extent an individual believes he or she can fully accomplish a specific task when facing various obstacles [23]. As suggested by a systematic review, feeling competent or having higher self-efficacy would generally reduce caregiver burden and promote caregiver’s mental health [24]. In addition to the protective effect, the self-efficacy in controlling upsetting thoughts also have a moderating effect in the negative impacts of PwD’s behavioural symptoms. This moderation effect of self-efficacy was supported by multiple studies [25, 26]. However, it is not clear whether self-efficacy would also moderate the direct effects of BPSD knowledge.
The present study
To fill the abovementioned research gap, the current study aimed to address the pathways linking BPSD knowledge and PAC with a self-developed measurement on caregiver’s BPSD knowledge. A cross-sectional study was conducted among healthcare workers at nursing home during the pandemic of COVID-19. The research purpose is two-fold: 1) to address the effects of BPSD knowledge on PAC; 2) to test how attitude and self-efficacy play a role in this effect. The findings will provide further evidence for tailoring intervention programs supporting healthcare workers who provide care for PwDs at nursing homes.
Based on the findings reported in earlier studies and in view of the existing gap in research literature we propose the two hypotheses (Fig. 1) as below.
Hypothesis 1: Nursing staff with better BPSD knowledge are more likely to report PAC, and this relationship could be at least partially explained by improved attitude toward the PwDs. Hypothesis 2: The positive effects of BPSD knowledge on promoting PAC could be more salient among the nursing staff with strong self-efficacy.
