Teaching Dementia Care Using a Competency-Based Approach in Physical Therapy Education: Findings from a Pilot Study

Abstract

Background/Objectives: With the expected growth in the number of people with dementia and the effect it has on their daily life, physical therapists will be required to provide competent care across all settings for people with dementia. This study aimed to explore the effects of a competency-based education (CBE) intervention consisting of interprofessional education (IPE) and experiential learning on perceived dementia care competence and confidence among physical therapy students and to determine recruitment and retention rates of the multi-phasic study. Methods: A total of 13 sixth-semester Doctor of Physical Therapy students participated in IPE (Phase 1) and experiential learning (Phase 2) and completed the Dementia Care Competency Model (DCCM) 2.0 and Confidence in Dementia Scale (CODE) at three time points (pre-test and after Phases 1 and 2). Results: The recruitment and retention rates were 89% and 36%, respectively. The DCCM 2.0 (F-test = 10.57, partial eta squared = 0.66) and the CODE (F-test = 21.27, partial eta squared = 0.80) showed large effect sizes between the three measurement time points. Conclusions: The findings of this study suggest that CBE facilitates the development of core dementia care competencies of interprofessional collaborative practice and person-centered care, as well as practitioner confidence development in dementia care.

1. Introduction

Dementia is a neurocognitive disorder that causes a progressive decline in cognitive, physical, psychological, and behavioral function. Dementia is ranked as the seventh leading cause of death and is a significant cause of disability and dependency among older adults globally [1]. Approximately 55.2 million people in the world are currently living with dementia; this number is growing and is expected to reach 139 million by the year 2050 [2]. Given the multi-dimensional impact of dementia on a person’s ability to function in daily life and the expected growth of the population, increasing numbers of competent physical therapists will be needed to provide care across all settings to people with dementia [3]. Delivering expert care to people with dementia is recognized as a global challenge and priority for healthcare workers [4]. Yet, healthcare students often lack an understanding of the progressive and life-altering nature of Alzheimer’s disease and related dementias (ADRD) and do not view ADRD as a terminal disease [5]. This lack of knowledge requires healthcare educational programs to prepare their students to possess foundational competencies in dementia care, and to address gaps in frames of reference and knowledge to meet the needs of people with dementia.

Research indicates that confidence in their ability to provide effective dementia care among both practicing physical therapists (PTs) and Doctor of Physical Therapy (DPT) students is low [6]. Additionally, dementia care training in healthcare curricula appears insufficient to meet students’ needs. Physical therapy students have articulated patient care areas they wish they had been more familiar with before clinical placement and have suggested that they need additional teaching and development in dementia care [7]. The overall quality of dementia care depends upon the knowledge and confidence levels of providers, and these factors are enhanced by the amount of time spent on dementia education and training [6,8]. Students and professionals with higher levels of dementia care competence and confidence have more positive attitudes and greater job satisfaction and willingness to work with and care for people with dementia [9]. However, the lack of educational opportunities related to dementia care during academic training has contributed to a critical workforce gap [10].

Competency-based education (CBE) is a pedagogical approach to educational design in which learners’ advancement is based upon demonstration of identified competencies. CBE is grounded in the foundational assumption that there are standard competency outcomes across all levels of professional practice, and these competencies can be demonstrated and assessed [11]. Without the integration of CBE into educational design and assessment for competency demonstration, variations in practice can occur, potentially affecting the quality of care delivered in professional practice [11]. CBE has been identified as one of the pillars of physical therapy education by the educational leadership partnership between the American Council of Academic Physical Therapy (ACAPT), the American Physical Therapy Association (APTA), and the APTA Academy of Education to achieve a vision for excellence in physical therapy education [12]. CBE offers the benefits of lifelong learning through development and maintenance of competencies that are driven by health and societal needs [11,12].

A competency is defined as “the acquisition of the knowledge, skills, and abilities for effective performance” [13] (p. 4) and can be organized within domains for CBE in the health professions, along with milestones and entrustable professional activities [12]. The Dementia Care Competency Model (DCCM) 2.0 provides a framework for integrating CBE into physical therapy (PT) programs and identifying dementia care competencies for learning outcomes. The DCCM 2.0 consists of two overarching competencies: person-centered care with seven sub-competencies and interprofessional collaborative care with four sub-competencies [14]. Having established and defined dementia-care competencies provides PT programs with a common language in the evaluation of preparedness of PT graduates [11]. Additionally, milestones or indicators of competency attainment can be helpful in the evaluation of practice preparedness. Use of tools such as the National Institute of Health (NIH) proficiency 5-point Likert scale, which runs from basic knowledge to expertise, depending on the level of supervision required, can assist in identifying competency attainment [15].

To achieve the dementia care competencies of person-centered and interprofessional collaborative care, learning activities can be planned in the curriculum to allow practice of entrustable professional activities [11]. Experiential learning activities, including direct hands-on experience and role-play, can assist physical therapy students in developing dementia care competence by applying knowledge, engaging with people with dementia, and inhabiting their future professional roles [16]. Both hands-on and role-play experiences provide opportunities for the student to practice entrustable skills and engage with concepts in a real-world context, enabling students to reframe points of view, engage in problem solving, and enhance self-reflection and confidence [17].

Interprofessional education (IPE) is viewed as a teaching strategy to develop competencies associated with interprofessional collaborative care [18,19,20,21]. IPE integrates knowledge and competencies in the team members’ professional roles, collaboration skills (e.g., communication, shared decision-making, problem solving, conflict management), and values that support team functioning [22]. Incorporation of IPE and experiential learning into health professions education has been shown to positively impact student development of competence and confidence, supporting inclusion of IPE and experiential learning in CBE [23]. To our knowledge, there has been no study on utilizing a CBE pedagogy with inclusion of IPE and experiential learning components in teaching dementia care in physical therapy education. This study aimed to explore the effects of a multimodal CBE approach on dementia care-specific competencies in PT students. A secondary aim was to assess the effects on dementia care confidence of PT students after participating in the multimodal CBE learning intervention. This study hypothesized that PT students who participated in a dementia care competency-focused multimodal CBE learning intervention, including experiential learning and IPE, would show an increase in competence and confidence as measured by the DCCM 2.0 and CODE, respectively.

2. Materials and Methods

2.1. Study Design and Setting

The study employed a single-group quasi-experimental repeated-measure design to explore the impact of the multimodal and multiphasic CBE, which included IPE and experiential learning sessions from October to December 2023 at the University of St. Augustine for Health Sciences and a National Council on Aging Memory Care Center. The study was approved by the University of St. Augustine for Health Sciences Institutional Review Board (IRB approval number 23-0425-169).

2.2. Subjects

A convenience source population of Doctor of Physical Therapy students enrolled in the Geriatric Physical Therapy course, fall 2023 semester, at an affiliated university, were recruited to participate. Inclusion criteria were consenting to complete the anonymous online surveys at three time points and attendance in the IPE and experiential learning activities. The only exclusion criterion was incomplete surveys. No participation incentives were offered. Students were recruited through an in-course announcement posted in their learning management system (LMS), which included a copy of the informed consent and key information about the study. Informed consent for participation was obtained from all subjects involved in the study using a link in their LMS. This link took students to anonymous surveys hosted on SurveyMonkey©. Students could consent to or opt out of the study at the time of the pre-test (i.e., DCCM 2.0 and CODE). To promote participant anonymity, no demographic information was collected. Participants were asked to input a memorable four-digit number (e.g., the last four digits of their phone number) into the surveys to allow matching of the test scores collected at three time points. A priori analysis was conducted using G*Power 3.1 to determine the required sample size for a one-way repeated measure ANOVA. A minimum of 28 participants is needed to detect a moderate effect size of 0.25, alpha of 0.05, and 80% power for a single-group design with three measurements [24].

2.3. Intervention

Completion of the multimodal CBE was part of the participants’ coursework; therefore, it was not possible to have a control group. Students were expected to complete online coursework, estimated to take one hour, before beginning the multimodal CBE. The online coursework was based on identified dementia care competencies and included readings and videos reviewing knowledge of dementia, communication or interaction with people with dementia, person-centered care, interdisciplinary care, and care for the self and caregivers [10]. The multimodal CBE had two phases—IPE and experiential learning—to target the two domains of the Dementia Care Competency Model (DCCM) 2.0, which are interprofessional collaborative care and person-centered care.

2.3.1. Phase 1

Phase 1 of the CBE was an IPE activity consisting of various learning interventions offered in one class meeting, lasting three hours. The IPE portion consisted of a symposium, case studies, and an interprofessional standardized patient simulation depicting a person with advanced dementia. The IPE experience included occupational and physical therapy students, who were divided into three groups. The three smaller groups engaged in symposiums, case studies, and simulations facilitated by either an occupational therapy or physical therapy faculty member.

Initially, a 45 min symposium was conducted to review and explore the online coursework that was to be completed before the symposium. Once the symposium was completed, the students engaged in approximately 30 min of work on IPE-focused case studies concerning relevant and essential information on dementia, delirium, depression, elder abuse, and caregiver issues (e.g., stress). Once the case studies were completed, the groups presented their findings to the class. Finally, after a short break, the IPE student groups participated in a standardized patient simulation depicting a person with advanced dementia and their caregiver. The simulation experience followed national healthcare simulation practices and standards, including a pre-brief and debriefing session, and lasted 1.5 h in total [25,26].

2.3.2. Phase 2

Phase 2 of the CBE occurred after students completed the IPE activities and focused on experiential learning. In Phase 2, the physical therapy students were divided into smaller groups consisting of eight to nine students. Each group created and submitted a role-playing video of a group exercise session that included functional activities/therapeutic exercises for people with advanced dementia. These videos were reviewed by the physical therapy faculty, and feedback was given to the students. After the students were able to review feedback and synthesize the feedback for any changes or improvements, the group engaged in a one-time experiential learning activity at a local memory care center, with persons with dementia. During the experiential learning session, the group implemented their proposed group exercise session during their assigned clinical week for residents of the memory care center. The student-led experiential group exercise session lasted approximately 30 to 40 min and consisted of a minimum of six to seven functional activities/therapeutic exercises targeting balance, strength, flexibility, transfer/gait, or endurance.

2.4. Data Collection and Outcome Measures

The data were collected at three time points using the SurveyMonkey© platform: a pretest and posttests after Phases 1 and 2 of the CBE intervention. The pretest and first posttest surveys were given before and after Phase 1 (IPE session), while the second posttest surveys were collected five weeks after all the physical therapy student groups completed Phase 2 (experiential learning). Survey data on participants’ dementia competence and confidence were collected using two validated Likert-style instruments: Dementia Care Competency Model (DCCM) 2.0 and Confidence in Dementia (CODE). See

Table 1. Intervention and data collection timeline (based upon a 15-week semester).

Phase	Intervention/Data Collection
One	Laboratory Meeting—Week 5 Symposium Case Studies IPE Pretest (DCCM 2.0 and CODE)—Week 5 Collected before laboratory meeting Posttest 1 (DCCM 2.0 and CODE)—Week 5 Collected after laboratory meeting
Two	Preparatory Work—Week 6 Submission of role-play video Experiential Learning—Weeks 7 to 9 Student-led experiential group exercise session at a local memory center Posttest 2 (DCCM 2.0 and CODE)—Week 14

for timeline of interventions and data collection.

The Dementia Care Competency Model (DCCM) 2.0 was developed by Jasper and Josephsen and is based on the DCCM put forth by Josephsen et al. [10,14]. The DCCM 2.0 was developed utilizing psychometric analysis with occupational and physical therapy students. The DCCM 2.0 analysis found internal consistency of the initial DCCM and support for a two-factor model regarding dementia care competencies, related to occupational and physical therapy students, rather than the three factors and population on which the initial DCCM was based [14].

The dementia care competency domains supported in the DCCM 2.0 included person-centered care and interprofessional collaborative care, with high internal reliability and a Cronbach’s alpha of 0.936 [14]. These two overarching competency domains had various sub-competencies: person-centered care had seven sub-competencies, and interprofessional collaborative care had four sub-competencies.

For the purposes of this research, the DCCM 2.0 was scored using the National Institute of Health (NIH) proficiency 5-point Likert Scale and interpreted as 1 = fundamental awareness (basic knowledge), 2 = novice (limited experience), 3 = intermediate (practical application), 4 = advanced (applied theory), and 5 = expert (recognized authority) with a total score ranging from 11 to 55 [15].

The CODE uses a 5-point Likert Scale with anchored ratings ranging from 1 to 5, with 1 being not confident and 5 being very confident [27]. Total scores in the CODE range from 9 to 45, with less than 18 being not confident and 36 or more being very confident. The CODE is an appropriate measurement tool to use, as it has high internal consistency and reliability, Cronbach’s alpha = 0.91 [27], and has been used previously in studies with physical therapy students [8].

2.5. Statistical Analysis

Data obtained from the pretest and Phase 1 and 2 posttests were exported to Microsoft Excel. Incomplete records were removed, and data were imported into the IBM SPSS Program version 29.0 for analysis. Recruitment was calculated by obtaining the percentage of students who consented to participate over the total invited students, while retention was determined by calculating the percentage of participants who completed all outcome measures at the three time points over the total recruited participants. Each item of the two scales (DCCM 2.0 and CODE) was represented using the median scores and range. The statistical significance of differences in the median scores for each item were calculated using Friedman’s Two-Way Analysis of Variance by Ranks. The Shapiro–Wilk normality test was performed on the total DCCM 2.0 and CODE scores. The mean and 95% confidence intervals for the total DCCM 2.0 and CODE scores for the three time points were reported. Variances in the change in scores for the three time points were calculated using Repeated Measures ANOVA to obtain the partial eta squared for effect sizes for the normally distributed total scores of DCCM 2.0 and CODE. An alpha of 0.05 was the basis of data analysis, and effect sizes were interpreted as follows: small (r = 0.10), medium (r = 0.30), and large (r = 0.50) [28].

3. Results

3.1. Participants

Participants comprised a convenience sample of sixth-semester DPT students in a eight-semester program enrolled in the older adult physical therapy course at the time of the study. At this stage of their education, the students had completed one clinical rotation with exposure to older adult clients. All students in the source population (n = 41) were eligible and invited to participate. Thirty-six students consented to participate and completed the pretest survey. Twenty-seven completed the first posttest survey in Phase 1, while thirteen completed the second posttest survey in Phase 2. These two survey completion rates resulted in a recruitment rate of 89% and a data retention rate of 36% (see Figure 1).

3.2. Dementia Care Competency Model (DCCM) 2.0

The premedian and postmedian scores for the first and second posttests of each subdomain of interprofessional collaborative care (ICC) and person-centered care (PCC) are presented in

Table 2. Dementia Care Competency Model 2.0 pre- and post-self-assessment.

DCCM 2.0 Domains	Sub-Competencies	Premedian (Range)	Postmedian 1 (Range)	Postmedian 2 (Range)	Significance (2-Tailed)
Interprofessional Collaborative Care	Facilitate coordination and continuity of care with a multi-disciplinary team.	1 (1–5)	4 (1–4)	3 (1–5)	0.29
	Ability to facilitate discussion and education about legal and ethical concerns regarding Alzheimer’s Disease and Related Dementias (ADRD).	2 (1–3)	3 (1–5)	3 (1–5)	* 0.03
	Distinguish the signs, symptoms, and progression of dementia.	1 (1–3)	3 (1–5)	3 (1–5)	* 0.02
	Incorporate support and resources into plan of care.	3 (1–4)	3 (1–5)	4 (1–5)	0.16
Person-Centered Dementia Care	Promotion of safety through effective communication.	3 (1–4)	4 (1–5)	4 (1–5)	0.19
	Use of communication to promote patient-centered care planning.	3 (1–4)	4 (1–5)	4 (1–5)	0.07
	Situational adaptability of verbal and nonverbal communication.	3 (1–4)	4 (1–5)	4 (1–5)	* 0.01
	Promotion of personal safety when delivering care.	3 (1–5)	4 (1–5)	4 (1–5)	0.47
	Recognize signs and symptoms of caregiver stress and burnout.	2 (1–5)	3 (1–4)	4 (1–5)	0.31
	Integrate cultural background and lived experience into plan of care.	3 (1–5)	3 (1–5)	3 (1–5)	0.37
	Recognition of the signs and symptoms of neglect, self-neglect, and abuse in the family/caregiver and/or those with Alzheimer’s Disease and Related Dementias (ADRD).	2 (1–4)	4 (1–5)	4 (1–5)	* 0.00

Friedman’s Two-Way Analysis of Variance by Ranks. Significance at * p < 0.05. Premedian n = 13; Postmedian n = 13.

. Two of the four subdomains of ICC had a premedian score of 1 (fundamental awareness), while the other two subdomains had premedian scores of 2 (limited experiences) and 3 (practical application). Three of the four subdomains in ICC had a postmedian score of 3 (practical application) while one had a postmedian score of 4 (applied theory) at the end of the study. For PCC, five of the seven subdomains had premedian scores of 3 (practical application), while two subdomains had premedian scores of 2 (limited experiences). At the end of the study, six subdomains of the PCC had postmedian scores of 4 (applied theory), while one subdomain had a postmedian score of 3 (practical application). Two ICC subdomains and two subdomains in PCC showed significant differences in the median scores.

3.3. Confidence in Dementia Scale (CODE)

Six of the nine questions had premedian scores of 3, two had premedian scores of 4, and one had a premedian score of 2. At the end of the study, seven questions had postmedian scores of 4, while two questions had postmedian scores of 3 and 5, respectively. Six of the nine questions showed significant differences (see

Table 3. Confidence in Dementia Scale (CODE) pretest and posttest questionnaire [27].

Questions	Premedian (Range)	Postmedian 1 (Range)	Postmedian 2 (Range)	Significance (2-Tailed)
I feel able to identify when a person may have a dementia.	3 (1–3)	4 (3–5)	4 (1–5)	* <0.00
I feel able to understand the needs of a person with dementia when they can communicate well verbally.	4 (2–5)	4 (2–5)	4 (1–5)	0.19
I feel able to understand the needs of a person with dementia when they cannot communicate well verbally.	3 (2–5)	4 (3–5)	3 (2–5)	* 0.00
I feel able to interact with a person with dementia when they can communicate well verbally.	4 (2–5)	4 (2–5)	5 (3–5)	0.14
I feel able to interact with a person with dementia when they cannot communicate well verbally.	3 (2–5)	4 (3–5)	4 (3–5)	* 0.01
I feel able to manage situations when a person with dementia becomes agitated.	2 (2–4)	4 (2–5)	4 (2–5)	* <0.00
I feel able to gather relevant information to understand the needs of a person with dementia.	3 (2–5)	4 (3–5)	4 (3–5)	* 0.00
I feel able to help a person with dementia feel safe during their stay in hospital.	3 (2–5)	4 (3–5)	4 (3–5)	0.117
I feel able to work with people who have a diagnosis of dementia.	3 (1–5)	4 (3–5)	4 (4–5)	* <0.00

Friedman’s Two-Way Analysis of Variance by Ranks. Significance at * p < 0.05. Premedian n = 13; Postmedian n = 13.

).

3.4. Cumulative Results in Competence and Confidence

Table 4. Total scores pretest, posttest 1, and posttest 2 survey results.

Survey	Pretest Total Scores (n = 13)	Posttest 1 Total Scores (n = 13)	Posttest 2 Total Scores (n = 13)	F-Test	Partial Eta Squared	Significance
Mean DCCM 2.0 Total Score (95% Confidence Interval)	25.08 (18.41–31.74)	32.69 (23.36–42.02)	36.69 (29–44)	10.57	0.66	* 0.003
Mean CODE Total Score (95% Confidence Interval)	27.85 (24.36–31.33)	34.62 (31.75–37.48)	34.69 (31.84–37.54)	21.27	0.80	* <0.001

Significance at * p < 0.05.

presents the mean total pretest and posttest scores in the DCCM 2.0 and CODE, including their 95% confidence intervals. Statistically significant differences (p = 0.003) were found in the total DCCM 2.0 scores between the three measurements with a large effect size (F-test = 10.57, partial eta squared = 0.66). The CODE total scores showed statistically significant differences (p < 0.001) between the three measurements with large effect sizes (F-test = 21.27, partial eta squared = 0.80). All three code scores were interpreted as somewhat confident.

4. Discussion

Dementia affects all aspects of a person’s daily life and functional abilities. The number of people diagnosed with dementia is expected to increase exponentially over the next 25 years [2]. Physical therapists will be called to care for people with dementia, providing functional and therapeutic interventions and support. Therefore, competency and confidence in the provision of dementia care are essential areas of educational preparation for physical therapy students. Safe and quality care for people with dementia can be supported by offering educational interventions that simultaneously address confidence and competence development with CBE and support calibration [29].

This study showed the potential of a multimodal CBE approach, including IPE and experiential learning, to enhance competence and confidence in dementia care for physical therapy students. National physical therapy organizations, such as the Academic Education Committee of the American Physical Therapy Association (APTA) Geriatrics, support competencies in health promotion, screening, and evidence-based practice for entry-level physical therapists, including brain health and chronic conditions like dementia in older adults [30]. Affirming the findings of Beer et al. [31], educational modules can enhance the understanding of dementia but not self-perceived competence and confidence in dementia care. Follow-up activities to didactics, such as experiential learning, can enhance the acquisition of clinical skills during academic training. A multimodal approach, such as the combination of teaching strategies, like IPE and experiential learning, offers the advantages of maximizing learning by addressing various learning styles [32].

The results of the DCCM 2.0 and CODE across the three phases of data collection identified that the multimodal CBE intervention significantly affected competence and confidence development in physical therapy students. Specifically, the multimodal CBE was shown to have a significant effect on the dementia care competencies in the interprofessional collaborative care domain concerning facilitating discussions and providing education regarding ADRD and distinguishing the signs, symptoms, and progression of dementia. Additionally, under the domain of person-centered dementia care, the multimodal CBE showed a significant effect in the sub-competencies of situational adaptability of verbal and nonverbal communication and recognition of signs and symptoms of neglect or abuse in the family/caregiver and/or person with ADRD. Confidence in the ability to identify when a person may have dementia; understand the needs of a person with dementia, interact with a person with dementia; manage situations when a person with dementia may become agitated; the ability to gather relevant information to understand the needs of a person with dementia; and the ability to work with a person with dementia, all showed a significant effect. These results support using a multimodal CBE with IPE and experiential learning components to develop competence and confidence in dementia care with physical therapy students.

4.1. Interprofesional Education

The outcomes of the IPE in this study, using a modified Kirkpatrick’s model at the most, are level 2, which corresponds to the acquisition of knowledge and skills [33], appropriate for the level of learning of undergraduate students. Through enhancement of competency and self-efficacy levels, students may be better prepared to work collaboratively in an interprofessional team before entering final clinical internships [34].

Both the DCCM 2.0 and the CODE showed changes in the items for nonverbal communication. Communication strategies have been cited by students in the study of Hunter et al. as one of the areas lacking confidence [8]. Healthcare providers working with persons with dementia conveyed a lack of competence in behavior management and communication strategies, especially when patients are nonverbal. Interprofessional activities, as suggested in the study of Reichel et al. [34], such as with occupational therapy (OT) students, could have contributed to development in this area. Our findings on the impact of IPE on communication and teamwork are similar to the work of Dressel et al. [35], which involved PT, speech therapy, nutrition, and counseling students. IPE provides opportunities for various disciplines to learn from each other, comparing professional roles and responsibilities and observing communication strategies of other disciplines, such as the OT students who have roles in social and functional cognition.

4.2. Experiential Learning

Kolb’s theory of experiential learning emphasizes the crucial role of real-world experiences in providing opportunities for diverse learners to understand and reflect on their experiences [36]. Additionally, student calibration, or the ability to accurately assess their competence and confidence, has been found to support safe and effective care delivery [29]. A scoping review on dementia education opportunities in PT and OT students affirmed the positive impact of experiential learning on the students’ attitude, knowledge, and confidence [37]. Our preliminary findings of improvement in competence and confidence were similar to the study of Wood et al. [32], who found experiential learning performed through volunteer care homework resulted in improvement in the knowledge, confidence, and perceived competence in dementia care of physiotherapy and nursing students. Through experiential learning activities, the student is introduced to the subjective experiences of people with dementia regarding their environment, situation, and future plans, which can enhance person-centered dementia care competency and improve patient outcomes [38]. This study highlights the need for ongoing opportunities for experiential learning to support competency and confidence development during the clinical internship to address person-centered care competence.

5. Conclusions

Although the findings of this study suggest the potential of a multimodal CBE in improving the competence and confidence of PT students in dementia care, a few methodological limitations should be explored. Convenience sampling can be a source of participation bias and may not truly represent the general population. This study was conducted in one school with a single student population and without a control group. This contributes to the lack of generalizability of the study across all physical therapy or other healthcare education programs and cannot exclude the potential influence of external factors. Additionally, student demographics were not collected, so there is an inability to analyze competency and confidence scores related to areas such as level of education, gender, or past experiential activities.

Concerning the recruitment and retention of the research, although the target sample size was not achieved due to high attrition, which could be from survey fatigue, post hoc analysis revealed large effect sizes for DCCM 2.0 and CODE. The underpowered sample size could have contributed to a Type II error and may limit detection of meaningful effect and generalizability of results. The low data retention rate could be due to the surveys being administered at three time points. To avoid contamination, the last posttest surveys were administered after all groups completed the experiential learning, which may have contributed to the low retention rate. Minimizing the gap between the completion of Phase 2 and the administration of the second posttest surveys or providing incentives for participating in the survey may have mitigated the low retention rate.

Further research is needed to demonstrate that multimodal CBE, including IPE and experiential learning, can enhance dementia care competency and confidence development in physical therapy students through a multi-site study to represent physical therapy programs in different organizations and geographical areas. This could include studies comparing programs using CBE versus programs that do not in dementia care competency and confidence measurement. While self-report surveys can provide insight into the self-perceived competence and confidence of PT students, this could have been enhanced through pairing student self-reports of competency and confidence with observation or other types of objective assessment. Lastly, future research in this area could be strengthened with the progression to a powered study using effect sizes.

CBE with physical therapy students allows students to transform their frame of reference to one with a shared language and expected competencies for professional practice. Interprofessional practice is essential in delivering competent dementia care and is a critical component of CBE in health education [11]. Furthermore, experiential learning opportunities are essential as the student can apply the knowledge and skills of the profession, and competence and confidence can be enhanced. However, for CBE to be effective, it is required that the competencies be defined as well as the essential characteristics of the competencies [11]. In this study, by use of the DCCM 2.0 and CODE, the competencies and their subsequent characteristics were clearly defined, allowing for a robust multimodal CBE intervention to be developed and implemented.

Educational programs preparing physical therapists for practice are called to ensure that relevant and essential competencies for practice are instilled. As the need for proficiency in dementia care is an identified global challenge [4], educational programs must explore and develop frameworks for best educational practices concerning dementia care competency and confidence development. This study found that by integrating a multimodal CBE intervention with IPE and experiential learning, competency and confidence development in dementia care can be enhanced. This multimodal CBE intervention addressed core dementia care competencies of interprofessional collaborative practice and person-centered care, as well as confidence development, essential for calibration of competence and confidence, supporting the call for better dementia care outcomes and quality of care for people with dementia.