Education and training to support physiotherapists working in dementia care: a scoping review protocol [version 1; peer review: 3 approved]

Background: The care of people with dementia is of global concern. Physiotherapeutic intervention can be of benefit to patients with dementia. Physiotherapists can play a role in assessment, falls prevention, pain management and gait re-education. Dementia care forms a significant part of the workload of a physiotherapist. However, there is a paucity of evidence on what constitutes effective education and training for physiotherapists working in dementia care. Objective: This scoping review aims to explore and map the evidence on education and training for physiotherapists working in dementia care. Inclusion criteria: Studies that explore dementia training and/or education for physiotherapists or for multidisciplinary teams, in which physiotherapists have been included. Studies that explore student physiotherapy training will also be considered. Systematic reviews, qualitative, quantitative, mixed methods studies, case studies and observational studies will be included. Methods: This scoping review will follow the Joanna Briggs Institute (JBI) methodology for scoping reviews. Databases to be searched as part of this review include: Medline, Cochrane Database of Systematic Reviews, SocINDEX, CINAHL and, PsycINFO, with no limitation on publication date. Google Scholar and Open-Grey will be searched for grey literature, limited to the first 100 searches.  Titles and abstracts will be screened for inclusion and identified full texts reviewed independently by two reviewers. Data will be extracted using a draft data extraction tool based on the JBI data extraction tool. A chronological narrative synthesis of the data will outline how the results relate to the aims and objective of this scoping review.


Introduction
Dementia is one of the greatest health and social care challenges of our time 1 . Dementia is characterised by progressive cognitive impairment in domains such as memory, orientation, comprehension, language and judgement 2 . The complexity of dementia, coupled with the significant health and social care costs make dementia a major challenge to our healthcare system. As Ireland's ageing population continues to grow, it is estimated that by 2036, there will be over 112,000 adults in Ireland living with dementia 3 . The consequences of dementia for the individual and family are profound as it is associated with impairment in both physical and functional ability, as well as non-cognitive symptoms (often called behavioural and psychological symptoms of dementia). Physical impairments associated with dementia include impaired mobility, reduced muscle strength and poor balance while non-cognitive symptoms include agitation, anxiety, depression and delusions 4 . Rehabilitation interventions are an important component of the management of those with dementia and physiotherapy plays a key role in many aspects of dementia care, including the maintenance of mobility, falls risk assessment and strength training 5 . Even though physiotherapists working in acute and primary care settings carry a significant caseload of patients with dementia 6 , very little formal undergraduate and post-graduate training is available to allied health care professionals 7 . The World Health Organisation has acknowledged that developing the knowledge and skills of all healthcare professionals who are involved in dementia care is a priority 8 . Indeed the Irish National Dementia Strategy has included training and upskilling of healthcare professionals in dementia care as a primary objective 3 .
Understanding what constitutes effective education, for those caring for patients with dementia in the healthcare setting is an ongoing challenge 9 . The diversity of knowledge, abilities, skills and qualities required to be a competent healthcare professional in dementia care highlights both the complexity and importance of education in this area. However, there remains a gap in the literature on what effective dementia care training for physiotherapists should address, consist of, how it should be delivered and how it should be evaluated. Even though basic didactic knowledge is outlined in the curricula of most allied health professional courses 10 , Surr and Gates argued that the ability to effectively transfer theoretical knowledge from the curricula to clinical practice remains challenging 9 . A preliminary search of the JBI Database of Systematic Reviews and the Cochrane Library, Medline and CINAHL databases did not find any scoping reviews of dementia educational interventions for physiotherapists. Similarly, a search of the PROSPERO database found no similar systematic review protocol registered or currently ongoing. However, previous research 9,11,12 has explored what constitutes effective dementia training and education for the wider health and social care workforce. For instance, a critical synthesis 9 that analysed dementia training for hospital staff examined staff's knowledge gains, changes in attitudes, confidence and behaviour change. This review found that the aspects of dementia training that were most effective are those strategies that participants can apply in their day to day practice and are related to the content and delivery 9 . The 20 papers included in this review by Surr and Gates 9 , evaluated 16 different training programmes, however, the methods of evaluation varied from study to study. Moreover, it is difficult to quantify perceived increase in knowledge as a result of training, as many questionnaires measuring knowledge are non-validated 9 . It is evident that dementia training can lead to more positive attitudes which in-turn results in improved patient outcomes 13 . Yet, in spite of this, there remains a paucity of evidence in the literature as to what constitutes effective dementia training for physiotherapists and more importantly, what type of curriculum will translate into better patient care.

Aim
This scoping review aims to explore and chart the evidence relating to education and training for physiotherapists working with people with dementia with a view to identifying any gaps within the literature.

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To identify studies that have evaluated physiotherapy dementia educational interventions.
• To critically appraise included studies, in order to update the current evidence base.
• To use the findings of the review to inform the design and delivery of a dementia educational programme for physiotherapists.
Purpose A greater understanding of what constitutes effective dementia education and training for physiotherapists will lead to appropriately designed educational interventions for physiotherapists, ultimately leading to the opportunity for enhanced patient care.

Inclusion criteria Population
The review will consider studies that include dementia education or training for both qualified physiotherapists and student physiotherapists. It will also include studies that looked at multi-disciplinary dementia training only if physiotherapy was an included profession.

Concept
The proposed scoping review is designed to explore education and training for physiotherapists working in dementia care. Therefore all studies with a focus on any aspect of physiotherapy education and training will be considered.

Context
This scoping review aims to establish the breadth and extent of the current literature published on dementia training for physiotherapists and student physiotherapists. Therefore, studies conducted in any setting (acute/primary care/residential care) or any educational setting in any geographical location will be considered. The WHO describes primary care as "first contact, accessible, continued, comprehensive and co-ordinated care" 16 .

Types of studies
This scoping review will look at all systematic, qualitative, quantitative and mixed methods studies that explore dementia education and physiotherapy. Case studies, as well as observational studies will also be included.

Methods
This scoping review will follow the Joanna Briggs Institute (JBI) methodology for scoping reviews 17 . This protocol was registered with Open Science Framework on 26 October 2020.

Search strategy
As recommended in the JBI guidelines, a three step search strategy will be used 17 . The first step, which has already been completed, involved a broad search of Medline (via EBSCO) and CINAHL using keywords for physiotherapy, dementia and education. This initial search was then followed by an analysis of the text words found in the identified titles and abstracts 18,19 . This ensured that relevant literature was captured. The search strategy was developed by one reviewer (TOS) with assistance from a librarian in University College Cork. The final search strategy for CINAHL is presented in Table 1. The final step in the search strategy will include a detailed search of the reference lists of identified studies. Databases to be searched as part of this review include: Medline, CINAHL, PsycINFO and SocINDEX. Google Scholar and Open-Grey will be searched for grey literature. Only studies published in English will be considered.

Study selection
Following the search, all identified citations will be collated and uploaded to EndNote X9.2 and duplicates removed.
Titles and abstracts will then be reviewed independently by two reviewers (TOS and TF) for assessment against inclusion criteria. Where uncertainty occurs, a third reviewer (JMcV) will be consulted. The full texts of selected studies will be then screened for inclusion. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion recorded. The results of this search will be comprehensively detailed and reported in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram 20,21 .

Data extraction
Data extraction will focus on identifying and charting data relating to physiotherapy education in dementia care. Data will be extracted using a draft data extraction tool based on the JBI data extraction tool 17 . The data extracted will include study characteristics such as author, year, type of study, publication title, country, clinical setting, participants, purpose, education content, mode of delivery, key findings, barriers and facilitators to learning and limitations. The Kirkpatrick Framework 22 , a hierarchy of evaluation of training, will be used to classify data extracted. The Kirkpatrick Framework 22 was chosen as it is widely used to evaluate educational interventions in healthcare. The four level model outlined by Kirkpatrick comprises of 1) reaction, 2) learning, 3) behaviour and 4) results 22 . The draft data extraction tool will be independently piloted on three papers by two reviewers (TOS, JMcV) and modified where necessary. Modifications will be detailed in the full scoping review report. Data will be extracted by one reviewer (TOS) and reviewed by another reviewer. Any disagreements that arise will be resolved through discussion or with a third reviewer. Missing or additional data will be obtained by contacting study authors where required. Data presentation A chronological narrative synthesis of the data will outline how the results relate to the aims and objective of this scoping review. The review will characterise what constitutes effective dementia care training for physiotherapists, the various teaching and learning approaches used and the outcomes of the training intervention. Kirkpatrick's framework will be used to report the effectiveness of the educational intervention. This will involve looking at reaction and satisfaction of participants, learning and knowledge, participants behaviour and patient outcomes. The various dementia training interventions will be tabulated in suitable categories.

Dissemination of information
The findings of this review will be disseminated in several ways. The scoping review will be published in an international peer reviewed journal, the results will also be presented at national and international conferences. More locally, the findings of the review will be disseminated through the Dementia Research Network Ireland (DRNI) and to clinical colleagues in the Health Service Executive (HSE).

Study status
This study is at stage 1: scoping review to explore and chart the evidence relating to education and training of physiotherapists working in dementia care.

Data availability
Underlying data No data are associated with this article. Thank you for the opportunity to review this paper. The focus of enhancing skills in professionals' support of people living with dementia is a key priority, particularly in the context of an increasing ageing population.

Open Peer Review
Physiotherapists have a key role in this regard, yet having bespoke education and training may be limited, despite the high potential for enhancement of quality of life.
From a cursory review of this area within the context of a literature search, there seems to be scant literature on physiotherapy and education and training. The literature appears to generally describe contributions (actual and potential) of physiotherapy and treatment efficacy. Consequently, the focus to widen the search to include multi-disciplinary teams within which physiotherapists deliver care allows more scope, but care will have to be taken to isolate the education and training needs for physiotherapy professionals in particular.
Defining what types/forms of education and training would be useful: within undergraduate programmes for physiotherapists, within postgraduate for physiotherapists, or within interdisciplinary graduate programmes.
In addition, identifying what is 'training'-is this bespoke to the discipline, inter-discipline, accredited continuous professional education programmes, study days etc. Is there a focus on competencies acquisition in clinical practice (and validated by a mentor?).
The process of the literature search is enhanced by the skills of the subject librarian and the mapping to Kirkpatrick's framework will enable a credible anchor for classification.
The methods for data extraction and resolving any disputes are transparent. Details of data dissemination are clear and suggest this is also of interest to physiotherapists outside the HSE (ie private hospitals) and has the potential to raise areas of competency development potential of private physiotherapists who deliver care in nursing homes.

Is the rationale for, and objectives of, the study clearly described? Yes
Is the study design appropriate for the research question? Yes

Are sufficient details of the methods provided to allow replication by others? Yes
Are the datasets clearly presented in a useable and accessible format? Yes

Yes
Are the datasets clearly presented in a useable and accessible format? Not applicable