DOI: https://doi.org/10.21203/rs.3.rs-2029120/v1
Background: Ageing is an important emerging demographic spectacle across the world. Therefore, the number of people with dementia is increasing every year as aging is an inevitable risk factor for dementia. An increasing number of people with dementia infers the necessity for a better quantity and quality of geriatric care services. Therefore, good knowledge and positive attitude regarding the dementia is expected in nursing students to deliver adequate quality care as they are the future primary health care professionals.
Purpose: This study aims to investigate the knowledge and attitude of Nepalese nursing studentstowards dementia.
Methods: A descriptive correlational research design was adopted for the study. The data was collected from Nepalese nursing students (n=177). Alzheimer’s Disease Knowledge Scale (ADKS) and Dementia Attitude Scale (DAS) were used to measure students’ knowledge and attitude of dementia and obtained data were analyzed by using descriptive methods.
Results: The overall mean score of ADKS was found 19.64 (SD=3.363) out of 30, and the total mean score on dementia attitude of DAS was 93.82 (SD=10.09) out of 140, where a positive relationship was remained between the knowledge score and the attitude scores (r = 0.148, P=0.050). Moreover, the domain of Assessment and Diagnosis (2.94±0.851, out of 4) was found to have the highest correct answers (94.9%), whereas the life impact domain with mean score (1.56±0.714, out of 3) revealed the lowest correct responses (50.8%).
Conclusion: This study concluded that the nursing students in Nepal demonstrate limited knowledge of dementia, while show positive attitude towards people with dementia. Moreover, findings of the study also demand the proper dementia care training and more clinical exposure for the nursing students to improve the knowledge ofdementia to be ready in their professional career.
Dementia is a combination of various symptoms that are associated with the gradual declining of the brain response such as thinking, memory, cognition, language skills, understanding and judgment from its normal level (1–3). It is often insidious in onset and difficult to diagnose in the early stages making it a double challenge to primary care workers. It is a chronic and continuous neurodegenerative syndrome characterized by global deterioration in intellectual and social functioning (4). The cause of dementia lies in the damage to the structure of the brain in which small clumps of protein, known as plaques, begin to develop around brain cells (5, 6). Ageing is, however, an inevitable risk factor for dementia disease. Along with the ageing the other common risk factors are mid-life hypertension, low educational attainment, diabetes mellitus, tobacco use as well as physical inactivity, obesity, unbalanced diets, harmful use of alcohol, mid-life depression, social isolation and cognitive inactivity (7).
It is estimated that 35.6 million of people living with dementia worldwide, which will be increased to 65.7 million by 2030 and 115.4 million by 2050. Out of them nearly two-thirds are living in low and middle income countries (8, 9). Therefore, dementia is a rapidly growing problem for both developed and developing countries (10). Moreover, the fastest growth in the elderly population taking place in middle and low income countries such as China (11), India, and their south Asian and Western Pacific neighbors, which is projected that by 2050, people aged 60 and over will account for 22% of the world’s population with four-fifths living in Asia, Latin America and Africa (12, 13).
Since, the number of people with dementia is increasing every year, a significant proportion of nurses may come into direct contact with these patients during providing care. Nurses play a vital role in the management of patients in terms of supporting care and early identification. However, it may be quite challenging to take care of demented patients probably due to the lack of sufficient knowledge and specific skills that need to be required in nursing students (2, 14). The quality of care towards people with dementia during the clinical placement can be varied based on the standard of dementia care training and adult nursing curricula in undergraduate and postgraduate level of nursing study (15, 16). The student nurses who have more clinical placement experience during their study are correlated with improved knowledge towards dementia than others (14, 17–19). It is also found that nursing students who have completed the courses related to ageing are greatly interested to work with older adult at the completion of nursing school (20). Therefore, nursing students need to be prepared to enhance the quality of nursing care of demented patients as they are the future health care professionals.
However, till the date, the limited studies have been presented that the care of the demented people is not satisfactory in low- and middle-income countries (21–23). In addition, despite the increasing number of aged population every year in low and middle-income countries (LMIC) (11, 24), the systematic studies about the knowledge and attitudes of nursing students towards the people with dementia have not been well documented. Furthermore, undergraduate heath students in low and middle-income countries cannot get sufficient training in geriatric medicine and dementia care from their schools (25), which might have limited the knowledge and attitudes regarding dementia in medical students (26). On that point is a considerable deficit of trained professionals and there is little consciousness of dementia as a public health issue, which creates a great burden on both older patients and their relatives.
Therefore, this study aims to explore the knowledge and attitudes of nursing students who is studying in developing country like Nepal, and also examine effect of demographic factors on the knowledge and attitude of them towards the people with dementia. Hence, outcome of this study would be an important document for understanding overall perceptions of nursing students towards patients with dementia and give forward the necessary steps to improve the caring quality.
This is a descriptive correlational study carried out in Nepal to assess the knowledge, attitude and their relationship of nursing students towards people with dementia.
The study used a convenience sampling to recruit 177 nursing students from the Nepalese Army institute of Health Sciences, College of Nursing located in Nepal. The inclusion criteria were all the students enrolled in an undergraduate program. The study questionnaires were forwarded to the professors of the college and were asked to forward the questionnaires to their students via electronic mail. 177 undergraduate nursing students had completed an online survey through google form. The average time had taken around 30 minutes to complete the online survey form.
There were three instruments utilized in this study to collect the data; Demographic information form, Alzheimer’s Disease Knowledge Scale (ADKS) (27), and Dementia Attitude Scale (DAS) (O’Connor & McFadden, 2010). The demographic information form had included student’s age, sex, Nursing- first choice for studying, marital status, type of current grade level, work experience with dementia patients, learn some knowledge in undergraduate program, attending dementia care training courses and searched data in dementia care.
Knowledge level were measured through Alzheimer’s Disease Knowledge Scale (ADKS) which has 30-item true/false questionnaire. A total score was calculated by summing the correct scores for each item with a range of 0 to 30. This scale was selected in present study because its psychometric properties analysis of the original English version of this scale’s showed that it has an adequate reliability (test- retest correlation = .81; internal consistency reliability = .71) and validity (predictive validity correlation = .50, concurrent validity correlation = .44, and convergent validity correlation = .65). This scale covers the following 7 domains to measure the level of knowledge: risk factors (6 items), assessment and diagnosis (4 items), symptoms (4 items), course of disease (4 items), life impact (3 items), caregiving (5 items), treatment and management (4 items) (27).
Attitude level was measured through Dementia Attitude Scale (DAS) which consists of 20 items and rated on a 7-point Likert scale ranging from 1- strongly disagree to 7 - strongly agree. It consists following two sub domain “dementia knowledge’ (items 3, 7, 10, 11, 12, 14, 15, 18, 19, 20) and “social comfort” (items 1, 2, 4, 5, 6, 8, 9, 13, 16, 17). The total-scale Cronbach’s alpha ranged 0.83 − 0.85 which is considered as good psychometric properties. The possible total scores are from 20 to 140 with higher scores indicating more positives attitude (O’Connor & McFadden, 2010).
Ethical approval was granted from the both Institutional Review Board of Nepalese Army Institute of Health Sciences and School of Nursing. Permission to use the scale of ADKS and DAS was also granted from the related authors. Researcher introduction, purpose of the study and content of the consent form with questionnaires were distributed to the nursing students and students were also assured that their responses would be confidential as informed that they can stop participating in the study at any time without any negative effect. In addition, informed consent was also done from the students before data collection.
Before data analysis, the data were checked for errors and responses of the negative statements were reverse coded. Data were analyzed with the use of Statistical Package for Social Sciences (SPSS) (Version 21.0). Descriptive and inferential statistics were carried out to describe socio-demographic data, ADKS and DAS scores. The Kolmogorov-Smirnov test was adopted to assess normality of distribution of all variables, where ADKS and DAS scores showed normality of distribution. The relationship between knowledge, attitudes and social demographic characteristics was found using independent samples t-tests and Pearson correlation (r) and the statistical significance level was considered at 0.05.
Out of 180 targeted nursing students 177 female nursing students had responded the questionnaires. Among a total participant, three quarters of the participants were belonged to the younger age group 17–24 with a mean age of 22.68 and SD = 2.789. A majority (85.3%, n = 151) of the nursing students were unmarried whereas 78.0% of the participants had first choice for studying nursing. All the participants were studying in Bachelor level in nursing and only 22% had work experience with dementia patients. Additionally, 13.6% of the participants had dementia in their relatives. friends and neighbors and majority of the participants (85.3%) had learned some knowledge of dementia in their undergraduate program. Most of the participants (97.2%) reported that they never received any dementia care training programs, few participants (16%) only ever actively searched data in dementia care and more than half of the participants (78.5%) have no any other dementia learning. The Socio Demographic Characteristics of nursing students are summarized in Table 1.
| Characteristics | Frequency(n) | Percentage (%) |
|---|---|---|
| Age (Mean age ± SD: 22.68 ± 2.789) | ||
| 17–24 | 141 | 79.6 |
| 25–32 | 36 | 20.4 |
| Sex | ||
| Female | 177 | 100.0 |
| Male | 0 | 0 |
| Marital status | ||
| Married | 26 | 14.7 |
| Unmarried | 151 | 85.3 |
| Nursing first choice for studying | ||
| Yes | 138 | 78.0 |
| No | 39 | 22.0 |
| Work experience with dementia patients | ||
| No | 138 | 78.0 |
| Yes | 39 | 22.0 |
| Relatives, friends or neighbors have dementia | ||
| No | 153 | 86.4 |
| Yes | 24 | 13.6 |
| Ever learned some knowledge of dementia in your undergraduate program | ||
| Yes | 151 | 85.3 |
| No | 26 | 14.7 |
| Ever received any dementia care training programs | ||
| No | 172 | 97.2 |
| Yes | 5 | 2.8 |
| Ever actively searched data in dementia care | ||
| No | 161 | 91.0 |
| Yes | 16 | 9.0 |
| Others dementia learning | ||
| No | 139 | 78.5 |
| Yes | 38 | 21.5 |
Table 2 demonstrates the participants dementia knowledge score through ADKS which contains 30 items and 7 domains. The overall mean ADKS scores of nursing students is 19.64 (SD = 3.363) out of 30, which is equivalent to 80.8% of correct answers, with highest and lowest mean total scores are 30 and 12 respectively. In terms of the corrected responses, 6 domains out of 7 domains are in the range of 75–95%. In addition, the assessment and Diagnosis domain mean score (2.94 ± 0.851, out of 4) indicates the highest correct answers (94.9%), followed by slightly lower in case of Treatment and management domain (93.8%) with mean score (3.05 ± 0.922, out of 4). In contrast, the life impact domain with mean score (1.56 ± 0.714, out of 3) showed the lowest correct responses (50.8%).
| Content domains | Items | Mean ± SD | Correct answers (%) |
|---|---|---|---|
| Assessment and Diagnosis | 4 | 2.94 ± 0.85 | 94.9 |
| Treatment and management | 4 | 3.05 ± 0.92 | 93.8 |
| Caregiving | 5 | 3.81 ± 1.01 | 86.4 |
| Course | 4 | 2.49 ± 1.04 | 83.6 |
| Symptoms | 4 | 2.35 ± 1.00 | 79.1 |
| Risk factor | 6 | 3.52 ± 1.36 | 76.8 |
| Life impact | 3 | 1.56 ± 0.71 | 50.8 |
| Total knowledge mean score | 30 | 19.64 ± 3.36 | 80.8 |
Even though the Life impact domain scored the lowest percent, one item from it scored the best correct rate “People with Alzheimer’s disease are particularly prone to depression (93.2%)”. Similarly, others items which score the best correct rate were “Alzheimer’s disease is one type of dementia (90.4%)” of Assessment and diagnosis domain and “poor nutrition can make the symptoms of Alzheimer’s disease worse (88.7%)” of treatment and management domain, while the items which scored the poorest responses were “When people with Alzheimer’s disease begin to have difficulty taking care of themselves, caregivers should take over right away(15.3%)” of caregiving domain, “When a person has Alzheimer’s disease using reminder notes is a crutch that can contribute to decline (25.4%)” of Treatment and Management domain and “When people with Alzheimer’s disease repeat the same question or story several times, it is helpful to remind them that they are repeating themselves (33.3%)” of caregiving domain. More details are presented in Table 2 and Table 3.
| Item number | Items | Number of correct answers (%) |
|---|---|---|
| 1 | People with Alzheimer’s disease are particularly prone to depression. | 165(93.2) |
| 21 | Alzheimer’s disease is one type of dementia | 160(90.4) |
| 12 | Poor nutrition can make the symptoms of Alzheimer’s disease worse. | 157(88.7) |
| 5 | People with Alzheimer’s disease do best with simple instructions given one step at a time. | 155(87.6) |
| 14 | A person with Alzheimer’s disease becomes increasingly likely to fall down as the disease gets worse | 145(81.9) |
| 7 | If a person with Alzheimer’s disease becomes alert and agitated at night, a good strategy is to try to make sure that the persons get plenty of physical activity during the day. | 145(81.9) |
| 9 | People whose Alzheimer’s disease is not yet severe can benefit from psychotherapy for depression and anxiety. | 140(79.1) |
| 27 | Genes can only partially account for the development of Alzheimer’s disease. | 138(78.0) |
| 22 | Trouble handling money or paying bills is a common early symptom of Alzheimer’s disease | 137(77.4) |
| 4 | When a person with Alzheimer’s disease becomes agitated a medical examination might reveal other health problems that caused the agitation. | 135(76.3) |
| 17 | Eventually a person with Alzheimer’s disease will need 24-hour supervision | 130(73.4) |
| 20 | Symptoms of severe depression can be mistaken for symptoms of Alzheimer’s disease. | 125(70.6) |
| 2 | It has been scientifically proven that mental exercise can prevent a person from getting Alzheimer’s disease. | 124(70.1) |
| 28 | It is safe for people with Alzheimer’s disease to drive, as long as they have a companion in the car at all times. | 123(69.5) |
| 11 | Most people with Alzheimer’s disease live in nursing homes | 120(67.8) |
| 26 | Having high blood pressure may increase a person’s risk of developing Alzheimer’s disease. | 114(64.4) |
| 29 | Alzheimer’s disease cannot be cured | 110(62.1) |
| 18 | Having high cholesterol may increase a person’s risk of developing Alzheimer’s disease. | 106(59.9) |
| 25 | Prescription drugs that prevent Alzheimer’s disease are available. | 99(55.9) |
| 8 | In rare cases people have recovered from Alzheimer’s disease. | 97(54.8) |
| 10 | If trouble with memory and confused thinking appears suddenly, it is likely due to Alzheimer’s disease. | 90(50.8) |
| 3 | After symptoms of Alzheimer’s disease appear the average life expectancy is 6 to 12 years. | 86(48.6) |
| 23 | One symptom that can occur with Alzheimer’s disease is believing that other people are stealing one’s things | 85(48.0) |
| 30 | Most people with Alzheimer’s disease remember recent events better than things that happened in the past. | 84(47.5) |
| 19 | Tremor or shaking of the hands or arms is a common symptom in people with Alzheimer’s disease. | 76(42.9) |
| 16 | Once people have Alzheimer’s disease, they are no longer capable of making informed decisions about their own care. | 71(40.1) |
| 13 | People in their 30s can have Alzheimer’s disease | 63(35.6) |
| 15 | When people with Alzheimer’s disease repeat the same question or story several times, it is helpful to remind them that they are repeating themselves. | 59(33.3) |
| 24 | When a person has Alzheimer’s disease using reminder notes is a crutch that can contribute to decline. | 45(25.4) |
| 6 | When people with Alzheimer’s disease begin to have difficulty taking care of themselves, caregivers should take over right away. | 27(15.3) |
| Notes: Risk factors (item 2, 13, 18, 25, 26 and 27); Assessment and diagnosis (item 4, 10, 20 and 21); Symptoms (item 19, 22, 23 and 30); Disease progression (item 3, 8, 14 and 17); Life impact (item 1, 11 and 28); Caregiving (item 5, 6, 7, 15 and 16); Treatment and management (item 9, 12, 24 and 29) | ||
The overall mean score of dementia attitude was 93.82 (SD = 10.09) out of 140. Furthermore, the mean score 56.04 ± 7.12 of knowledge domain indicates that the nursing students have the sufficient knowledge related to attitude of dementia compare to comfort domain with mean score 37.78 ± 5.87 as presented in Table 4. However, the mean score of comfort domain (37.78 ± 5.871) is higher than the average score of 35 indicating that participants held positive attitude towards people with dementia in comfort domain.
| Content domain | Mean | SD | Theoretical full score |
|---|---|---|---|
| Knowledge | 56.04 | 7.12 | 70 |
| Comfort | 37.78 | 5.87 | 70 |
| Overall score of DAS | 93.82 | 10.09 | 140 |
Table 5 represents the results obtained for comfort and knowledge domain. 38.5% nursing students felt confident around people with ADRD and only 61% of the nursing students felt comfortable touching people with ADRD. Although, 66.7% nursing students disagree to avoid an agitated person with ADRD and also, 43% nursing students feel frustrated because they do not know how to help people with ADRD. 42.9% nursing students neutrally felt relaxed around people with ADRD. There were 62.2% nursing students agreed that it is rewarding to work with people who have ADRD in comfort domain.
| Items Number | Items | Agree | Neutral | Disagree | Mean ± SD | |
|---|---|---|---|---|---|---|
| Knowledge of attitude domain | ||||||
| 11. | It is important to know the past history of people with ADRD. | 169(95.5%) | 3(1.7%) | 5(2.8%) | 6.51 ± 1.001 | |
| 19. | We can do a lot now to improve the lives of people with ADRD. | 164(92.7%) | 5(2.8%) | 8(4.6%) | 6.25 ± 1.156 | |
| 7. | Every person with ADRD has different needs. | 162(91.5%) | 9(5.1%) | 6(3.5%) | 6.23 ± 1.100 | |
| 12. | It is possible to enjoy interacting with people with ADRD. | 146(82.4%) | 23(13.0%) | 8(4.5%) | 5.73 ± 1.212 | |
| 10. | People with ADRD like having familiar things nearby. | 138(78%) | 23(13.0%) | 16(9.1%) | 5.58 ± 1.502 | |
| 18. | I admire the coping skills of people with ADRD. | 131(74%) | 38(21.5%) | 8(4.6%) | 5.45 ± 1.265 | |
| 15. | People with ADRD can feel when others are kind to them. | 135(76.3%) | 23(13.0%) | 19(10.7%) | 5.40 ± 1.399 | |
| 20. | Difficult behaviors may be a form of communication for people with ADRD. | 130(73.5%) | 23(13.0%) | 24(13.6%) | 5.26 ± 1.662 | |
| 14. | People with ADRD can enjoy life. | 131(74%) | 18(10.2%) | 28(15.7%) | 5.14 ± 1.587 | |
| 3. | People with ADRD can be creative. | 98(55.3%) | 31(17.5%) | 48(27.1%) | 4.50 ± 1.809 | |
| Social comfort of attitude domain | ||||||
| 17. | I cannot imagine caring for someone with ADRD* | 21(11.9%) | 15(8.5%) | 141(79.7%) | 5.54 ± 1.430 | |
| 2. | I am afraid of people with ADRD* | 25(14.1%) | 22(12.4%) | 130(73.4%) | 5.42 ± 1.576 | |
| 6. | I feel uncomfortable being around people with ADRD* | 34(19.2%) | 27(15.3%) | 116(65.5%) | 5.15 ± 1.672 | |
| 1. | It is rewarding to work with people who have ADRD | 110(62.2%) | 51(28.8%) | 16(9.1%) | 5.08 ± 1.373 | |
| 9. | I would avoid an agitated person with ADRD* | 39(22.1%) | 20(11.3%) | 118(66.7%) | 4.98 ± 1.724 | |
| 5. | I am comfortable touching people with ADRD. | 108(61%) | 37(20.9%) | 32(18.1%) | 4.93 ± 1.667 | |
| 4. | I feel confident around people with ADRD. | 68(38.5%) | 66(37.3%) | 43(24.3%) | 4.28 ± 1.402 | |
| 16. | I feel frustrated because I do not know how to help people with ADRD* | 72(40.7%) | 29(16.4%) | 76(43%) | 4.19 ± 1.629 | |
| 13. | I feel relaxed around people with ADRD. | 56(31.7%) | 76(42.9%) | 45(25.4%) | 4.08 ± 1.303 | |
| 8. | I am not very familiar with ADRD* | 96(54.2%) | 34(19.2%) | 47(26.6%) | 3.32 ± 1.806 | |
| *Reverse scored item | ||||||
On the other hand, in case of knowledge domain, 95.5% of the nursing students agreed that it is important to know the past history of people with ADRD. Moreover, 92.7% of the nursing students also agreed that they can do a lot now to improve the lives of people with ADRD. They believed that People with ADRD can enjoy life (74%). Meanwhile, 91.5% of the nursing students agreed that every person with ADRD has different needs while 74% nursing students admired the coping skills of people with ADRD.
Table 6 showed a positive relationship remained between the knowledge scores and the attitude scores (r = 0.148, P = 0.050). A similar relationship was showed between knowledge score and ‘social comfort’ (r = 0.158, P = 0.036) whereas no clear relationship with knowledge domain of attitude scale (r = 0.079, P = 0.293).
| ADKS | DAS | |||||
|---|---|---|---|---|---|---|
| Overall score | Comfort domain | Knowledge domain | ||||
| r | p | r | p | r | p | |
| Overall score | 0.148 | 0.050* | 0.158 | 0.036* | 0.079 | 0.293 |
| Life impact | 0.233 | 0.002** | 0.139 | 0.064 | 0.216 | 0.004** |
| Risk factor | 0.108 | 0.151 | 0.152 | 0.044* | 0.028 | 0.709 |
| Course | 0.059 | 0.432 | 0.096 | 0.204 | 0.005 | 0.947 |
| Caregiving | 0.037 | 0.627 | 0.090 | 0.236 | − .022 | 0.773 |
| Treatment and management | 0.106 | 0.161 | − .007 | 0.931 | 0.156 | 0.039* |
| Symptoms | 0.039 | 0.607 | 0.063 | 0.408 | 0.004 | 0.962 |
| Assessment | − .104 | 0.167 | − .089 | 0.239 | − .075 | 0.323 |
| * P < 0.05, **P < 0.01 | ||||||
Table 7 illustrates the relationship of knowledge and attitude of nursing students with socio- demographic characteristics. The results revealed that marital status is independently associated with knowledge level (t=-3.003, P = 0.003). Unmarried students have better knowledge score than married ones. Moreover, only those nursing students who did not have dementia in their relatives, friends or neighbors (p = 0.043) and who did not have others dementia learning (P = 0.04) is found positively associated with attitude.
| Characteristics | Number (%) | Mean ± SD of ADKS score | t value or r value | p-value | Mean ± SD of DAS score | t value or r value | p-value |
|---|---|---|---|---|---|---|---|
| Age Mean 22.68 ± 2.789 | 19.64 ± 3.363 | -0.142 a | 0.060 | 93.82 ± 10.090 | -0.028 a | 0.710 | |
| Marital status | -3.008 b | 0.003** | 0.877 b | 0.382 | |||
| Married | 26(14.7) | 17.85 ± 3.196 | 95.42 ± 8.505 | ||||
| Unmarried | 151(85.3) | 19.95 ± 3.304 | 93.54 ± 10.338 | ||||
| Nursing first choice for studying | -0.365 b | 0.715 | -0.052 b | 0.959 | |||
| Yes | 138(78.0) | 19.60 ± 3.298 | 93.85 ± 10.083 | ||||
| No | 39(22.0) | 19.82 ± 3.698 | 93.95 ± 10.435 | ||||
| Work experience with dementia patients | 1.741 b | 0.083 | -0.681 b | 0.497 | |||
| No | 138(78.0) | 19.41 ± 3.350 | 94.09 ± 9.967 | ||||
| Yes | 39(22.0) | 20.46 ± 3.323 | 92.85 ± 10.589 | ||||
| Relatives, friends or neighbors have dementia | 0.500 b | 0.618 | -2.034 b | 0.043* | |||
| No | 153(86.4) | 19.59 ± 3.390 | 94.42 ± 9.972 | ||||
| Yes | 24(13.6) | 19.96 ± 3.237 | 89.96 ± 10.192 | ||||
| Ever learned some knowledge of dementia in your undergraduate program | 0.985 b | 0.326 | 0.691 b | 0.495 | |||
| Yes | 151(85.3) | 19.74 ± 3.473 | 94.11 ± 9.317 | ||||
| No | 26(14.7) | 19.04 ± 2.615 | 92.15 ± 13.873 | ||||
| Ever received any dementia care training programs | 19.64 ± 3.363 | -0.049 a | 0.518 | 93.82 ± 10.090 | 0.055 a | 0.471 | |
| No | 172(97.2) | ||||||
| Yes | 5(2.8) | ||||||
| Ever actively searched data in dementia care | -0.122 a | 0.105 | 0.006 a | 0.936 | |||
| No | 161(91.0) | 19.51 ± 3.339 | 93.84 ± 10.072 | ||||
| Yes | 16(9.0) | 20.94 ± 3.435 | 93.63 ± 10.607 | ||||
| Others dementia learning | 0.312 b | 0.756 | -2.911 b | 0.004** | |||
| No | 139(78.5) | 19.60 ± 3.434 | 94.95 ± 9.714 | ||||
| Yes | 38(21.5) | 19.79 ± 3.129 | 89.68 ± 10.488 | ||||
| a- statistics based on Pearson correlation analysis; b -statistics based on independent sample t-test; * P < 0.05, **P < 0.01 | |||||||
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.
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.
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.
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.
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.
Majority of the nursing students in Nepal had not received any dementia care training. Moreover, very low percentage of the participants in this study had work experience with demented people. The finding concluded that nursing students in Nepal demonstrate limited knowledge of dementia, while showed positive attitude towards people with dementia. Moreover, the knowledge of nursing students towards people with dementia was influenced by the socio-demographic factors especially marital status and found that unmarried students are more knowledgeable than married students, while presence of demented people in family, friends and relatives and other dementia learning directly influenced the attitude of nursing students towards people with dementia. Furthermore, besides the prescribed curriculum by college setting, nursing students have received the information associated to dementia from other dementia learning (The sources of other dementia learning could probably be the media, social communication and other resources in their daily lives). This study also pointed out the deficit of dementia care education program and dementia care training in undergraduate nursing students in Nepal. Therefore, study seriously insists to include adequate dementia knowledge training and dementia learning activities in the undergraduate nursing study curriculum to transform them into practice to improve care outcomes in their professional career. It is anticipated that the finding thus obtained would facilitate concerned authorities to modify the strategy to promote dementia knowledge and attitude among nursing students in Nepal.
Availability of data and materials
All data produced and analyzed during this study are included in this article.
Ethical approval and consent to participate
The conduction of this survey was approved by the Institutional Review Board (IRB) of Nepalese Army Institute of Health Sciences (NAIHS), Nepal and NAIHS School of Nursing. ADKS and DAS scales were used by granting the permission from related authors. The consent from the students was taken before data collection and assured that their responses would be confidential as informed that they were free to quit their participation at any time without any negative effect. All methods were carried out in accordance with relevant guidelines and regulations.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Funding
This work was financially supported by Department of Science & Technology of Liaoning province of China (No.2019JH8/10300013).
Acknowledgements
Authors are very grateful to Department of Science & Technology of Liaoning Province of China for their financial support for this project. We thank the Institutional Review Board (IRB) of Nepalese Army Institute of Health Sciences (NAIHS), Nepal and NAIHS school of nursing for approving conduction of this project. We are most grateful to the nursing students, who participated in the survey. Special thanks go to Dr. Durga Bhakta Pokharel, a Postdoctoral Research Fellow in Orthopedic Research Center, Affiliated Zhongshan Hospital of Dalian University, Dalian China, for his valuable comments and constructive suggestions.
Authors’ contributions
Ranjana Khatiwada designed the study, analyzed the data and prepared draft of the manuscript. Lyu Siman and Haocheng Wang re-analyzed the data and contributed to the revision of the manuscript. Sushila Devi Bhandari participated in the study design and contributed to the critical revision of the manuscript. Yu Liu designed the study, re-analyzed the data and contributed to the critical revision of the manuscript. All authors read and approved the final manuscript.