Dementia is a global public health issue, with Alzheimer's disease being the main cause (World Health Organization, 2016). In the United States, the prevalence of Alzheimer's disease among individuals age 65 years and older is expected to increase from 5.2 million in 2016 to 13.8 million by 2050 (Alzheimer's Association, 2016). It is estimated that every state within the United States will experience at least a 14% upsurge in the prevalence of Alzheimer's disease by 2050 due to an increase in the aging population (Alzheimer's Association, 2016).
The progression of dementia in affected individuals with or without comorbidities poses unique challenges, such as the prevention and management of progressive memory loss and agitation, to RNs and other health care professionals' abilities to provide quality care (Cowdell, 2010; Cronin, 2013; Gandesha, Souza, Chaplin, & Hood, 2012; Lewis, 2014; Marx et al., 2014; Monroe, Parish, & Mion, 2015). The National Alzheimer Project's goals include a call for a workforce's development to provide evidence-based services, including dementia care, to all people living with dementia (PLWD) across the health care continuum (U.S. Department of Health & Human Services, 2014). In this study, dementia care is described as an individualized approach to assessing and meeting the needs of PLWD and their caregivers (Brooker, 2007).
Many scholars around the globe have called for a robust educational foundation about dementia in undergraduate curricula to prepare health care profession graduates to provide competent dementia care upon graduation (Crookes, 2010; Pulsford, Hope, & Thompson, 2007; Thompson, Hope, & Pulsford, 2009; Tullo & Gordon, 2013). Schools of nursing have a unique role to play in ensuring that prelicensure nurses are prepared to provide dementia care. Studies of undergraduate medical programs in the United Kingdom and the United States, as well as nursing programs in Australia, showed how dementia content is integrated into the curricula (Crookes, 2010; Nagle, Usita, & Edland, 2013; Tullo & Gordon, 2013). In the United States, limited data exist regarding the integration of dementia care content within entry-level undergraduate nursing curricula. Consequently, it is not clear whether nursing education programs are adequately preparing graduates to provide care for PLWD. Therefore, the purpose of this mixed-methods study was to investigate how prelicensure registered nursing programs in the United States were integrating dementia care content into their curricula. From a quantitative perspective, the study examined the resources and activities schools of nursing used in integrating dementia care content into entry-level undergraduate nursing curricula and the contextual situations that influenced this process. Within the qualitative strand, schools of nursing representatives' perceptions and experiences regarding the integration of dementia care content in their entry-level undergraduate nursing program curricula were explored.
The study (Figure) was guided by the program logic model and Gagné theory. The use of the logic model's constructs provided a clear diagrammatical representation of multiple variables that interacted among entry-level nursing programs' resources, activities, and contextual factors in an attempt to integrate dementia care content into their curricula. The Gagné theory's taxonomy of learning outcomes informed the curricular outcomes that were investigated. These included knowledge, skills, and attitudes as advocated by Quality and Safety Education for Nurses (2014).
Theoretical framework: Synthesis of program logic model and Gagné's theory.
A sequential explanatory mixed-methods design (Creswell & Plano-Clark, 2011) was used to conduct this study. The quantitative phase was conducted first, followed by the qualitative phase. The quantitative and qualitative phases were conducted as cross-sectional and descriptive studies, respectively. Results of both phases were integrated to see how the qualitative findings further explained the quantitative results. The methodological approaches for each phase are described separately. Institutional review board approval was obtained from Mercer University prior to implementing the study. All identifiers were removed from the collected data and accessible to the investigators only.
Quantitative Phase: Sampling, Data Collection, and Analysis
Targeted Population and Sampling Method. A stratified multistage sampling method was used to obtain a sample of entry-level undergraduate nursing faculty in the United States from the targeted population. First, the Alzheimer's disease database (Alzheimer's Association, 2014) was used to identify states with more than 150,000 projected cases of Alzheimer's disease in 2025. The decision to use a minimum of 150,000 in determining the states to include in the sample frame was to ensure an accurate reflection of the geographical areas where the effect of dementia care is expected to be most felt by the populace and health care systems. Eleven states met the criterion: Arizona, California, Florida, Georgia, Illinois, North Carolina, New Jersey, New York, Pennsylvania, Texas, and Virginia.
The identified states' boards of nursing websites were used to identify schools with approved prelicensure registered nursing programs. An equal number of randomly selected schools from each of the 11 states was invited to participate in the study. The inclusion criteria were that (a) the school of nursing has a state board–approved prelicensure registered nursing education program and (b) it is located in a state with more than 150,000 projected cases of Alzheimer's disease in 2025. There were no exclusion criteria for the study.
Instrument. No specific instrument to measure the integration of dementia care content in entry-level undergraduate nursing curricula was found through an extensive literature search. Thus, an instrument was developed by adapting items, with the authors' permission, from the instruments developed by Rosenfeld, Bottrell, Fulmer, and Mezey (1999), Ironside, Tageliareni, McLaughlin, King, and Mengel (2010), and Tullo and Gordon (2013). The adapted items were combined with additional investigator-developed items into a single instrument, the Dementia Care Content in Entry-Level Undergraduate Nursing Curricula (DCCNC). The DCCNC instrument composed 37 multiple-choice and open-ended items organized into two sections: institutional profile, and dementia care content in entry-level nursing curriculum. The instrument and participant's profile items made up the survey. The time estimated to complete the survey was 30 to 45 minutes.
Validation. Prior to implementing the main study, evidence of content validity for the DCCNC was established by a panel of six nurse education experts using Lynn's (1986) recommendations. The results showed that item-level content validity index (I-CVI) ranged from .83 to 1.0. The scale-level CVI (SCVI/Ave) result was 0.91, which demonstrated strong content validity (Lynn, 1986)
Data Collection. The DCCNC instrument was converted to web-based survey format within SurveyMonkey™ and a link was generated to be inserted into recruitment e-mails. Deans and directors of the selected registered nursing programs were contacted via an e-mail recruitment invitation to participate in the web-based survey by clicking on the active link or by forwarding the e-mail with the link to an individual faculty member in their schools who was knowledgeable of the undergraduate nursing curriculum. A reminder e-mail with the same content was sent after 2 weeks of the initial e-mail. Data collection began in August 2015 and ended in December 2015.
Data Analysis. Data were imported directly from SurveyMonkey into the SPSS for Windows, version 23.0 statistical software package for analysis. Data cleaning was performed by running frequency distributions on all the variables to identify outliers, implausible, or missing values. All identified outliers were tracked back to the originally submitted survey for verification. Identified outlier values within the range of possible values for the variables were retained in the dataset. Implausible values were deleted and coded as missing.
Qualitative Phase: Sampling, Data Collection, and Analysis
Sampling Method. A purposive sampling method was used to contact the 20 participants who participated in the quantitative phase's web-based survey and who also indicated interest to participate in the qualitative phase. The inclusion criterion for the qualitative phase was that participants had to have reported integrating dementia care content into their entry-level nursing programs. Eight of the 20 individuals agreed to participate in the qualitative phase.
Data Collection. Based on the results of the quantitative data analysis, a nine-item semistructured interview questionnaire with probes was developed. The interview questionnaire was administered via the e-mail interviewing method (Hunt & McHale, 2007) to the recruited subsample. Participants answered an initial set of interview questions via e-mail. The investigator followed up with additional e-mails with probes to clarify and elaborate on their responses. Data collection began in February and ended in April 2016. The participants received an incentive of a $25 Amazon e-gift card after completion of the interview.
Data Analysis. The collected text data from the e-mails were imported directly into NVivo 10.0 software. The analysis began as soon as the first data were collected (Creswell & Plano-Clark, 2011) and involved coding the data for major themes. Five main overarching themes emerged: Key Components/Weak Areas of Dementia Care Content, Influencing Factors, Instruction Materials, Teaching Effectiveness/Learning Outcomes, and Challenges/Barriers.
Deans and directors of 300 schools of nursing were contacted via e-mail about participation in the study. One hundred thirty-nine individuals accessed the survey. Two individuals declined consent to participate in the study, resulting in a response rate of 46%. A response rate of 33% or greater is considered acceptable for web-based surveys (Nutty, 2008). Using this criterion, the response rate for this study was acceptable. Item responses to individual questions varied. Consequently, surveys that did not have complete data for 50% or more of the items were not included in the final data analysis. Twenty-eight (20.1%) of the 139 submitted surveys were missing data for more than 50% of items. The final analytical sample for the quantitative phase of the study was 111. The qualitative phase involved purposeful sampling of a subsample of eight participants who had completed the quantitative phase and were actively engaged in delivery of dementia care content.
Integration of Dementia Care Content Into Nursing Curricula and Dementia Care Competencies
One hundred and three of the 111 participants (92.8%) indicated that dementia care content was included in their curricula. Table 1 presents the characteristics of the participating institutions. The greatest percentage of programs represented was baccalaureate degree programs. Only four diploma programs were represented in the study. Most participating institutions were located in urban areas and were public institutions. Overall, the NCLEX-RN pass rates for the programs were strong. Programs were evenly divided with respect to whether they had clinical partnerships with dementia-focused centers or institutes.
Demographic Characteristics (N = 111)
Table 2 indicates the dementia-specific competencies reported as being included within the curricula. The most commonly reported competency was utilizing effective communication to meet the cognitive and emotional needs of PLWD (n = 76, 54.7%). The least commonly reported competencies were promoting a positive environment for PLWD (n = 53, 38.1%) and awareness of stigma (n = 1, 0.7%). In the qualitative data, participants reported content areas that needed to be improved, such as providing more information on geriatric syndromes, differentiating nursing care of dementia and delirium, and improving clinical time and clinical experiences. The qualitative theme Influencing Factors clarified the quantitative findings around how decisions were made about when dementia content would be taught within the curriculum. One participant wrote:
Our curriculum changed Nursing Care of the Older Adult from Junior II semester to Senior II. It was felt [that] prelicensure student nurses needed the foundational knowledge gained from previous semesters caring for older adults in the hospital in order to progress to health and wellness of the older adult in a community setting.
Identified Dementia-Specific Competencies (N = 111)
Clinical Experiences and Dementia Care
Within the survey, participants were asked about the sites used for dementia care clinical experiences. Participants reported hospitals as the most common sites used for dementia care clinical experience (n = 76, 54.7%). Mental health facilities and nursing homes were used by 37.4% (n = 52) and 31.7% (n = 44) of participants' programs, respectively. Clinical experiences mostly took place during multiple semesters, with the most cited being the second semester of the programs (n = 41, 29.5%). Only nine (10.3%) of the participants were very satisfied with the overall quality of clinical experiences. An in-depth understanding of the factors that influence the selection of clinical sites was revealed by the qualitative findings. Identified factors that influenced the selection of clinical sites for dementia care experience included sites' accessibility, proximity, and availability. Participant 7 stated:
We (like many nursing programs across the country) struggle to find adequate clinical sites for student experiences so one large factor is simply one of availability. The college I teach at is in a rural part of [name redacted]…which also makes finding appropriate clinical sites very challenging at times.
Instructional Methods Used to Teach Dementia Content
The quantitative results showed that multiple instructional methods were used by faculty to teach about dementia care to prelicensure student nurses. The most commonly reported was lecture method (n = 99, 71.2%). The least used method was electronic learning podcast (n = 6, 4.3%). Qualitative findings supported the quantitative survey findings. For example, participant 6 commented:
I use a combination of lecture highlighting main concepts in the readings (textbook, research articles, and associated online resources) and in-class videos from Hartford Institute for Geriatric Nursing Consult Geri.org.
Highlighting the use of video clips in teaching dementia care, participant 7 stated:
I show my prelicensure student nurses YouTube clips done by an expert working in the field. She talks about simple yet important things like how to get a dementia client to cooperate during bathing, how to teach family members how to take away car keys when driving is no longer safe, etc.
A detailed explanation by one participant revealed an associated advantage and the cost of using electronic innovative technology online simulation program simulation:
I thought that the best way to get some hands on realistic experience would be to incorporate a geriatric simulation program as part of the course. The only negative thing I have found is that it is costly and it would be an added expense to the students usually.
Nurse educators rely on reliable and informative instructional materials to inform their teaching of any content. The participants identified some problems associated with textbooks that could pose limitations on their abilities to teach dementia care content. For example, participant 6 pointed out:
Most books are focused on the basics and less content is on what we can actually do to intervene and provide comfort and support for these patients…. How do we ensure they receive adequate nutrition and hydration without forceful means? How can we support and calm down patients whose dementia symptoms are not well managed?
Curricular Challenges and Facilitators With Integrating Dementia Content
Most participants indicated multiple challenging factors related to integrating dementia content into the curriculum. The most commonly identified factor was that the curriculum was already overloaded (n = 61, 43.9%). Flexibility of faculty and curriculum was the most commonly identified facilitating factor for integration of dementia content (n = 56, 40.3%). The qualitative findings within the theme Challenges/Barriers expounded on these results. For example, participant 2 gave a detailed explanation on challenges and possible solutions:
I think it should always be a priority to integrate this content in all entry-level nursing programs. However, there is so much that is unique to care of older adults that I think it really does need to be addressed in a specific course set aside for this content. When it is grouped with medical–surgical nursing, often the uniqueness of the older population—especially those with dementia, is overlooked. Providing an opportunity for prelicensure student nurses to practice basic skills in a rehabilitation hospital that often has a higher number of older adults might accomplish this, or even providing memory care settings for clinical rotations would be beneficial. The key is finding units and settings that have a very proactive approach to care of the aging patient, as well as the patients with dementia.
The challenge that overloaded curriculum posed to the integration of dementia care content into entry-level nursing programs was further demonstrated in the statement made by participant 6:
I feel that this would be beneficial in providing them competence, however the program is at (over) its maximum capacity for credits that the college allows.
The theme Challenges/Barriers revealed that allocated clinical hours posed a challenge to the teaching of dementia care. Participant 7 explained:
Currently the prelicensure student nurses only get assigned to two 10-hour days in a long-term care area. Of those 2 weeks, some of them will get to work with dementia care patients and others will not. Unfortunately, it is “hit or miss” for the limited clinical hours allotted in our associate degree program.
Another significant finding in this study was the emphasis responding programs placed on NCLEX-RN items in relation to the content of their curricula. In fact, a statement by a respondent in the commentary box of the web-based survey indicated that unless the NCLEX-RN focuses more on dementia care, it is not an area of high priority in the program curriculum.
Evaluating Dementia Care Teaching Effectiveness
Only 30 (29.4%) of the participants reported they evaluated dementia care teaching effectiveness. Participants reported evaluating change in students' knowledge (n = 20, 14.4%), skills (n = 12, 8.6%), and attitudes (n = 16, 11.5%). The qualitative data within the theme Teaching Effectiveness/Learning Outcomes revealed the use of surveys through Qualtrics to students to evaluate the course content and theoretical teaching effectiveness of faculty member. Also within the same theme, the data revealed that evaluating students' attitudes was particularly challenging. Participant 3 explained:
I cannot grade their change in attitudes, but it is evident in their posts. Evaluation of their knowledge about the care of older adults is through unit exams based on the stated learning objectives from the text and others reading assignments.
Resources Used in Curricular Planning of Dementia Care Content
The majority of the participants (n = 71, 81.6%) reported that their programs did not involve PLWD or their caregivers in curriculum planning. Seventy-five (86.2%) of 87 participants who responded to survey questions on familiarity with dementia care educational resources indicated unfamiliarity with a free resource for undergraduate dementia education from the United Kingdom dementia resource. Also, many participants' programs were not familiar with the three cited Hartford Institute for Geriatric Nursing's resources, namely Geriatric Nursing Education Consortium Podcasts (n = 40, 46%), Portal of Geriatrics Online Education (n = 42, 48.3%), and Geriatric Nursing Education Consortium (n = 35, 40.2%). In total, less than 20% of the participants reported frequent use of the three cited Hartford Institute for Geriatric Nursing Institute's resources.
Institutional Profile and Integration of Dementia Care Content
A chi-square test of independence was performed to examine the relationship among the institutional profiles and integration of dementia care content into the curriculum. In comparison to participants' programs located in urban areas (n = 58, 52.3%), those located in the rural areas (n = 23, 20.7%) and suburban areas (n = 30, 27%) were less likely to report a partnership with a dementia-focused center, χ2 (2, N = 111) = 6.50, p = . 039. Also, there was an association between programs that had a clinical partnership with dementia care–focused centers (n = 55, 49.5%) and the requirement for prelicensure nursing students to interact with PLWD before graduation, χ2 (1, N = 87) = 5.40, p = .020. There was no difference in the involvement of PLWD/their caregivers in the designing and delivery of dementia care content between programs that had a clinical partnership with dementia focused centers and those that did not, χ2 (1, N = 43) = .776, p = .378.
The results of this study revealed 92.8% of entry-level nursing programs integrated dementia care content into their curricula, with 7.2% of programs reporting no dementia care content in their programs. Programs that lack dementia care content are of critical concern because the absence of opportunities to learn about dementia care both theoretically and clinically during undergraduate programs could later reflect on graduate nurses' abilities to provide competent dementia care or gaps in dementia education. In their summary paper, the American Association of Colleges of Nursing (2015) reported a positive correlation between educational preparation of prelicensure nursing students and their knowledge, skills, and attitudes in providing competent and effective nursing care to diverse populations. Issues with competency in dementia care among RNs is well documented in the literature (Coffey et al., 2014; Gandesha et al., 2012; Nilsson, Lindkvist, Rasmussen, & Edvardsson, 2012; Marx et al., 2014).
In addition to undergraduate nursing curriculum being already overloaded (Donohue-Porter, Forbes, & White, 2011), most of the content are based on NCLEX-RN blueprint (Partusch, 2008). The curricular emphasis on items relevant to NCLEX-RN success is understandable given the accrediting implications related to NCLEX-RN pass rates. The use of a NCLEX-RN test blueprint to structure curricula is common (Partusch, 2008) but may overlook content not directly outlined on the blueprint. For example, overemphasis of content on the 2016 NCLEX-RN test blueprint (National Council of State Boards of Nursing, 2016) could miss the inclusion of managing of agitation and nursing care of PLWD experiencing progressive cognitive impairment. Schools of nursing need to continuously revise their curriculum via content and contextual perspectives, as suggested by Benner, Sutphen, Leonard, and Day (2010), to prepare prelicensure nurses to provide quality dementia care.
Lecture topped the list of pedagogical methods used by the participants' programs, but few participants' programs highlighted the use of technological, innovative, and interactive approaches. In as much as traditional lecture has its advantages, Benner et al. (2010) emphasized that one of the weaknesses of pedagogical approaches in nursing education is the persistent use of lecture, during which nurse educators give much information with little involvement of the learners.
One key qualitative finding revealed by this study was the lack of in-depth practical information about how to provide dementia care in many nursing textbooks, including those on mental health. This finding coincides with that of Beck, Buckwalter, and Evans (2012) that there was poor coverage of content related to dementia and delirium in generalist baccalaureate psychiatric–mental health nursing textbooks. For example, many of the textbooks identified behavior and psychological symptoms in dementia but do not provide detailed nursing skill instruction on how to prevent and management them.
Moreover, the inclusion of many core topics on dementia care is consistent with many dementia-specific competencies identified by the participants' programs. The identified competencies are consistent with many scholars' findings (Michigan Dementia Coalition, 2008; Thompson et al., 2009; Traynor, Inoue, & Crookes, 2011; Williams, Kelly, Leger-Krall, & Tappen, 2005) except for the provision of a positive environment for PLWD. This exception was not often identified as a required dementia care competency within the programs. In their study, Digby and Bloomer (2014) showed that PLWD and their caregivers valued environmental and design features that promoted feelings of being in a home setting, quiet spaces, privacy, and appropriate amenities, such as bathrooms that are more easily accessible to PLWD. Consequently, nursing programs may need better emphasize environmental factors within the curriculum.
Participants reported difficulty in evaluating students' attitudes about PLWD. Similar results have been reported in studies conducted on dementia content in medical professional curricula (Nagle et al., 2013; Tullo & Gordon, 2013). Patient management essay questions and objective structured clinical examination could be useful tools in evaluating prelicensure nursing students' knowledge, skills, and attitudes about dementia care. Furthermore, the lack of satisfaction with the quality of dementia care clinical experiences among participants could be attributed to many factors, including lack of role models, negative role modeling, and impoverished care environments (Chan & Chan, 2009; Skaalvik, Normann, & Henriksen 2010; Watts & Davies, 2014). In addition, many of the participants were not familiar with the Hartford Institute for Geriatric Nursing Institute's free published resources on dementia care. It is imperative that nurse educators are aware of these free available resources because they provide access to the most current and comprehensive geriatric patient care information.
The main limitation of the study was that the data were collected cross-sectionally. Consequently, they represent a onetime snapshot of dementia care content within entry-level nursing programs' curricula. It did not examine any changes to the integration of dementia content that might have occurred over time. Another limitation of the study was obtaining data by self-report of recruited participants rather than having an additional objective review of curriculum content. Thus, the study relied entirely on participants' knowledge of the entire curriculum and their willingness to report this knowledge. It is possible the findings from the study would have been different if multiple informants had been recruited from the same institution. Finally, the study did not include graduate/master entry programs. Future studies should consider including those programs for more representation of the scope of prelicensure nursing programs.
Implications for Nursing Education and Practice
Undergraduate nursing education is foundational to future nursing practice and should be a key focus for nurse clinicians and educators who want to make a difference. How dementia care is being taught within these programs could contribute to an improvement in the outcomes of PLWD and their caregivers. By better understanding of the current state of dementia care content in entry-level nursing programs, nurse educators could be informed of important curriculum decisions. Because dementia is a high public health priority (World Health Organization, 2016), findings of this study support that it be recognized and deemed as a focus area by the National Council of State Boards of Nursing and schools of nursing. Collectively, these organizations and schools of nursing are in the unique position of recognizing and responding to dementia care nursing educational needs by the inclusion of content in the curriculum and NCLEX-RN.
Adding dementia care content to entry-level nursing education presents some curricular and clinical challenges. However, the quality of health care for Americans living with dementia and their caregivers depends on a well-prepared cadre of graduate nurses.
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Demographic Characteristics (N = 111)
|Types of programa|
| Baccalaureate degree||62 (44.6)|
| Diploma degree||4 (2.9)|
| Associate degree/Associate of Science degree||52 (37.4)|
| Urban||58 (52.3)|
| Rural||23 (20.7)|
| Suburban||30 (27)|
| Public||73 (65.8)|
| Private||38 (34.2)|
|NCLEX-RN pass rate in 2014|
| Less than 49%||2 (1.8)|
| 50% to 75%||9 (8.1)|
| Above 75%||100 (90.1)|
|Clinical partnership with dementia focused centers/institutes|
| Yes||55 (49.5)|
| No||56 (50.5)|
|Inclusion of dementia care content in curriculum|
| Yes||103 (92.8)|
| No||8 (7.2)|
Identified Dementia-Specific Competencies (N = 111)
|Dementia-Specific Competency||n (%)a|
|Recognizes, prevents, and manages distress behaviors including agitation, pacing, exit-seeking, combativeness, withdrawal, and repetitive vocalizations||63 (45.3)|
|Understand ethical issues that arise in dementia care and incorporates these into person-centered care approaches||66 (47.5)|
|Utilize effective communication to cognitive/emotional needs of the person with dementia||76 (54.7)|
|Understanding legal aspects of working with people with dementia||54 (38.8)|
|Knowledge of the characteristics of dementia disorder||72 (51.8)|
|Assist people with dementia with daily living activities||59 (42.4)|
|Promote a positive environment||53 (38.1)|
|Facilitate therapeutic interventions||64 (46)|
|Understand and respond to special needs of family and/or caregivers of people with dementia||57 (41)|
|Other: awareness of stigma||1 (0.7)|