In providing long-term nursing care to elderly people, knowledge and skills required of the nurse have changed considerably over the last 15 years. For the most part, formal educational preparation of nurses for gerontological nursing has been deficient in both quality and quantity. Nursing administrators have been forced to employ generalists or specialists in areas other than gerontology to deal with the complex and multifaceted problems presented by increasing numbers and proportions of old people.
Increased costs of providing health care to aged people and others have prompted adoption of measures to control expenses without sacrificing quality. One approach has been to provide continuing education programs to increase the knowledge and skills of nursing personnel engaged in the delivery of long-term care.
Personnel responsible for continuing education face an enormous challenge. Program content must be highly applicable and lend itself to implementation in such a way as to accomplish the "greatest good for the greatest numbers" of aged clients without further taxing the depleted resources of nursing personnel. Programs must be sufficiently appealing to compete favorably with nurses' compulsion to attend to the ever-present and obvious physical needs of clients. The time allotted for continuing education programs must be brief. Provision must be made to offer educational programs to employees during the evening and night hours. The situation is complicated further by the rapid turnover of nursing personnel.
A first step in addressing this challenge should be assessment of nurses' levels of knowledge about old age, and identification of factors associated with knowledge levels.
Purpose of the Study
Our study was designed to assess the extent of gerontological nursing knowledge operational in nursing staff at a large VA Medical Center and to identify relationships between knowledge and selected factors commonly believed to influence levels of knowledge. This information was expected to give direction to continuing education programs for nursing personnel and to influence nursing academicians concerning gerontological content within curricula. Since knowledge is a required but not necessary sufficient condition to insure quality nursing practice, this study was viewed as one in a series of endeavors with the purpose of promoting excellence in gerontological nursing practice.
The literature was reviewed to determine the extent and nature of efforts to assess knowledge levels of personnel engaged in the practice of both general and gerontological nursing.
Few reports of studies to discern nursing staff knowledge levels have been reported in literature reviewed as far back as 1965. Available reports indicate that nursing personnel have not known very much about the topics under consideration. Crowder1 studied both licensed practical and registered nurses employed in maternity nursing to assess their knowledge of factors promoting successful breast feeding. Results revealed that nurses' levels of education affected their knowledge, as reflected in the higher test scores of the registered nurses. Areas of greatest weaknesses were knowledge about drugs, maternal emotions, neonatal physiology, and nursing intervention. Nurses' knowledge of infant feeding and maternal feeding was judged to be adequate.
An assessment to determine nurses' knowledge of glycosuria testing in diabetes mellitus2 indicated a mean score of 4.8 out of a possible 12 points for the registered and licensed practical nurse respondents. Thirty-seven of the 45 subjects were unable to recognize the description of the two-drop Clinitest method that is useful in quantifying glycosuria in excess of two percent. Forty-three subjects failed to identify Clinitest as an inappropriate test for lactating clients, and 12 failed to recognize that this same test was inappropriate for clients receiving cephalothin (Keflin) therapy. These deficiencies in nurses' knowledge have potentially serious consequences for quality client care.
In the area of gerontological nursing, Farady3 found that there was not a standard quality of range of motion provided for nursing home. This conclusion was based on a brief written test that measured ability to describe all ranges of motion of the upper extremity and knowledge of the purpose and optimal frequency of range of motion exercises.
In studying the correlation of staff nurses' cognitive knowledge about the aged with their attitudes toward and interest in assisting the aged, Stafford4 concluded that information alone was not significantly correlated with attitudes toward old people (p <.05), but was significantly associated (r .53) with interest in working with them.
Dye and Sassenrath5 studied health professionals' (including nurses') abilities to identify physiologic and functional conditions either as normal aging processes or as disease-related processes. Results indicated that disease processes were easier to detect. Respondents tended to err in the direction of classifying a "condition" as a disease process when it really was the normal aging process. This type of error can lead to needless expenditures of time, energy, and money. The aged person may receive unnecessary medication, and may experience frustration from expecting improvement that does not occur.
Implicitly, the assumption prevails that services can be provided to elderly clients regardless of the accuracy of information held by the service providers. This assumption runs counter to logic that says, for example, if a nurse doesn't know that behavior management has reversed chronic screaming behavior in elderly clients, that nurse will not employ behavior management as an intervention when confronted by a client who repetitively calls out, "Nurse, nurse, nurse."
In this study, the following definitions were used:
Knowledge. Empirically established facts about human behavior in health and illness.
Elderly person. A person aged 65 years or older.
Nursing personnel, nursing staff. Individuals assigned to function as registered professional nurses licensed practical nurses, or nursing assistants.
Formal. For academic credit, as in a formal course.
The following hypotheses were tested at the .05 level of significance. There was no difference in knowledge scores among nursing personnel according to:
1. Division (acute or long-term care),
2. Nursing position level (registered professional nurse, licensed practical nurse, or nursing assistant),
3. Academic preparation for nursing,
4. Length of time since completion of formal education (0-5 years, 6-10 years, 11-15 years, 16+ years),
5. Completion of a formal course in gerontological nursing,
6. Amount of time since completion of a continuing education program in gerontological nursing (0-6 months, 7-12 months, 13-24 months, 25+ months),
7. Perceived interest in gerontological nursing (very high, high, average, low, very low),
8. Age Group (21-30, 31-40, 4150, 51-60, 60+).
A self-administered questionnaire was distributed to 275 nurses on duty during a four-week period. Participation was voluntary, and anonymity of responses was guaranteed. Each respondent was asked to complete the questionnaire within a 48-hour period, return it to a central collection point, and not discuss the questions prior to completion of the data collection phase of the study. Responses were obtained from 223 persons (81%). Reasons for non-response varied: heavy client care assignments, death in the family, vacation, and others.
The study population consisted of 435 people employed to provide direct clinical nursing care to the predominantly elderly clients served in the VA Medical Center. Those assigned to specialty areas like intensive care, ambulatory care, and hemodialysis, were not included, because their contact with elderly clients was either brief or infrequent. An initial randomly chosen sample was planned to include 250 participants, stratified on the basis of their division (acute care or long-term care) and their level of nursing preparation (registered professional nurse, licensed practical nurse, and nursing assistant), and chosen in proportion to their actual numbers in the population. A 10% over-sample was drawn initially within each stratum in an effort to insure a final sample of 250 nursing personnel. Despite this precaution, the desired proportions were not achieved in all strata. Thus, a decision was made to reduce the final sample to a total of 200. Excess respondents were randomly eliminated in the few strata in which they occurred. These questionnaires were scored and reported separately from those of the 200 included in the final report of the study.
A 75-item cognitive test of gerontological nursing knowledge was by Gunter and Ryan.6 Approximately 35 new items were developed by the researchers, based upon gerontological literature. The original 150-item test was pilot-tested at two VA Medical Centers outside of the Pittsburgh area. A total of 65 people participated in the pilot test. Based upon results of this pilot test, the 75 "best" questions were selected. "Best" questions were those having a difficulty index between 5% and 100% and a discrimination index of +.30 or better. An additional used in selecting test questions was their relevance to five major functional statuses in which the elderly frequently experience impairments. The final distribution of the 75 test items was as follows: mental status, 20 items; sensory status, 10 items; mobility status, 20 items; elimination status, 15 items; and sexual status, 10 items. Nine items that related to additional study variables of interest increased the length of the questionnaire to 84 items. Data analysis Mean differences in scores for the variables of interest were analyzed using one-way analyses of variance and
method for analyzing contrasts when more than two groups were involved. The significance level for the Scheffe procedure was set at p<.05. T-tests for independent groups were applied when only two groups were involved. The mean number of correct responses to the 75-item test of knowledge for the sample as a whole was
to be 53 (s.d. = 8, N = 200), with a range in scores from 27 to 67. Overall test reliability, as determined by Chronbach's alpha, was .82 out of a possible 1.00. Individual test questions ranged
in difficulty from .23 to .98, while discrimination values ranged from .01 to .91. These results indicate that the test was not difficult; 76 to 98% of the respondents answered more than half of the items correctly. TABLE I INDEPENDENT T-TEST SUMMARY FOR VARIABLES BELIEVED TO BE ASSOCIATED WITH KNOWLEDGE LEVELS The research findings suggested that
and specificallycally coursework in gerontological nursing, had positive influence on cognitive
learning. None of the groups of scores was significant in hypotheses 1 and 7, concerned respectively with division of employment or long-term care) and interest in caring for elderly people. However, testing of the remaining six hypotheses revealed that registered nurses with associate or higher degrees who were aged 20 to 30 years, had earned academic credit for one or more courses in gerontological nursing, had completed formal educational preparation for nursing within the past 10 years, and were assigned to acute care settings, were the most knowledgeable about gerontological nursing. Effect of Nursing Position Level There were significant differences (F = 59.23, df = 2, p < .000)
in the mean scores among
each of the three levels of nursing personnel, with nursing assistants earning the lowest scores (X = 44; s.d. = 8: N = 44); licensed practical nurses earning the next highest scores (X = 51; s.d. = 7; N = 38); and registered nurses earning the highest scores (X = 57; s.d. = 5; N = 118). Results of this analysis of variance are presented in Table II, Section A. Effect of Academic Preparation for Nursing As education preparation for nursing increased from licensed practical nurse programs through
master's degree programs, so did scores,
for the most part (F = 10.88, df = 4, p<.000). Results for those who had completed the licensed practical nurse program were X =51, s.d. = 7, N = 46; registered nurse diploma program X = 56, s.d. = 5, N = 66; associate degree program X = 58, s.d. = 4, N = 11; bachelor's degree program X = 58, s.d. = 5, N = 37; and master's degree program X = 56, s.d. = 3, N = 4. The licensed practical nurse program group was found to differ significantly from both the associate and bachelor's degree program groups. The slightly lower mean score observed for the master's degree program group may be explained on the basis of small sample size. Results of this analysis of variance are included in Table II, Section B. Effect of Recently Completing Formal Education Nurses who completed education further in the past tended to earn lower
scores. However, the only significant difference
found was that between the group whose education was completed from three to five years previously and the group whose education was completed 16 years or more previously. Results of this analysis of variance may be found in Table II, Section C.
ONE-WAY BETWEEN GROUPS ANALYSIS OF VARIANCE SUMMARY FOR VARIABLES BELIEVED TO BE ASSOCIATED WITH KNOWLEDGE LEVELS
Effect of Formal Coursework in Gerontological Nursing
The scores of those who had taken a course in gerontological nursing for credit were significantly higher (p<.004) than thç scores of those who had not (X = 57, s.d. = 9, N = 24 versus X = 52, s.d. = 8, N = 173). These results are included in Table I, Section B.
Effect of Recent Exposure to Gerontological Programs
The trend in mean scores was opposite from what might be expected. Nursing personnel who completed an informal course or attended a program more recently scored lower than those who completed a course further back in time: 0 to 6 months ago, X = 52.2 (s.d. = 7.9, N = 34); 7 to 12 months ago, X = 49.4 (s.d. = 10.0, N = 32); 13 to 24 months ago, X = 53.9 (s.d. = 7.0, N = 36); and 25 or more months ago, X = 54.2 (s.d. = 7.1, N = 91). The only signiticant contrast in mean scores occurred between the 7-12 month and the 25-month and over groups. This analysis of variance is presented in Table II, Section D.
Effect of Age
Mean scores were found to decline significantly as the age group of respondents increased from young to old (F = 9.13, df = 4, p < .000). Results from this analysis of variance may be found in Table II, Section F. Scores declined from X = 57 (s.d. = 5, N = 53) for the group aged 21-30 years to X = 39 (s.d. = 16, N = 2) for the group aged 61 years and older. Scores for the groups between these ages were X = 54 (s.d. 7, N = 50) for the 31 to 40 year old group, X = 50 (s.d. = 8, N = 44) for the 41 to 50 year old group, and X = 50 (s.d. = 9, N = 48) for the group aged 51 to 60 years. Significant contrasts were found between the youngest group and each of the three oldest groups.
Discussion and Implications
Several implications for nursing education, administration and research may be derived from this study. To the extent that knowledge is assumed to influence nursing practices and, in turn, the outcomes manifested by clients, results of this study support the contention of experts in gerontological nursing (Gunter and Estes,8 Brower9) that gerontological nursing should be included as a discrete, versus an integrated, part of nursing curricula. At whatever level-bachelor's, master's, or doctorate-it is necessary to insure that nurses who work with elderly people who are receiving long-term care are adequately prepared for their work. Implications of not having such courses extend beyond nurses' knowledge of this subject matter to their selection of the aged as a target group for future professional activities. The Foundation Project, reported in a special issue of The Gerontologist (Part II, 1980, Volume 20, Number 3), provides considerable direction for curricular content for all gerontologists as well as for practitioners in selected professions, including nursing.
Both research and education interests would be served by further development of our test in terms of validity and additional types of reliability. Systematic evaluation of various gerontological educational programs would be facilitated greatly through the use of properly developed tests of nurse-participants' knowledge. Support for this notion is found in the growing body of literature that reports development, controversy, and applications of Erdman Palmore's "Facts on Aging" quiz.10-14 This 25-item quiz is designed to cover basic social, mental, and physical facts, as well as common misbeliefs about aging. As normative data accumulate from various applications of this quiz, its popularity as an evaluation tool increases. At present, there are very few sources of developed test items that may be used to assess nurses' knowledge levels relating to gerontology. Gunter's and Ryan's 19766 compilation of test items lacks normative and item data. Content is somewhat dated, and focuses heavily on physiologic and demographic material. The Psychological Corporation* developed a Geriatric Nursing achievement test in 1977 comprised of 27 items related to the aging process in general, socioeconomic factors, medical and surgical problems, mental confusion, community agencies and rehabilitation. The National League for Nursing has no achievement test in the area of geriatrics/gerontology. None of the available test pools provides items structured to correspond with a nursing process (assess, plan, implement, and evaluate) framework.
Until formal nursing curricula address the gerontological content gap, personnel responsible for continuing education in service settings need to provide this content. Pre-program assessment that uses a broad instrument to determine nurses' knowledge needs may well facilitate development of programs that are highly relevant to practitioners' greatest needs. Such programs are likely to be well received despite structural constraints on continuing education endeavors conducted in service settings.
Nursing administrators seem to be in the best position to restructure continuing education programs, to establish the expectations that practicing nurses be knowledgeable about gerontological clinical activities, and to manipulate reward systems to insure that these expectations are realized.
Several relevant empirical questions for future study occurred. The most obvious was whether gerontological nursing practice is associated with nurses' knowledge levels. Considerable developmental work must be completed before quality review methodologies will permit an adequate answer to this question. In the meantime, information is required to : (a) decide how long and how complex nursing courses should be to influence knowledge levels over time; (b) determine factors, other than those presented in this study, that affect nurses' knowledge of gérontologie nursing; and (c) identify factors that influence the use and retention of such knowledge in work settings.
Photographs courtesy of Saul Weiss, Chief, Medical Media, Medical Media Service, l'A Medical Center, Pittsburgh, Pennsylvania.
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and specificallycally coursework in gerontological nursing, had positive influence on cognitive
ONE-WAY BETWEEN GROUPS ANALYSIS OF VARIANCE SUMMARY FOR VARIABLES BELIEVED TO BE ASSOCIATED WITH KNOWLEDGE LEVELS