This mixed methods pilot study used a pretest-posttest design to evaluate a 3-month dementia training program for nursing home direct care staff. The quantitative component measured changes in empathy and dementia communication knowledge before and after the intervention. The qualitative component consisted of focus group interviews conducted at posttest to explore participants’ perceptions of the program’s content, delivery, and relevance to their work.

The study was conducted in a nursing home located in northern Virginia. Conducting studies in nursing homes, especially the entry phase of recruitment, has been documented as difficult due to organizational, administrative, and staff barriers [45]. Specifically, clear support from top management, ability to coordinate shifts with colleagues, and maneuvering high workload and turnover rates have been reported as important conditions for successful research [46]. Hence, this study used a nonprobability, convenience sampling approach. Recruitment was conducted through public posting and distribution of flyers that included the study description and inclusion criteria. Eligible participants were staff who (1) worked in direct care roles, (2) could communicate in English, and (3) were willing to complete all components of the training and data collection. There were no formal screening procedures used. With permission from the nursing home administrative team, flyers created by the investigators were distributed to the nursing home’s direct care staff. Interested staff members volunteered to participate in the study. Administrative staff also helped with recruitment by speaking directly to care staff and encouraging participation. Recruitment was coordinated through facility administrators. In particular, developing a trusting personal contact with one of the key administrators was very helpful to manage the recruitment process [45].

The training program was conducted by the principal investigator and coinvestigator once a month over the course of 3 months from March to May 2025 using a combination of the 3 complementary learning formats described below. This multimodal approach was designed to layer conceptual understanding (online module), experiential insight (VR), and application (group discussion).

Pre- and posttest outcomes were measured using 2 standardized tests. Empathy was assessed using the 10-item Jefferson Scale of Empathy–Healthcare Provider Version [50], which uses a 7-point Likert scale (1=“strongly disagree”; 7=“strongly agree”). Items reflecting a lack of empathy were reverse scored. Higher scores indicated greater empathy. Dementia communication knowledge [51] was measured using a 10-item multiple-choice test focusing on effective communication techniques with persons living with dementia. Scores reflected the number of correct responses. We also collected participants’ demographics, including age, gender, race and ethnicity, language spoken at home, years of experience in direct care, work status, and personal experiences with persons living with dementia. Additionally, we conducted focus group interviews with open-ended questions exploring learning experiences, perceived applicability, and perceived changes in attitudes or behaviors. Three open-ended questions were posed: (1) “How was the overall training?” (2) “What did you think about the VR experience?” (3) “What did you think about the online videos?”

Baseline surveys were conducted in February 2025. Training sessions took place monthly from March 2025 to May 2025, with each month’s in-person session including VR and discussion. Postintervention surveys and focus groups were completed in May 2025. These sessions were all conducted before or after the participants’ work shifts. Jolly Good Inc provided the VR headsets, software, and on-site technical support.

The study protocol was determined to be exempt from in George Mason University’s Institutional Review Board (STUDY00000298). However, we collected informed consent from our participants, which delineated their rights to terminate participation at any time and to be protected in terms of privacy and confidentiality. Participation was voluntary, and all data were deidentified prior to analysis. All participants received a US $100 addition to their salaries at the start of the training and a US $100 gift card upon completion of the training.

Quantitative analyses were performed in the SPSS statistical software (IBM Corp). Paired-sample 2-tailed t tests were conducted to compare pre- and postintervention empathy and knowledge scores for participants who completed both assessments. Effect sizes were calculated using the Cohen d.

After the intervention, qualitative focus group interviews were conducted, videotaped, transcribed verbatim, and analyzed using thematic analysis to identify patterns related to perceived learning, feasibility, and practical application. The initial analysis was conducted by the principal investigator, and the results were then discussed and validated by the team of investigators through team discussion meetings. Data from both strands of the study were integrated during interpretation to provide a comprehensive understanding of program outcomes.

A detailed demographic profile of the participants is provided in Table 1. The study included 21 participants, with 76.2% (16/21) completing both pre- and postassessments. Participants’ mean age was 45.8 (SD 15.0) years for the full sample and 45.7 (SD 16.3) years for the complete-case subset. Most participants were female (19/21, 90.5% in the full sample; 15/16, 93.8% in the complete-case subset) and identified as Black or African American (20/21, 95.2% in the full sample; 15/16, 93.8% in the complete-case subset). Nearly half (10/21, 47.6%) of the full sample reported more than 16 years of experience in dementia care, with a similar distribution in the matched subset (7/16, 43.8%). Informal or on-the-job dementia training was the most common form of prior training (15/21, 71.4% in the full sample; 11/16, 68.8% in the complete-case subset). Primary work shifts were split between day (8/21, 38.1%) and evening (13/21, 61.9%) in the full sample, whereas the complete-case subset predominantly worked day shifts (11/16, 68.8%). Regarding the number of residents living with dementia in their care, the full sample reported that 28.6% (6/21) cared for 1 to 3 residents, 14.3% (3/21) cared for 4 to 6 residents, 52.4% (11/21) cared for 7 to 10 residents, and 4.8% (1/21) cared for more than 10 residents. The complete-case subset had a similar distribution. Most participants (18/21, 85.7% in the full sample; 14/16, 87.5% in the complete-case subset) spoke English at home, but it was an African dialect, not American English. Over one-third (7/21, 33.3% in the full sample; 5/16, 31.3% in the complete-case subset) reported a personal connection to dementia.

Table 2 reports the standardized test scores. For the paired-sample t tests, 16 participants who completed both the pre- and postassessments were included. Empathy was assessed using a 10-item composite scale, including 4 reverse-scored items with higher values indicating greater empathy. The results showed a slight increase in empathy from pretest (mean 5.31, SD 0.74) to posttest (mean 5.51, SD 0.61). The mean difference was 0.20 (SD 0.43) points, with a 95% CI for the mean difference of −0.03 to 0.43. This change did not reach statistical significance (t₁₅=1.88; P=.08), although the corresponding effect size was in the small to moderate range (Cohen d=0.47).

Dementia knowledge was assessed using 10 items, with correct responses scored as 1 and incorrect responses scored as 0, yielding a total score ranging from 0 to 10. Knowledge scores increased from pretest (mean 5.50, SD 2.37) to posttest (mean 5.94, SD 2.11). The mean difference of 0.44 (SD 1.63) points, with a 95% CI of −0.43 to 1.31, was not statistically significant (t₁₅=1.07; P=.30). The associated effect size was small (Cohen d=0.27).

Thematic analysis identified three main themes: (1) reframing dementia, (2) growing empathy and understanding, and (3) preferred training formats.

This pilot study explored the effect of the integration of relationship-centered care training with immersive learning on direct care staff’s empathy and dementia knowledge. The study participants were predominantly female, Black care workers with over 16 years of experience in the field. Many learned about dementia primarily through informal, on-the-job training. They cared for multiple persons living with dementia per shift, reflecting the high emotional and physical demands typical of their roles.

As a pilot study, this investigation was designed to assess feasibility and generate preliminary estimates of intervention effects rather than test definitive hypotheses. Accordingly, the sample size (n=16) provided sufficient power to detect only large within-person effects, and the absence of statistically significant changes in empathy and dementia knowledge outcomes was anticipated. Therefore, emphasis is placed on effect size estimation and CIs to inform the design of a future adequately powered study.

While the overall changes in empathy and knowledge did not reach statistical significance, both moved in the expected positive direction. The small to moderate effect size for empathy (Cohen d=0.47) suggests that there may be meaningful benefits even within the short time frame of this intervention. This aligns with findings from relationship-centered care programs that foster personhood and potentially boost self-efficacy [52,53].

The qualitative findings complement the quantitative results by providing context for the small but positive changes observed in empathy and knowledge scores. Participants described the VR training as reframing their perceptions of dementia; reducing stigma; and prompting more compassionate, person-centered perspectives. Many favored interactive, immersive formats over online modules. Emotional learning appeared to be a particular strength of the VR component even though the scenarios were set in an Asian cultural context.

The knowledge effect (Cohen d=0.27) was more modest, which mirrored the observation by Stafford et al [54] that VR can be engaging but not always more effective than traditional dementia training. Given that most participants spoke African dialects of English and had limited baseline knowledge of dementia, traditional mainstream, web-based training methods or handouts and content written or explained in formal English may be less effective. A combination of visual learning using VR and more time spent on explaining dementia knowledge in simple English during group sessions may improve comprehension and retention.

The modest improvement observed in dementia communication knowledge (Cohen d=0.27) should also be interpreted in light of the qualitative findings. Several participants reported that they did not complete the online modules as intended and, instead, relied primarily on the in-person VR and facilitated discussion sessions. Therefore, limited engagement with the asynchronous modules may partially explain the small knowledge effect size observed in the quantitative analysis. This finding highlights an important structural challenge in dementia workforce training. Although online modules are often used to increase accessibility, direct care staff in long-term care settings often have limited time during work hours to access and complete them as intended. Participants indicated that training was most feasible when administrators allowed them to attend sessions during paid work time. Taken together, these mixed methods findings suggest that while immersive VR and facilitated discussion may promote emotional learning and engagement, knowledge acquisition through online modules may require stronger organizational support and protected training time to ensure consistent participation and successful attainment of training objectives.

The findings also speak about broader workforce development needs. This was an experienced, committed workforce, yet access to formal training opportunities remained limited. For certified nurse assistants, training was often feasible if administrators freed them from floor duties during work hours. Appropriate time and space for structured, evidence-based education can strengthen both empathy and knowledge outcomes. Past literature also points to stronger benefits when coupled with sustained practice and reinforcement [55]. Future programs might consider extending the duration, incorporating booster sessions, and embedding other scenarios.

There are several study limitations. First, the training was implemented in 1 setting with a fairly homogenous workforce, which limits generalizability. Second, due to the small sample size, statistical power was limited. Participation may have been hindered by the nursing home’s initial decision not to offer direct incentives; recruitment improved once gift cards were introduced. More visible and systemic incentives should be adopted to encourage participation in training for direct care staff. Third, given that many participants began the training with relatively high empathy scores, the potential for a ceiling effect should be considered. The smaller gains in dementia knowledge may be due to the variability in baseline knowledge and the need for repeated reinforcement to consolidate new information. Nevertheless, the positive direction of change and the strong engagement from participants point to the promise of this approach.

Although this was a small pilot study, the combination of immersive VR and relationship-centered care content shows potential as part of a larger, sustained training strategy. Future work should address VR accessibility and affordability for direct care staff training for those who will benefit the most. Larger studies with more diverse samples and longer follow-up periods are needed to see whether these early gains translate into lasting changes in attitudes, communication, and care practices.