4.1 Socio-demographic characteristic of nursing students from Nepal
The participants in this study were belonged to younger age group with a mean age of 22.68 (SD=2.789) years old and were studying bachelor level in nursing program in Nepal. It is found that most of the respondents (97.2%) in this study had never received any dementia care training programs, while more than two-third of the participants (78.5%) had no any idea about other dementia learning such as the media, social communication and other resources in their daily lives). These deficits in Nepalese nursing students specify the necessity for continuous workshop and training specifically in taking care of elderly with dementia in the curriculum of bachelor level nursing program. Meanwhile, few participants (22%) had work experience with dementia patients, while (13.6%) of the participants had dementia on their relatives, friends or neighbors in this study. This is suggesting that undergraduate Nepalese nursing students have lack of adequate geriatric care experience during their clinical practicum.
4.2 Knowledge of the nursing students toward people with dementia
The results show that the overall mean score of dementia knowledge was 19.64±3.36, out of 30, which is just above the half score and similar to the Maltese nursing students (19.36 ±3.30) (14) and staffs for nursing homes (19.50±3.0) in Indian nurses (29). However, the result is not satisfactory compared to studies conducted among undergraduate students and health care staff in USA (M = 20.42±3.97 ) and Australia respectively (23.6 ±3.26) (30,31). This is probably due to the lack of specialized dementia care curriculum in the nursing study program in Nepal, because dementia disease is not yet considered as a serious health care issue by the concerned authorities (26). Hence, awareness to the public level could be limited in Nepal (26,32).
The best correct response on Assessment and Diagnosis domain (94.9%) and Treatment and Management domain (93.8%) were obtained compared to existing reports (31,33). This could acknowledge the inclusion of mostly theoretical question in these two domains, suggesting that the nursing students in our study might have learned basic information on dementia in their undergraduate program. On the other hand, poor knowledge in life impact domain (1.56±0.71) was found compared to the study conducted among undergraduate nursing students (2.14±0.90) in Malta (14) as well as in a study conducted in China (2.43±0.68) among General practitioners (33). This could be related to the presence of daily life related questions in this domain, which might have been difficult to answer for nursing students due to the lack of work experience with dementia patients as well as deficiency of training related to dementia care. Moreover, culturally specific elderly care center in Nepal is not common so far (24), so that nursing students could not get easy access to the elder people who might have dementia.
4.3 Attitude of the Nursing Students Toward Dementia
The overall mean score of Dementia Attitude Scale (93.82+10.09) indicates that nursing students had positive attitude toward people with dementia. The result is in the line with the existing studies in US undergraduate psychology students (98.64± 12.82) (34) and Maltase nursing students (103.51±13.43) (14). The positive dementia related attitude obtained in this study could be attributed to the cultural influence on the nursing students in Nepal, as living three-generation in a family is a common cultural practice in Nepal, which might have positively affected the attitude of nursing students and increased the respect towards the older people, no matter what sort of disease do older people have (35).
On the other hand, this study exhibits the lower comfort domain mean score (37.78±5.871) and relatively higher knowledge domain mean score (56.04±7.117) compared to the existing studies (14,36). Furthermore, majority of nursing students in this study has disagreed that they are afraid of people with ADRD (73.4%) and agreed that they feel comfortable touching people with ADRD (61%). A similar finding has been reported by Poreddi et al. (36) in Indian undergraduate nursing students. Moreover, 95.5% of the nursing students in this study agreed that it is important to know the past history of people with ADRD. So that they can do a lot now to improve the lives of people with ADRD (92.7%). There were 82.4% of nursing students also believe that people with ADRD can enjoy their life. All these results are consistent with the finding reported by Strøm et al. (29). These promising results from our study indicate that nursing students hold encouraging attitude towards demented people, which would positively influence on the dementia care in future professional career.
4.4 Correlation between Knowledge and Attitude of Nursing Students Toward People with Dementia
This study revealed that there remained a positive relationship between the knowledge scores and attitude towards dementia (r= 0.148, P=0.050). Similar findings are reported by previous studies (14,37). This should be acknowledged that based on the knowledge-attitude-behavioral theory, knowledge could influence attitude, and influence the behavior. Meanwhile, influence of demographic factors on clinical outcomes is not direct but is mediated through knowledge, attitude, and behavior (38,39). Moreover, demographic factors such as education, proper training related to dementia, other dementia learning may improve knowledge and attitude, and that improved knowledge enhances behavior. Improved attitude improves behavior, and improved practice leads to improved outcomes during the clinical practice (40).
This study showed a positive relationship between ADKS and ‘social comfort’ (r=0.158*, P=0.036), whereas no association between ADKS and knowledge score of attitudes was found. However, Scerri et al. (14) reported that the dementia knowledge on the DAS was notably associated to ADKS but ‘social comfort’ was not. This should be acknowledged that most of the nursing students in our study might have been unaware about ADRD. It is previously reported that participants who know a person with ADRD score higher on the DAS, indicate the relationship between positive feelings and supportive behaviors, which is correlated with more positive attitude (34). Furthermore, life impact domain of knowledge scale was found to have a positive relationship with both attitude and knowledge factor of DAS, while risk factor was positively associated with comfort factor of DAS. Meanwhile, relationship of treatment and management with knowledge factor of DAS was found positive in our study. However, rest of the sub-domains of ADKS in our study had no association with DAS Scale. This could be attributed that the students with better knowledge will have more positive affect and behavioral (40). In this study, we have not tested the caring behavioral toward people with dementia, but the correlation between knowledge and attitude has been verified again. Future studies will be needed to test the correlation among knowledge, attitude and caring behavior toward people with dementia in Nepal.
4.5 Factors affecting Nursing Student's Knowledge and Attitude Towards People with Dementia
Previous research has suggested that the knowledge and attitude of nursing students towards demented people is positively correlated with age, where older age group of nursing students had shown better knowledge and positive attitude towards PWD (14,30,41). However, this study shows an opposite result that the level of dementia knowledge and attitude were not correlated with age. The reason has been explained earlier that Nepalese culture could have encouraged younger generation to respect towards the older people, no matter which sort of disease do older people have (35). However, present study suggests that the marital status of the nursing students influences the knowledge towards PWD (t=-3.003, p= 0.003). This finding is inconsistent with the previous study (42), which suggests that there is no any association of marital status with knowledge.
Moreover, our results also show that the attitude score had positive relation with those nursing students who do not have dementia in their relatives, friends or neighbors (p=0.043). It is inconsistent with report presented by Cheng et al. (43) in Hongkong, who found that knowing a relative or friend with dementia had lower stigmatizing attitude towards demented people. This might be because of limited knowledge in nursing students towards people with dementia due to the lack of exposure towards demented people. This should be acknowledged that the nursing students might have accepted easily and positively considered that dementia is the normal aging process. However, when they have a real experience with demented patients or relatives, they may not understand the abnormal symptoms of dementia. In some studies, the abnormal symptoms of dementia compared to other chronic illness can result in stigma of caregivers, relatives, or any other people involved. This negative feeling may lead to worse attitude on dementia (44,45). By contrast, it is surprising that no others dementia learning was positively associated with attitude towards dementia which is inconsistent with the study by Carpenter et al. and Smyth et al. (30,46). The study found that students attending a dementia-specific educational session was positively associated with attitude of dementia. Future study is needed to explore the effects of related training program on attitude towards dementia among different population.
Strength and Limitations
The main strength of the present study was to determine the knowledge, attitude and factors that affect both knowledge and attitude regarding people with dementia among nursing students in Nepal which has not been investigated so far. The results can be compared with that from other countries which also used the same measurements.
However, there are some limitations associated with the present study. Firstly, all participants were recruited only from bachelor level within a single university. The representation of the results is limited. In future studies, students from different universities and programs can be compared and analyzed. Secondly, the sample was only female students, which made it impossible to compare possible gender differences. In future study, male nursing students will be recruited even though the majority of nursing staff in Nepal are still female.