Alzheimer's disease (AD) is a chronic degenerative disorder that causes senile dementia and currently has no known etiology or cure. In coping with this devastating disease, persons with AD and their families experience many social, medical, and psychological problems. With the rapid growth of the older population, nurses and other health care professionals will be called upon to provide care for increasing numbers of older patients, many of whom may also have AD.
In order to provide appropriate care for patients with AD and their families, nurses must have basic knowledge about gerontology as well as an understanding of the disease. A number of studies have suggested that nursing students have inadequate knowledge about aging (Dye & Sassenrath, 1979; Holtzman & Beck, 1981; Huckstadt, 1983; Palmore, 1980). These studies support the contention that many nursing education programs lack sufficient gerontology content (Huckstadt, 1983; Joel, Baldwin, Sc Stevens, 1989; Johnson & Connelly, 199Oa; Tappen & Brower, 1985) or consistent gerontology content (Johnson & Connelly, 199Ob). No studies were found that assessed nursing students' specific knowledge about AD.
The purpose of this study is to assess knowledge about aging and about AD among junior and senior baccalaureate nursing students. An additional purpose is to assess the relationship between students' knowledge of aging and of AD, and to investigate the relationship between selected demographic variables and these knowledge variables.
Review of Literature
Although the exact prevalence of AD among persons over 65 is unknown, Dietsche and Pollmann (1982) reported that an estimated 4.4% of persons over the age of 65 showed moderate to severe dementia, with approximately 65% of those believed to have AD. One recent study indicated that AD may affect as many as 10% of all individuals over age 65 (Evans et al., 1989). The condition also exhibits a strong positive association with age; as many as 47% of those over 85 may have AD (Evans et al.). Since this age cohort represents the fastest growing segment of the elderly population, the proportion of patients with AD is expected to increase dramatically.
Research related to knowledge of and attitudes toward the elderly has focused largely on assessing differences between pre- and postmeasures following some intervention. While attempts to improve attitudes have produced mixed results, findings suggest that improvements are possible. A few studies attribute an increase in knowledge and favorable attitudes to structured experiences that emphasize gerontological training (Greenhill & Baker, 1986; Hannon, 1980; Harriaon & Novak, 1988), or experiences with well elderly (King & Cobb, 1983; Ross, 1983). Other studies, however, have foiled to demonstrate improvements in knowledge or attitudes (Eddy, 1986). Another important finding is that even though attitudes may improve, attitudes toward the elderly often remain negative (Hannon, 1980; King & Cobb, 1983; Ross, 1983).
Figure 1. Conceptual model depicting study variables.
Knowledge deficiencies related to gerontology may be associated with unfavorable attitudes toward the elderly among nurses and nursing students (Reed, Beali, & Baumhover, in press) and to their lack of interest in working in gerontological settings (Ross, 1983). Other factors associated with knowledge levels also have been explored with mixed results. Williams, Lusk, and Kline (1986) found a significant correlation between grade point average and knowledge of the elderly. On the other hand, experiences with the elderly did not predict students' knowledge about aging. A weak association between age and knowledge of aging was found by Holtzman and Beck (1981). More educated groups also demonstrated more knowledge of aging, which supports earlier findings by Palmore(1980).
Research related to knowledge of AD, although scarce, also suggests that improvements in knowledge are possible through structured learning experiences and may be associated with educational status (Dieckmann, Zarit, Zarit, & Gatz, 1988). Findings were based on a series of studies comparing pre- and posttest scores on knowledge of AD among four groups representing different educational levels. While improvements in knowledge were significant among all groups, those groups receiving specific instruction in AD experienced the greatest increase. Test scores between groups were found to increase with advanced educational preparation and significant differences were found between three of the four groups.
Since nurses play a vital role in the management of patients with AD and in assisting their caregivers, it is important to evaluate nurses' knowledge of this disease. The model that guided this study is conceptualized in Figure 1. The characteristics of age, previous experience with AD and related disorders (ADRD), and educational background are antecedents believed to influence nursing students' knowledge about the elderly and those with AD. Furthermore, this knowledge is assumed to influence the outcome of quality care provided to elderly patients and to those with AD. An additional variable of interest was the degree to which students were cognizant of their level of knowledge about AD.
Study Questions and Hypotheses
This research was designed to answer the following study questions:
1. What is the level of knowledge about AD and about the elderly among junior and senior baccalaureate nursing students?
2. What proportion of the variance in scores on tests of knowledge about the elderly and about AD is accounted for by selected demographic variables, past experiences related to AD, and self-reported knowledge about AD?
In addition, the following hypotheses were tested:
1. Scores on the Alzheimer's Disease Knowledge (ADK) Test (Dieckmann et al., 1988) will be positively related to scores on the Facts on Aging Quiz, Version 2 (FAQ2) (Palmore, 1988).
2. There will be significant differences in knowledge scores about aging and about AD among baccalaureate nursing students with older students, seniors, those with previous course work related to AD, those with previous clinical and personal experience with AD, and those with higher self-reported knowledge about AD demonstrating more knowledge than other students.
To test subjects' knowledge of aging, the FAQ2 (Palmore, 1988) was used. Students' knowledge of AD was measured by the ADK Test (Dieckmann et al., 1988). Seven additional questions related to study variables were included in the questionnaire. These included age; year in school; whether subjects have had a family member, close relative, or friend diagnosed with ADRD; whether subjects had seen patients diagnosed as having ADRD; whether subjects have worked extensively or been directly involved with someone diagnosed with ADRD; whether subjects have had any previous courses covering senile dementias or AD; and a selfassessment of subjects* knowledge related to AD.
The ADK ITsst. The ADK Test, developed in 1988, was designed to assess subjects' overall level of knowledge about AD, and emphasized information needed to understand and manage patients with AD. It also can be used to identify specific areas of misinformation and to determine degree of positive or negative response bias. The instrument consists of 20 multiple-choice items in direct question or incomplete statement form with four specific response alternatives plus an "I don't know" option (Dieckmann et al., 1988).
Dieckmann et al. (1988) reported that alpha coefficients for the instrument ranged from .71 to .91 in administrations of the ADK Test to four different samples: undergraduate students receiving no gerontology instruction; undergraduate gerontology students; graduate students in gerontology, social work, or counseling; and mental health professionals. The alpha coefficients suggest that the test has adequate internal consistency. For students in the present sample, however, internal consistency was .52, suggesting the need for further testing of this tool with a variety of populations.
Test-retest reliability in the study by Dieckmann et al. (1988) was moderate with a correlation of .62 for students not receiving instruction related to AD. Content validity was established by use of item analysis procedures and a pre- and postinstruction difference index (PPDI) during the development of the instrument to select the best 20 items from an original 30-item pool. Construct validity was also suggested by the findings of Dieckmann et al. in which results of the ADK Test were consistent with the hypothesis that group differences would reflect knowledge differences. Progressively higher scores were observed from general undergraduate students to students in an undergraduate gerontology class, to graduate students in gerontology, to mental health professionals attending a workshop on AD.
Palmore's FAQ2. The FAQ2 (1988) consists of 25 true/false items focusing on sociodemographic, biological, and psychological characteristics of the elderly and was used in this study to measure nursing students' knowledge of the elderly. This instrument was designed primarily to be used as an alternate form to the original Facts on Aging Quiz (FAQl) for test-retest purposes. The FAQ2 was chosen because the FAQl had been administered previously to another sample included in a study yoked to this one (Baumhover et al., 1990). Like the FAQl, the FAQ2 can also be used to identify misconceptions and to measure bias toward the elderly (Palmore, 1981).
Although the FAQ2 has not been used as extensively as the FAQl, Palmore (1981) has provided information on its validity and reliability. The validity of the instrument rests on selection of items that have been documented through nationally representative studies or through several smaller studies. Although interitem correlations are generally low, reliability between the two forms has been acceptable, with correlations ranging from .50 to .80. Scores for all groups average approximately 5% higher on the FAQl than the FAQ2.
Design and sample
Questionnaires were distributed to 59 junior and 100 senior baccalaureate nursing students during regularly scheduled classes. All sample subjects had completed at least one semester of clinical nursing experience that frequently involved caring for older patients. Students were informed that their participation in the study was voluntary and that their responses would be anonymous. A total of 99 questionnaires (62%) were returned, which included 53 junior and 46 senior students who were predominantly female (89%) and ranged in age from 20 to 45, with two thirds under 25 years of age.
Data were analyzed using SPSS-X, version 3.1 (1987) to investigate the study questions and to test hypotheses. Descriptive statistics were used to analyze the level of knowledge about AD and about the elderly using the ADK Test and FAQ2, respectively. To test the first hypothesis, the relationship between scores on these two tests was analyzed using the Pearson correlation coefficient. To test the second hypothesis, independent t tests between nominallevel study variables and total scores on the ADK Test and FAQ2 were employed. One-way analysis of variance was used to test self-reported level of knowledge about AD and actual scores on the ADK Test and FAQ2. Finally, multiple regression was used to determine the amount of variance in AD knowledge and aging knowledge that could be accounted for by demographic variables, past experiences related to AD, and self-reported knowledge of AD.
Few respondents (21%) reported having family members or friends with AD. While most (80%) had previously seen patients with AD, comparatively few (36%) had actually worked with such patients. Most of the respondents (85%) reported having had course work on AD, but no one reported having *a lot" of knowledge about AD. The majority (71%) indicated they had only *a little" or "some" knowledge about AD.
Regarding the ADK Test, scores ranged from 25% to 85% correct (M =53%) with a standard deviation of 14.0. Analysis of specific items revealed that questions on the ADK Test receiving the highest percentage of "I don't know" responses included those related to the use of lecithin as a treatment for AD (50%) and Medicare payments for AD patients (47%). Questions receiving the highest percentage of incorrect answers were related to procedures required to confirm a diagnosis of AD (65% incorrect), the percentage of persons over age 65 who have ADRD (61% incorrect), and the primary function of the ADRD Association (51% incorrect).
FAQ2 Scores by Selected Sociodemographic Variables
On the FAQ2, individual scores ranged from 28% to 80% correct (M= 56%) with a standard deviation of 7.9. With regard to specific items, questions with a 50% or greater error rate were related to: elder home injuries (93%), proportionate share of the nation's income among elders (89%), elderly poverty rate (86%), Social Security benefits for the elderly (85%), number of elders living alone (83%), proportion of aged widows (71%), problems of elders adjusting to "empty nest" (66%), aged voting patterns (65%), number of elders in public office (64%), and criminal victimization among elders (62%).
Contrary to expectations, knowledge of aging as reflected by the FAQ2 was not related to knowledge of AD (r = -.0026, p = .98). Therefore, the first hypothesis was not supported.
With regard to the FAQ2, no significant differences were found hi knowledge scores on aging among the selected demographic variables (Table 1). As shown in Table 2, there was also no significant difference in the ADK Test scores among students who had clinical or personal experience with AD, or who had previous course work that included information about AD when compared to other sample subjects. ADK Test scores, however, were found to be significantly related to students' age, year in school, and self-reported level of knowledge, with older students, seniors, and those who reported greater AD knowledge having significantly better scores. Therefore, the second hypothesis was partially supported.
Further analysis using multiple regression showed that once the effects of respondents' age have been controlled, students' year in school and self-reported knowledge of AD did not account for a statistically significant amount of variance on the ADK Test total score. Thus, of the three independent variables, age appears to be the most important predictor of students' knowledge of AD.
In addition to answering specific study questions and testing specific hypotheses, two additional data analysis procedures were employed. Following the method described by Palmore (1981) for the FAQ2, pro- and anti-aged bias scores were calculated on grouped data. Palmore (1981) notes that this method provides only an indirect measure for calculating bias; however, despite limitations of this method, the net bias score does provide a rough indicator of the sample's attitude toward the aged.
ADK Scores by Selected Sociodemographic Variables
For nursing students in this study, the group mean score on the FAQ2 56% correct) was somewhat lower than scores cited by previous research with nursing students (Greenhill & Baker, 1986; King & Cobb, 1983; Ross, 1983). However, each of these studies used the FAQl and the results are not directly comparable (Palmore, 1981).
Ten frequent misconceptions among participants with regard to aging were noted. Each of these items received an incorrect answer from 50% or more of the sample. Seven of these items also were reported by Palmore (1981) as common misconceptions among students, faculty, and workshop participants . When using Palmore's ( 1 98 1 ) method for calculating bias, all but one of the misconceptions identified in this study involved negative stereotypes of the elderly. The group as a whole exhibited a net anti-aged bias of 34.2%.
Finally, nursing student scores on the ADK Test were compared to scores reported for the four samples in the study by Dieckmann et al. in 1988. The total group mean score on the ADK Test (53%) does not reflect a high level of AD knowledge. However, when the percentages of correct responses for individual questions on the ADK Test are compared to results in the previous study, nursing students did better than the general subject pool on all questions and better than gerontology undergraduates on all but two items (1, 8) (Table 3). When compared to graduate students, nursing students performed surprisingly well, with more frequent correct responses on 9 of the 20 items; and nursing students outperformed mental health professionals on three questions (14, 17, 18).
Of particular interest was the relatively low percentage (36%) of nursing students who had cared for an individual with AD. Even though seniors represented approximately half of the sample, self-reported data indicated that many students had not cared for a patient with AD. While such assignments may not always be possible due to the case mix of clients in the clinical settings and the enormous variety of clinical experiences needed, faculty should examine their responsibility to prepare students to meet the future health care needs of our society.
Comparison of Correct, Incorrect, and "I Don't Know" Responses by Percent
Comparison of Correct, incontct, and "I Don't Know" Responses by Percent
Another important finding was the relatively low self-reported knowledge level about AD, particularly since most students (85%) reported completing some course work related to AD. Since the questionnaire did not attempt to identify the amount and depth of such course work, actual AD content is unknown and may have varied considerably.
The finding that students who had either previous course work related to AD or had previous personal or educational experience with AD did not score higher on either the ADK Test or the FAQ2 than other students raises important questions about how specific educational experiences contribute to knowledge of AD. These findings might be partially explained by the fact that very few students had actually cared for patients with AD. In addition, 33% of the subjects had completed only one semester of clinical experience, and the focus of this initial clinical experience is on beginning nursing skills and not on the elderly or specific age-related diseases. However, the fact remains that almost half (46%) of these subjects were seniors, and half of the seniors were in their last semester of course work. Low mean scores raise several questions about: (a) the adequacy of gerontology and AD content within the curriculum, (b) the retention of gerontology and AD content by students over time, and (c) the validity of individual items on the ADK Test and the FAQ2 in measuring essential nursing knowledge.
A primary finding in this study was the degree to which age is associated with knowledge of AD. Other variables, such as personal and educational experiences with AD, did not play as large a role as anticipated in understanding AD. This raises the question of where students actually acquire knowledge about AD. Perhaps life experiences in general, media exposure, and prior knowledge that older students bring with them to the educational setting all play a larger role than previously believed.
No significant relationship was found between scores on the ADK Test and those on the FAQ2. While it seems reasonable to expect that general knowledge about aging is related to specific knowledge about age-related disorders, it appears that the content of the two instruments is largely independent. In part, the lack of specificity of the FAQ2 to pathophysiological issues may explain this lack of congruence. It is certainly possible to have both knowledge about demographic and sociological aspects of aging and relative ignorance about biopsychological issues.
Analysis of specific items on the ADK Test suggest that questions related to the management of care for patients with AD, with the exception of question 11, were more frequently answered correctly than were questions related to diagnosis and symptoms. This finding is not surprising as a major nursing focus is the delivery and management of client care. This emphasis plus the knowledge explosion and extensive media reporting regarding AD that has occurred in recent years may explain why the percentage of correct responses by nursing students in this study was higher on many items than among the four groups reported by Dieckmann et al. (1988).
On the other hand, items on the ADK Test reflecting a low percentage (e.g., =£40%) of correct responses (1, 5, 7, 10, 11, 19, 20) and those with a high percentage (e.g., 5*40%) of "I don't know" responses (11, 19) are particularly important to nursing faculty since they may indicate knowledge deficits among nursing students that could reflect inadequacies in content related to AD. However, further research using the ADK Test is needed to determine validity of individual items in measuring essential nursing knowledge and practice outcomes.
Finally, the negative bias toward aging among this group of students is considerably higher than the 19% reported by Palmore in 1981 and represents a potential cause for concern, which is consistent with previous research and suggests that nursing students have more anti-aged bias than pro-aged bias (Hannon, 1980; King & Cobb, 1983; Ross, 1983; Williams et al., 1986). Perhaps experiences with elderly clients in acute and chronic care settings and the negative bias of other health care providers have played a role in students' misconceptions and negative biases toward the elderly.
The present study has three limitations. First, the convenience sample was limited to nursing students enrolled in upper division courses in a single baccalaureate nursing program, therefore results cannot be generalized to other populations. Secondly, the ADK tool has had limited testing with a variety of different populations and has not been used before with nursing students. Similarly, the FAQ2 used in this study has not been used as extensively as the FAQl, and the anti-aged bias score provides only an indirect method for estimating attitudes.
Implications for nursing education, practice, and research
Results of this study, while not generalizable to other nursing programs, emphasize the need for nursing educators to evaluate the effectiveness of their role, as well as the overall curriculum, in preparing students for the complexities involved in caring for the elderly and those with AD. Faculty should act as mentors with nursing students by role modeling quality practice with assigned elders and particularly those with AD.
Gerontological content integrated throughout the curriculum without a clearly identified plan may not be sufficient in preparing nursing students to care for the elderly and those with age-related conditions such as AD. As the body of knowledge in gerontology expands, there will be a need for comprehensive curriculum planning directed toward incorporating specific gerontology content and clinical experiences. Students must have the opportunity to care for patients with AD when such clinical experiences are available. Effective role models in gerontologies! nursing must be encouraged.
There is also a need to develop outcome measures to evaluate the effectiveness of teaching strategies designed to provide students with a substantial gerontologie knowledge base. Finally, it is strongly recommended that nursing programs should identify and implement essential gerontology content within the curriculum and develop mechanisms to track, update, and evaluate this content.
The findings of this study raise the following questions and suggest the need for additional research:
1. What is the optimal method to measure nursing students' knowledge of aging and AD that will reflect nursing knowledge essential in the practice setting?
2. What specific structured learning experiences increase nursing students' knowledge about aging and AD?
3. What is the relationship between knowledge of aging and of AD and actual clinical practice outcomes?
4. What gerontological content and experiences reduce anti-aged bias among nursing students?
Among chronic conditions affecting the elderly, AD represents a particularly difficult problem for both family and professional caregivers of the elderly. While there is no known cure for AD, careful management of patients may alleviate certain symptoms or behavioral problems associated with the disease. Nurses play a key role in this process (Williams, 1986). In addition, nurses may assist family caregivers of patients with AD by providing accurate information about the disease and community resources available to support family members (Lipkin & Faude, 1987). Clearly, knowledge about aging and about AD is essential if nurses are to meet the complex demands of patients with AD and their families.
Study results suggest that sample subjects had limited knowledge about aging and AD as measured by the FAQ2 and the ADK Test, respectively. Few nursing students had experience in caring for patients with AD, and past educational experiences had a questionable, if any, relationship to knowledge concerning AD. These findings have important educational implications for all nursing faculty and particularly for those involved in curricular decisions.
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FAQ2 Scores by Selected Sociodemographic Variables
ADK Scores by Selected Sociodemographic Variables
Comparison of Correct, Incorrect, and "I Don't Know" Responses by Percent
Comparison of Correct, incontct, and "I Don't Know" Responses by Percent