According to the World Health Organization, dementia is one of the main health problems affecting older people [1
]. The most common form of dementia worldwide is Alzheimer’s disease (AD) (50–70% of cases) [2
], followed by vascular dementia (12.5–25%) [3
]. In Spain, approximately 600,000 people suffer from any type of dementia, of whom 400,000 suffer from Alzheimer’s disease [5
]. The prevalence of dementia ranges from 5% to 17.2% [5
In the advanced stages of Alzheimer’s disease (AD), the care required is more complex, so high-quality care can often only be provided in institutions such as nursing homes. As a result, many elderly people with AD are admitted [8
]. In Spain, two-thirds of the elderly people admitted to nursing homes suffer from dementia [9
Optimal dementia care in nursing homes adopts a person-centered perspective that focuses on maximizing residents’ quality of life [10
]. Nursing homes play an important role in providing care for dependent elderly people, so ensuring high quality of care for residents in these settings is essential. Poor-quality care has been associated with inadequate nursing staffing and a poor skill mix [11
In nursing homes, quality has two dimensions: quality of care and quality of life. Quality of care refers to more technical aspects of care (such as the use of restraints or the prevalence of pressure ulcers) while quality of life refers to issues such as residents’ autonomy or decision-making capacity [11
]. The most commonly used indicators of quality of care are pressure ulcers, use of restraints, functional status, mortality, hospitalization, nutritional status, incontinence, etc. [11
]. Factors such as depression, conduct disorders, and functional limitation impair quality of life [10
]. The quality of care is not only determined by the staff ratio but also by other factors such as management practices, the education level of the nurses, proper staffing, care planning, and recruitment and retention issues [10
Until now, research in this area has tended to focus on measuring quality in relation to the number of nurses. Other determinants, such as turnover, workers’ stability, staff training and care management, may affect the staff’s performance and their relationship to the quality of care provided to residents [11
Nurses and health-care workers who care for people with dementia must receive specific training to provide high-quality care [12
]. Several studies have determined the knowledge that health-care professionals have about AD and other dementias, finding that registered nurses (RNs) have greater knowledge than assistant nurses (ANs) [13
]. In addition, among the staff who provide care to people with dementia in nursing homes, there is great variability in terms of academic education and training [15
]. Some studies found that usually the staff providing 90% of basic care to people with dementia have low qualifications (ANs or eldercare workers (EWs)) [16
Knowledge about dementia is determined by education and training [17
], but also by direct practical experience when caring for people with dementia [18
]. Nursing home managers should promote continuous education and in-service training activities aimed at engaging the staff [19
]. Training positively influences staff confidence, improving their performance and the quality of care provided [21
Several studies have addressed the issue of nurses and other health-care workers caring for people with dementia. In Portugal, a qualitative study found that nurses in hospitals have limited knowledge about the characterization of AD, risk factors, diagnostic means, complications, and drugs for the treatment and care of patients and carers [22
]. Another study in Australia concluded that health workers had moderate knowledge, but there were significant differences between workers with and without previous experience in caring for people with dementia [12
]. Robinson et al. compared the knowledge about dementia care among nurses, nursing assistants, and family members. Surprisingly, some family members have greater knowledge of dementia than RNs [23
Therefore, the literature shows that it is important to know the level of knowledge about AD and dementia of the nurses and care workers who care for people with dementia. The aims of this study were: (a) to determine the knowledge of staff in nursing homes in Spain about evidence-based practices in caring for people with AD; and (b) to analyze which factors are associated with this knowledge.
2. Materials and Methods
A cross-sectional study was conducted in 24 nursing homes (5 public and 19 private) located in the province of Jaén (southern Spain). Twenty-six nursing homes were contacted, two of which refused to participate; this is 33% of the total number of 72 nursing homes in the province. The staff of nursing homes is mainly composed of registered nurses, assistant nurses, and eldercare workers, as well as some physiotherapists, social workers, and occupational therapists. Only two of the nursing homes had a doctor on the staff; the others had doctors providing services a few hours some days of the week.
The STROBE guidelines were used for reporting this study [24
2.2. Study Population and Sample
The convenience sample consisted of 361 nursing professionals, i.e., registered nurses (RNs, four-year university degree), assistant nurses (ANs, two-year diploma) and eldercare workers (EWs, one-year technical education) working in 24 nursing homes.
The inclusion criteria were: (1) being registered nurses, assistant nurses, or eldercare workers; and (2) participating voluntarily.
2.3. Variables and Instruments
The data were collected by using a self-administered form with two sections:
Socio-demographic variables: gender, age, and experience
Education and training: attendance at courses and conferences
The knowledge about caring for people with AD and other dementias was measured using the UJA-Alzheimer’s Care Scale (Spanish version) (UJA stands for University of Jaén) [25
]. This is a 23-item questionnaire with three response options: “Yes”, “No”, and “I don’t know”. Correct answers are scored with 1 point; errors and “don’t know” with 0 points. Total score: 0–23 (more points means more knowledge). This questionnaire has good psychometric characteristics among Spanish nursing home staff: internal consistency (α = 0.70), test-retest reliability (intraclass correlation coefficient = 0.83), and convergent validity with the Spanish version of the Dementia Knowledge Assessment Tool 2 (DKAT2-Sp) [26
] (ICC = 0.62). It is easy to administer and can usually be completed in 5–10 min.
2.4. Data Collection
Data collection was conducted from November 2016 to January 2017. The research protocol was approved by the Jaén Research Ethics Committee (project code 25102012).
First, we contacted the directors of the nursing homes to request collaboration and the authorization to administer the questionnaires to the staff of these centers. Then, each center received a number of printed questionnaires in accordance with the number of people on their staff. To guarantee anonymity, no personal data were included in the questionnaire.
2.5. Data Analysis
The characteristics of participants were analyzed using descriptive statistics, frequencies and percentages for categorical variables, and mean and standard deviation for continuous variables. To obtain knowledge scores, the mean, standard deviation, 95% confidence interval (CI), and the percentages of correct, incorrect, and “don’t know” answers were calculated. The final score of the scale corresponds to the number of correct answers. In addition, the count and percentage of errors (incorrect answers) and “don’t know” (explicitly marked) were calculated. The option “don’t know” allows identifying the gaps in knowledge.
The association between demographic or educational variables and the knowledge score was tested using the Student’s t-test or one-way ANOVA. The effect size was estimated using the Cohen’s d statistic. A multivariate analysis by stepwise linear regression was carried out with the variables with statistical significance in the bivariate analysis. Analyses were performed with SPSS 21 (IBM® International Business Machines Corporation, Armonk, NY, USA). A value of p < 0.05 was used as the level of statistical significance.
The results of our study show that the staff of the nursing homes in the province of Jaén has a medium to high level of knowledge about the care of people with Alzheimer’s disease and other dementias. The knowledge is high among RNs (83.3% of the maximum score on the UJA Alzheimer’s Care Scale) and slightly lower among ANs and EWs (71.3%). This difference in the knowledge score can be explained by the difference in education, although the score obtained in the group of ANs and EWs is higher than expected. These results are quite similar to those reported by other researchers. Smyth et al. [12
], in the health service of the Queensland area in Australia, found that the knowledge score regarding AD was higher in professional categories with more years of education (physicians 86.6%; nurses 79.6%) and lower among ANs and support staff. Robinson et al. [23
] measured knowledge using the Dementia Knowledge Assessment Tool 2 (DKAT2) [27
] in a sample of nursing staff and family members in nursing homes, reporting that nurses scored higher than ANs. Similar findings were reported by Annear et al. [28
] in a study aimed at measuring the knowledge of nurses and assistant staff before and after a specific training program. They concluded that nurses have a higher level of knowledge than assistant staff. A study in a different cultural context, namely China, reported a moderate knowledge score in a group of non-professional carers in nursing homes (17.4 points out of 23) [29
], which is similar to the score for ANs and EWs in our study.
In our results, both groups (RNs and ANs and EWs) showed a high degree of coincidence in the items best known, such as “recording of mechanical containment”, “information to the carer”, “inclusion of patients’ representatives in decision-making”, and “recording in the clinical history of the behavioral and psychological symptoms of dementias”. In addition, there are coincidences in the worst-known items: “use of nasogastric tube and percutaneous gastrostomy” and “treatment of psychological and behavioral disorders”. We emphasize that the item on the measurement of carer overload by means of the Zarit scale has the highest self-declared ignorance (percentage of response “I don’t know” for RNs: 14.5% and ANs: 55.8%). Comparatively, in the study by Robinson et al. [23
], the best-known aspects were those related to the physiopathology, behavioral and psychological symptoms of dementias, and decision-making; and the least-known ones were those related to palliative care and the terminal phase of the disease. Our findings agree with other authors [30
] on the poor knowledge of staff about the topic of the management of behavior disorder. Other topics mentioned in terms of low knowledge were: effective communication strategies with patients; early recognition of dementia; and non-pharmacological treatment or epidemiology [30
It is important to emphasize that the identification of knowledge gaps among nursing staff through well-designed questionnaires makes it possible to organize staff training according to these gaps. Specialized training increases knowledge and improves the quality of care provided [28
]. Adequate training in AD care allows situations of bad care to be avoided in different areas such as pain treatment in people with dementia [31
], as well as unnecessary or futile tests and interventions in the last three months of life [23
]. Adequate recording of the use of mechanical restraints when needed is a well-known item in our findings. This is an important issue, with a high impact in clinical practice, as shown by some studies [32
Having updated training in dementia, measured by attendance at courses in the last three years, is the single most important factor associated with a high level of knowledge among nursing staff (RNs and ANs). This is in line with results found in studies on specialized training [12
]. The second factor associated with knowledge is the number of years of experience in nursing, but only within the RNs group. Both inadequate training and a lack of experience have been reported to be negatively associated with the quality of care provided by nurses [30
]. In our study, we did not find that the age of the staff was associated with knowledge, in contrast to the findings of other authors [12
In regard to the scores of each nursing home, we found a wide range of variation in the knowledge score. We found a small group of nursing homes with nursing staff scoring higher than average and another group scoring lower. Although our study was not specifically designed to investigate this difference, we tested some factors that could explain it, at least partially. Again, training and experience are associated with greater knowledge. Our findings show that those nursing homes with a higher percentage of nursing staff that have attended training courses recently (last three years) had a high level of knowledge. The same occurs in nursing homes where more than 33% of their staff has more than five years of experience. In contrast, we did not find any association between knowledge score and the size of the nursing home or with the ratio of residents to staff. Overall, our results support the theory that the quality of care in nursing homes is influenced by a variety of factors and not just by staffing [11
] or size [30
]. Factors such as staff training and professional experience influence the level of knowledge, which in turn influences the quality of care. Training programs lead to nurses having more positive attitudes and increase their satisfaction with the care of people with dementia [30
Research findings suggest that nursing home managers should evaluate the knowledge of the nursing staff about dementia care as a first step in planning and developing training activities. Several studies have shown an increase in the level of knowledge after developing training programs [33
]. Some authors, e.g. Gaugler et al. [10
], advocate that institutions should develop incentives, scholarships, and other initiatives to expand the training of staff. Other authors, e.g. Matsuda et al. [35
], propose training programs with good results. The program consists of two 90-min training sessions (on different days) developing topics such as types of dementia, symptoms, behavioral problems, early detection and treatment, prevention, and the attitude of professionals towards people with dementia. We emphasize the great importance of continuous training in nursing clinical practice, because a higher level of knowledge is related to a higher quality of care [11
] and less difficulty for professionals in interacting with people with dementia [35
]. Nursing staff of nursing homes must be trained to respond to the needs of their patients, adapting and updating themselves for person-centered care. The tool used in this study could be used to develop research in other settings, such as hospitals (where people with dementia are treated quite frequently) or community care to identify the training needs of nurses and healthcare providers.
This research has some limitations that should be pointed out. Data were obtained through self-administered questionnaires, so some information could be shared when filling them in. Sampling was not random and some nursing homes had a low response rate, thus it is possible that the most motivated staff predominantly responded, which may have led to an overestimation bias in the scores. We tried to overcome these limitations with the design of a multi-center study, including 24 nursing homes, thereby increasing the representativeness of the sample. In addition, the sample size of the group of RN is small for multivariate analysis and reduces its reliability. Finally, it is important to bear in mind that the questionnaire used has a “Don’t know” option for each item that allows independent analysis of errors and ignorance, as recommended by other authors [23