Received: 1 October 2017 Revised: 11 April 2018 Accepted: 22 April 2018

DOI: 10.1111/ppc.12291

R E V I E W AR T I C L E

Nurses’ knowledge and attitudes about dementia care:

Systematic literature review

Melina Evripidou RN PhD(c) Andreas Charalambous RN, PhD

Nicos Middleton PhD Evridiki Papastavrou RN, PhD

School of Health Sciences, Department of

Nursing, Cyprus University of Technology,
Limassol, Cyprus
Correspondence
Melina Evripidou, School of Health Sciences,
Department of Nursing, Cyprus University of
Technology, Limassol 3036, Cyprus.
Email: melinaevripidou@outlook.com
Abstract
Purpose: To explore nurse's knowledge and attitudes toward the care of people with dementia.
Design and Methods: A systematic review informed by the PRISMA-P (preferred reporting items
for systematic reviews and meta-analyses protocols) guidelines in four databases (CINAHL, Psy-
INFO, Pubmed, Cohrane, EMBASE) using keywords “attitudes,” “behaviors,” “dementia,” “knowl-
edge,” and “nurses.” Predetermined inclusion criteria were selected. The review was conducted
between January 1 and December 30, 2017.

Findings: Sixteen quantitative studies, one qualitative, and two mixed methods studies were
included. Nurses lack knowledge, communication skills, management strategies, and confidence
in the provision of dementia care. Interventional studies suggested that knowledge and attitudes
improved after training programs were implemented.

Practice Implication: This review contributes to care advancement and practice development
through the reinforcement of organizational support and educational opportunities for nurses.

KEYWORDS
attitudes, dementia, knowledge, nurses

1 INTRODU CTI ON
Across the globe, populations are aging rapidly. Considering that the
percentage of people over 60 with dementia ranges between 5% and
8%,1 caring for people with dementia (PwD) is a topic that merits
increased attention. Dementia has emerged as an important challenge
and key priority for health systems globally, as PwD can be intensive
users of health services.2 Almost 25% of acute hospital beds are occu-
pied by PwD,3 and data reveal that PwD are hospitalized for more days
than other patients without dementia but with similar health issues,
resulting in the consumption of more nursing resources.4,5 These addi-
tional hospital bed days cost between 64 and 80 million per year,6 sug-
gesting that dementia care management needs to be better organized
to maximize efficacy and minimize costs.
Dementia care can be very challenging due to the combination
of comorbidities, together with the cognitive and functional decline
of patients. This creates a fusion of complex needs together with
ever-increasing difficulty for the patient in articulating them. Also,
there is evidence that PwD may be at risk of neglect in terms of
basic care requirements, meaning that this group of patients is more
vulnerable to complications and may receive less than optimal quality
of care (Bail et al.).7 In spite of the significant role nurses have in
caring for these patients, little is known about nurses’ knowledge
and attitudes toward dementia care and the problems associated
with PwD care. Furthermore, studies revealed that structural dis-
crimination and stigmatization of PwD occurs among healthcare
providers,8,9 leading to unequal delivery of service between PwD
and other categories of patients. Nursing care has been identi-
fied as critical for meeting PwD needs and promoting quality of
care.10,11
2 AIMS
Since higher levels of knowledge and the adoption of a positive atti-
tude has been found to be associated with better patient outcomes,12
this systematic literature review aims to determine the knowledge lev-
els and attitudes among nurses with regard to dementia care. This is
achieved by improving the understanding of the provision of care to
PwD through synthesizing evidence from quantitative and qualitative
studies. More specifically, the following research questions guided this
review:

48 © 2018 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/ppc Perspect Psychiatr Care. 2019;55:48–60.

EVRIPIDOU ET AL.
• What are the attitudes and knowledge levels among nurses relating
to dementia care?
• What factors influence nurses’ knowledge and attitudes relating to
PwD?
3 METHOD
This systematic review, was guided by the PRISMA-P (preferred
reporting items for systematic reviews and meta-analyses protocols)
guidelines,13 which comprises a 17-item checklist and three-phase
flow diagram. The checklist includes items deemed essential for sys-
tematic review reporting14 and was used for the critical appraisal of
this systematic review.
3.1 Searching
A search strategy was developed to identify published studies describ-
ing knowledge levels and attitudes relating to dementia care among
nurses. The search was conducted between the January 1, 2016
and the March 31, 2016 and was updated in December 2017. Five
databases (PubMed, EMBASE, CINAHL, Cochrane, and PsycINFO)
were searched using combinations of the following keywords: “nurses,”
“knowledge,” “attitudes,” “behaviors,” “dementia,” and “patients.” The
following inclusion criteria guided the search efforts to identify all the
relevant studies.
3.2 Inclusion criteria
The inclusion criteria consisted of the following:
1. publications in English;
2. a study sample comprising of nurses at any level of experience
working in hospitals or community or mental health facilities; and
3. a focus on knowledge and attitudes in general as opposed to the
specific aspects of dementia care. No restrictions were set for
research design or year of publication. Methodological assessments
of the studies were not used as inclusion or exclusion criteria.
3.3 Screening
One researcher screened the titles (M.E.) and abstracts (M.E.) based on
the inclusion criteria, and any uncertainties during the screening and
selection process were discussed with the remaining members of the
research team (EP, AC, NM). Additionally, we contacted authors of the
included studies to identify other relevant searches in the field. Studies
using terms (such as skills or perceptions) synonymous with knowledge
or attitudes among nurses were also included. Based on this search,
2,093 relevant studies were identified for further screening. First, we
read the titles, and 1,773 papers were rejected due to irrelevance and
duplication (n = 156). Next, 164 abstracts were retrieved, and 131
were excluded because they did not meet the complete set of the inclu-
sion criteria or were not written in English. In total, 33 full text articles
were read, of which 17 were excluded due to a lack of relevance to the
49
3
research topic. After the renewal of the search, three studies found to
be relevant and included in the review. Finally, 19 studies were selected
and included in the review (Figure 1).
3.4 Quality appraisal
To assess the clarity and comprehensiveness of reporting, the
Strengthening the Reporting of Observational Studies in Epidemiology
Statement (STROBE) tool was used to evaluate cross-sectional studies
and to limit any potential biases from including unreliable results in our
literature review. The STROBE framework consists of 22 items related
to the article's title and abstract, introduction, methods, results, discus-
sion section, and other information, such as funding and limitations.15
One of the included studies was qualitative; thus, the Consolidated
Criteria for Reporting Qualitative Research (COREQ) tool was used to
assess this study,16 which is a 32-item tool divided in three main cate-
gories for research team and reflexivity, study design, and data anal-
ysis and findings. Because one study17 was a randomized controlled
trial, the Jadad scale was used to assess it,18 a tool that examines three
main parameters: randomization, blinding, withdrawals and loss to
follow-up.
Two of the included studies used mixed method design, so the Mixed
Method Appraisal Tool (MMAT) was used for assessment.19 It consists
of 21 questions, which examine methodological quality according to
the type of the study (quantitative, qualitative, randomized controlled
trial, nonrandomized, and mixed method).
The following major strengths were identified in the quantitative
studies reviewed:
1. All described eligibility criteria, sources, and methods of participant
selection; and
2. Data sources and methods of assessment were described for every
variable in all studies except one.
A major weakness identified was in statistical methods. Specifi-
cally, the process of how missing data were handled was inadequately
addressed in 9 of the 16 studies. Another weakness identified in
12 studies was a failure to describe any efforts to address potential
sources of bias. Additionally, nine studies did not include the dates dur-
ing which the study was conducted. Of the variable criteria, six studies
did not report how potential confounders were addressed. Finally, in
seven studies, funding was not reported.
A major strength of the qualitative study was its description of data
analysis and the presentation of its findings; however, it had some
limitations in the analysis domain as the number of data coders and
the coding tree were not described. Another major strength identified
in the study design domain was its theoretical framework; however,
under this domain, the description of its sampling methodology
was lacking. The qualitative study had certain limitations related
to relationship establishment under the first domain, as the study
did not mention either whether a relationship was established with
participants prior to its commencement or the level of knowledge
participants had about the researcher. Further, interviewer charac-
teristics were unreported. In addition, a major weakness identified
50
2 EVRIPIDOU
F I G U R E 1 Flow diagram for identifying and selection of the studies of the review [Color figure can be viewed at wileyonlinelibrary.com]
was the description of study settings, as the location of data collection
and the presence of nonparticipants during the collection of the data
were not described. The total score of the study, according to COREQ,
was 17/32, which indicates that the above-mentioned items were
unreported, thus explicitness and comprehensiveness of the particular
study were lacking.
One study was evaluated according to Jadad assessment tool. The
total score of the study was 3/5 because the blinding method was not
described. This score indicates that the methodological quality and the
effectiveness of blinding were inadequate.
With reference to the MMAT tool, two studies used mixed
method—one of which rated 100% in total score and the second 75%.
This was due to lack of representativeness of the sample (reasons for
not participating were not explained) as well as the rationale for inte-
grating qualitative and quantitative methods.
3.5 Data synthesis
Extracted data were synthesized and findings were divided into cate-
gories. The purpose of synthesizing data was to classify how the lit-
erature addresses the research question and to identify and analyze
key concepts. The emerged themes are patterns across data sets that
have high significance for the depiction of a phenomenon.20 Accord-
ing to Javadi et al.,21 thematic analysis reflects the reality and clar-
ifies any misconceptions. Structured synthesis methods were used,
in particular categorization of the findings, as the researchers were
ET AL.
from various clinical, academic, and research fields. In the face of that
method, the general epistemological stance was more aggregative than
interpretive. 22 The data synthesis process involved aggregation of the
findings by organizing the studies according to quality rating and then
categorizing them on the basis of the similarity of study findings.23
Two authors (ME, EP) extracted and summarized findings in the follow-
ing four main domains: the level of nurses’ knowledge about demen-
tia, the attitudes among nurses toward dementia care, the factors
associated with nurses’ knowledge, and attitudes and results from the
intervention.
4 RESULTS
All of the studies were published between 1997 and 2015 and study
samples included 4,274 nurses working from 3 to 25 years either in the
community, mental health, residential care facilities, and hospital units.
Nurses’ ages ranged from 22 to 60 years and most studies were con-
ducted in Europe (United Kingdom [n = 4], Norway [n = 3], and Swe-
den [n = 1], followed by the United States (n = 6), Australia (n = 2),
Korea (n = 2), and Israel (n = 1). The research topic of these studies
addressed the level of knowledge and/or attitudes among nurses with
reference to PwD. Additionally, some studies addressed the care envi-
ronments, educational needs of nurses, and factors associated with
attitudes among nurses caring for PwD. Dementia care and community
EVRIPIDOU ET AL.
mental health nurses were identified as having received previous train-
ing in treating PwD
Sixteen studies were quantitative,17,24–38 one study was
qualitative,39 and two studies utilized mixed methods.40,41 The
qualitative study used content analysis to assess perspectives
after implementing a training video. Among the quantitative stud-
ies, seven were interventional,25,26,30,32,36–38 seven were descr-
iptive,24,27–29,31,33,35 one was a randomized controlled trial,17 and one
was cross-sectional.34
The data in quantitative studies were collected through struc-
tured questionnaires specifically designed for the purpose of each
study.25,26,30,32,36–38 It is interesting to notice that only two instru-
ments were used more than once and these are the Approach to
Dementia Questionnaire (ADQ) created by42 and the Alzheimer Dis-
ease Knowledge Scale (ADKS) created by Carbernter et al.43 The ADQ
was used by Kada et al.,29 Kang et al.,31 Surr et al.,38 and the ADKS was
used by Marx et al.,34 and Kimzey et al.40 The reliability of the ADQ was
examined with a Cronbach's 𝛼 that was 0.5929 and 0.83,
respectively (Lintern et al.).42 As far as it concerns ADKS
instrument, Cronbach's alpha was 0.8043 and 0.98.40
All of the studies used convenience sampling, while one of them
used randomization17 and one used a control group.26 One of the stud-
ies conducted pre and posttests on the same day,36 while another
26,30
two conducted pre-, post-, and three-month posttests to assess
knowledge and attitudes of nurses regarding dementia. The rest of the
studies conducted only postintervention measures. Questionnaires to
assess the impact of the interventions on knowledge and attitudes
among nurses were administered after a three-month period,30,32,38 a
six-month period,26 or the same day. 17,25,36,37,39. Three training pro-
grams were lecture-based, two used training videos, two used activi-
ties and slides simultaneously, and one study implemented an educa-
tional workshop. Study characteristics are presented on Table 1.
4.1 Analysis of the findings
4.1.1 Nurses’ (lack of) knowledge about the care of PwD
This review identified significant deficit in knowledge relating to the
care of PwD among nurses, and suggests that these findings have been
consistent over time.17,24,28,30,33,34,37 According to Barett et al.,24 only
26% of nurses had knowledge of risk factors for developing Alzheimer's
disease. Nurses reported an understanding of basic knowledge regard-
ing dementia care, but little knowledge of specific techniques, such as
effective communication strategies, engaging PwD in activities, and
managing patients resistant to care.28,30,34 They also indicated the
need for information regarding early recognition of dementia, man-
agement of behavioral changes,30,34 and how to improve their skills
and enhance patient safety. 28,30,34 Interestingly, Marx et al.34
found that 91. 9% of nurses (n = 34) described the need for managing
behaviors nonpharmacologically. Additionally, the study's findings
revealed a low level of knowledge concerning the epidemiology and
diagnosis of dementia, and management of coexisting behavioral and
mental health problems.17 One study identified the lack of knowledge
relating to falls and fall injuries, which they attributed to insufficient
51
3
organizational support for competence development. 28 Furthermore,
the lack of appropriate knowledge on caring for PwD appeared to neg-
atively reflect on the nurses’ behavior. For example, Marx et al.34 found
that nurses reported feeling frustrated when managing the care of
PwD. This was due to inadvertent reinforcement of unwanted behav-
iors by reacting to negative verbalization and not supporting positive,
prosocial behaviors.34 Furthermore, low levels of confidence17,37 were
reported during nursing care that was directly related to self-rated
ability to identify and manage dementia (r = .20, p = .05).
4.1.2 Attitudes of nurses toward dementia care
Nurses’ negative attitudes toward the care of PwD were mainly asso-
ciated with the symptoms and progression of dementia (e.g., more neg-
ative attitudes were correlated with advanced stage of dementia) as
well as their own feelings about PwD (Galvin et al.).17,27,29,33–34,37,44
For instance, the memory and behavior problems that are very com-
mon in dementia (e.g., asking the same questions, aggressiveness, agi-
tation, hallucinations, confusion, etc.) led to more negative attitudes
by nurses. Nurses described their inability to manage behavioral prob-
lems associated with the disease (Galvin et al.)17,34,44 or feeling fear,
anxiety27,29,35,37 during their interaction with PwD.
Less hopeful attitudes were associated with negative attitudes
toward dementia care.29 Hopeful attitude is believed as a core con-
cept in the context of nursing care that facilitates care and contributes
to the improvement of patients’ well-being.45 This focus on success is
correlated with positive attitudes, thus hope and positivism are com-
monly regarded as equivalent terms.46 In particular, Oxford English
Dictionary refers to the word “hope” as a contributing factor of the
broad sense of positive attitude.47 Positive attitude toward PwD was
found to be context and training related. For example, nurses working
in community mental health presented positive attitudes and sufficient
knowledge and skills relating to dementia care, as they believed that
they were in a better position to coordinate services for people with
newly recognized dementia. 25 Similarly, specialized nurses reported
more positive attitudes (p = .04)29 than those not trained in dementia
care17,25,29 and believed that they should be placed as managers, coor-
dinators, or educators.29
4.1.3 Factors influencing knowledge and attitudes in
dementia care
Inadequate education, lack of experience, and large unit size were
found to negatively affect care provided by nurses27–29 (Shinan-
Altman et al.).48 Furthermore, nurses were found to face ethical dilem-
mas while attending to the physical needs of PwD, especially con-
cerning to what extent independence, choice, and dignity should be
maintained.27 Other findings showed that nurses attributed psycho-
also logical causes to Alzheimer's disease prevalence. 35 Additionally, poor
employer financial contributions to continuing education and insuf-
ficient organizational support for competence development28 were
described as reasons of ineffective dementia care.
However, variations of the factors (e.g., age, years of experience)
among nurses were supported by the evidence. Registered nurses
under 50 years of age or with more than 10 years of experience
 2

52
TA B L E 1 Characteristics of the quantitative studies reviewed

Type and
Author, year, Research Sample and size description of
country Aim design Instruments (+characteristics) intervention Analysis method Outcomes
Australia33 To assess the level Descriptive Dementia Knowledge 279 Nurses and care ANOVA Dementia knowledge deficits among formal
of knowledge Assessment Tool workers in Chi-square carers and family cohort. Findings also
about dementia residential aged Spearman's indicate problems among all level of aged
facilities rank-order care staff and resident's family members in
164 caregivers correlation dementia's life-limiting nature and the onset
Convenience sample of physical symptoms associated with its
progression.
United To assess the level Cross-sectional 1. A modification of the 39 Nurses working in t-Tests mean, SD, Nurses indicated a need for more information
States34 of knowledge, Alzheimer's Disease a chronic care and range and skills, specifically for managing behaviors
educational Knowledge Scale hospital unit. nonpharmacologically, enhancing patient
needs, and the 2. A questionnaire Convenience safety, coping with care challenges, and
care environment included 11 sample involving patients in activities. Although most
yes/no items on staff believed their care contributed a great
perceptions of deal to patient well-being, approximately
educational needs 75% reported frustration and being
overwhelmed by dementia care. There is
3. Nurses were asked to fundamental knowledge but lack on
rate their confidence techniques.
in care provision

Korea31 To describe nurses’ Descriptive Attitudes toward the 100 Registered t-Test, ANOVA, Moderately positive attitudes toward older
attitudes toward Elderly with Dementia nurses working in Levene's test PwD in the acute care setting were found.
people with (AED) acute care settings Two-thirds of the nurse participants (n = 65,
dementia (PwD) Approaches to Dementia of two hospitals 65.7%) working in medical wards
in acute care Questionnaire (ADQ) demonstrated significantly more positive
settings attitudes than those working in surgical
wards (n = 34, 34.3%). Demographics
including years of experience in the current
unit and in the service, and nurses’ position
did not correlate significantly with their
attitudes. The environment, work routine,
and technology may influence the likelihood
of negative attitude toward PwD.
Norway29 To explore the Descriptive The Approach to 291 (A mixture of ANOVA Nursing assistants, staff over 50 years and staff
attitudes of staff Dementia nurses), working in who had less than 10 years of experience had
caring for Questionnaire 14 nursing homes lower hope attitude. Also staff over 50 years
institutional- and 1 geriatric had lower person-centered attitude,
ized dementia ward convenience compared with their counterparts under the
residents sample age of 40. Nurses with specialized training in
geriatrics, psychiatry or dementia care had
significantly higher hope attitudes, compared
with nurses without any special training.

EVRIPIDOU
Education, age, experience and the size of the
unit affect nurse's attitudes.
(Continues)

ET AL.
TA B L E 1 (Continued)

Type and

EVRIPIDOU
Author, year, Research Sample and size description of
country Aim design Instruments (+characteristics) intervention Analysis method Outcomes
United To explore Descriptive Kitwood's “malignant 87 Nurses working in Descriptive Nurses have some knowledge and ability in
Kingdom27 knowledge, social psychology” and general hospitals statistic delivering person-centered care, but that this

ET AL.
understanding, “person-centered wards convenience is usually only evident where
and implications approach” sample person-centered care is a clear option. When
for care of it is a less obvious choice, some dilemmas are
nurses working raised. Issues of trying to maintain
with demented independence, choice, and dignity while
patients attending to physical care needs and
managing the care needs of others were
highlighted by the nurses as effective
standards to strive for, and these are aspects
of person-centered dementia care.
United Toinvestigate level Descriptive A 12-item scale with 693 (Experts in AD, One-way analysis Generalist healthcare professionals showed
States24 of knowledge psychometric nurses, primary chi-square important deficits in fundamental knowledge
about Alzheimer properties was care physicians, about AD. Although knowledge about
disease (AD) developed—UAB social workers, assessment and management of AD has
Alzheimer's disease psychologists, increased and has been widely disseminated,
Knowledge Test for nursing students) many healthcare professionals remain
Health Professionals convenience uninformed about AD.
sample
Israil35 To examine and Descriptive The sample was asked to 327 Nurses and social t-Test, chi-square Nurses attributed psychological reasons to AD
compare AD comparative report their cognitive workers (122 social means, SD, more than the social workers. Nevertheless,
illness and emotional workers and 205 percentages social workers perceived AD as more chronic
representations representations using nurses from five with severe consequences compared with the
among two main the Revised Illness medical centers nurses. Despite some resemblance, there
professional Perception and nursing homes) were differences between the social workers
groups involved Questionnaire (IPQ-R) Convenience and nurses regarding AD illness
in the care of sample representations.
Alzheimer
patients
Sweden28 To describe Nonexperimental, A structured 213 Nurses (95 Chi-square Nurses were on average not lacking or were
registered nurses descriptive questionnaire that was worked in dementia Man–Whitney hardly lacking knowledge in examined
perceptions of specifically designed care, 118 in general U-test domains. Nurses in geriatric care lacked
needs and for this study elder care) knowledge of dementia, falls, and fall injures
possibilities for to a greater extent than registered nurses in
competence dementia care. Most registered nurses
development requested a better organization
for competence development, especially in
geriatric care. The employers’ financial
contribution to registered nurse's continuing
education was poor.
United To determine the A convergent 1. Alzheimer's disease Convenience sample - AD clinical experience Mixed ANOVA The AD clinical group experienced increased
States40 effect of different mixed method Knowledge Scale of 94 senior level - Online learning content analysis knowledge and improved attitudes toward
educational design; a three 2. Dementia Attitude nursing students module people with AD compared with students who
experiences and group (pretest– Scale enrolled in the completed the online module or had no
attitudes on posttest) design undergraduate dementia-specific intervention. Four themes
nursing students’ and a focus nursing program's emerged from focus group data: basic AD
knowledge and group Community Health knowledge, need for AD experiential learning,
attitudes toward course negative feelings related to behaviors, and
people with appropriate responses to behavioral and
Alzheimers psychological symptoms of dementia. 3

53
(Continues)
TA B L E 1 (Continued)
2
Type and

54
Author, year, Research Sample and size description of
country Aim design Instruments (+characteristics) intervention Analysis method Outcomes
Korea41 To evaluate the Mixed-methods Knowledge of cognitive Purposive sample of Workshops (patient Wilcoxon The educational program had a positive impact
effect of an study that impairment was 12 registered scenarios, role-playing, signed-rank on nurses’ knowledge of cognitive
educational included a measured using five nurses participated discussion, lectures, tests and impairment and attitudes toward older
program on single group, case vignettes. Each in interviews self-directed study) McNemar tests adults. The qualitative data indicated that the
nurses’ pre–post design vignette has five and support sessions content analysis educational programme improved nurses’
knowledge and and interview multiple-choice knowledge of cognitive impairment and their
attitudes of older questions and four attitudes toward older adults with cognitive
adults with open-ended questions impairment. It also increased nurses’ initial
cognitive efforts to involve family caregivers in
impairment cognitive impairment care.
United To evaluate the Repeated 1. Person-centered Care 40 Acute hospital 3.5 Days training ANOVA The training program was effective in producing
Kingdom38 efficacy of a measures Training for Acute staff convenience program, comprised of a significant positive change.Training acute
training program design; Hospitals (PCTAH) sample two levels, foundation hospital staff is effective in producing
for nurses intervention program (0.5 day), and significant improvements in attitudes toward
regarding 2. Approaches to intermediate (3 days), and satisfaction in caring for PwD and
attitudes, Dementia delivered over a 3–4 feelings of caring efficacy
satisfaction, and Questionnaire (ADQ) months period
feelings of caring
efficacy, in 3. Staff Experiences of
dementia care Working with
Demented Residents
questionnaire
(SEWDR)
4. Caring Efficiency
Scale (CES)

United Toinvestigate level Intervention 1. A 20-item 5-point 355 Participants of The all-day Dementia t-tests ANOVA Changes in participant's attitudes and practices,
States36 of knowledge study Likert scale measuring whom 221 were Friendly Hospital confidence, and knowledge were evaluated.
about dementia attitudes, practices, and nurses from five Initiative (DFHI) Scores indicated significant improvement on
confidence for care of different hospitals program consists of the posttest.
patients with dementia convenience five modules of didactic
2. A final set of seven sample content, slides, videos,
knowledge about AD learning activities, and
and care issues handouts
3. Open-ended questions
to explore further
needs and challenges in
working with these
patients. A pre- and
posttest were
completed for the
program

United To report on the Intervention 1. Confidence in 72 Registered nurses A 6-hr training program t-Tests mean, SD, The program was well received and had a
Kingdom37 development and dementia (COED) working in a included four sessions and range, 95% significant impact on staff knowledge and
evaluation of the 2. Knowledge in general hospital each of 45–90 min confidence confidence. Before the implementation of the
“Getting to Know dementia (KIDE) duration interval program staff indicated low level of

EVRIPIDOU
Me” training confidence, which eventually increased. Also,
program. Also, to staff revealed that they had no prior training
measure in dementia care and during the program they
knowledge and suggest that focusing on knowledge about

ET AL.
confidence in communication and management of
dementia care dementia is of great importance.
(Continues)
 EVRIPIDOU
TA B L E 1 (Continued)

ET AL.
Type and
Author, year, Research Sample and size description of
country Aim design Instruments (+characteristics) intervention Analysis method Outcomes
United To create A two-group 1. True–false, multiple 162 (80 Medical A 15-week semester: Descriptive Findings from this interprofessional program
States32 interprofessional treat- choice tests and students in their Observation of: nurse statistic demonstrated that nurse practitioner
group for the ment/control semantic differential second year, 82 practitioner conducted students gained higher levels of knowledge
diagnosis and pretest posttest scale.2. Attitudes nurse students) memory-oriented regarding AD, and medical students gained
treatment of design was used toward convenience history, physical and more positive attitudes toward these patients
dementia Interdisciplinary Teams sample neuropsychological and their caregivers. Comments from
Scale and Attitudes examination. students indicated that both medical and
Toward Collaboration Participation in a nursing students found the experience
Scale diagnostic impression valuable.
meeting with the
patient and a family
member, to a caregiver
support group meeting
and in the activities
and care provided to
participants in the
early-stage day center.
Norway39 To assess the level Descriptive– Training video based on 26 Registered nurses, The staff received Marte Content analysis Nurses gained new knowledge, inform and
of knowledge qualitative MarteMeo principles, enrolled nurses, Meo Counseling enrich their nurse role, and raise their
after watching a interviews and in four dementia and nurse aids (MMC) from a trained abilities as their usefulness was determined
training video focus group specific care units therapist seven times and realized their interaction to patients.
(1.5-hr sessions each
time) during 2 months
period. Each counseling
session was based on a
short videotape, lasting
5–10 min
United To evaluate a Intervention 1. Six questions 540 Individuals at Program lasted 7 hr and Paired sample Significant gains in knowledge and confidence
States30 training program regarding current four community consisted of five t-tests, in recognizing, assessing, and managing
about knowledge practices and hospitalsconve- modules (introduction, chi-square tests, dementia. Also attendees report gains in
in dementia attitudes nience medical overview, and one-way communication skills and strategies to
2. Five questions about sample approaches to ANOVA improve the hospital environment, patient
confidence in communication and safety, and behavioral management. In the
assessing, behavior, dementia hospital that demonstrated lower knowledge
recognition, friendly care, and and confidence scores, the sample was older
management, connecting the and had more nurses and more years in
differentiating caregiver); pretest and practice.
delirium from a 120-day posttest
dementia were performed
3. A nine-item multiple
choice knowledge test

(Continues)

55
 2

56
TA B L E 1 (Continued)

Type and
Author, year, Research Sample and size description of
country Aim design Instruments (+characteristics) intervention Analysis method Outcomes
Australia26 To evaluate the Intervention 1. Maslach Burnout 29 Nurses and 35 1. Dementia training ANCOVA Staff members in both dementia training groups
impact of a inventory, residents received program that reported improved attitudes regarding their
training program 2. Self-Efficacy of training plus peer consisted of eight knowledge and skills in managing residents
for aged care Dementia Care support, 35 nurses sessions of 60–90 min with challenging behaviors, immediately after
staff in managing and 46 residents duration, which was the training and 6 months later. Facility
dementia-related 3. The Scale of Nursing received training delivered using a supervisors rated the nursing performance of
challenging Performance only, 26 nurses and combination of trained staff more positively, particularly
behaviors 4. Cohen-Mansfield 32 residents didactic and those who participated in a peer support
Agitation Inventory participated in the experiential learning group. The dementia training programs,
control group 2. Peer support program whether with or without the inclusion of peer
support, did not impact on levels of staff
burnout or substantially reduce the level of
challenging behaviors among aged care
residents.
United To investigate Intervention Baseline knowledge 78 Nurses (district Means, Low levels of knowledge about epidemiology
Kingdom17 knowledge, confidence and nurses, health percentages and diagnosis, but slightly higher levels about
attitudes, and perceived difficulties in visitors, practice correlation r management strategies. Self-reported ratings
confidence dementia care nurses, and of confidence were also low and were directly
among nurses to management and community staff related to ratings of difficulty in identifying
the diagnosis and attitudes nurses); dementia and dealing with coexisting
ongoing convenience behavioral and mental health problems.
management of sample Lower scores on all domains were recorded
dementia for practice nurses than for district nurses or
health visitors.
United Toexplore whether Intervention 1. Questionnaire 268 Nurses (79 1-Day educational Confidence Differences in knowledge, experience, and
Kingdom25 community comparative derived from Stirling CMHNs), 153 workshops on intervals 95% confidence between the three nurse groups.
mental health Dementia Service (CNs), 35 PNs) recognition of and Community mental health nurses (CMHNs)
nurses (CMHNs), Development Centre response to dementia were more confident in their abilities to
community about clinical role, recognize dementia and found providing
nurses (CNs), and experience, support less difficult than clinical nurses
practice nurses knowledge, caseload, (CNs) and practical nurses (PNs). CMHNs
(PNs) have epidemiological, and considered that they were best placed to
different confidence in coordinate services for people with newly
perspectives on recognizing the recognized dementia. CNs and PNs, however,
early diagnosis of dementias and reported experience of working with PwD
dementia perceived difficulties and many appeared able to respond to early
in providing care for signs and to identify potential sources of
PwD support.
2. Confidence and
difficulty were

EVRIPIDOU
assessed using a
10-point scale

ET AL.
EVRIPIDOU ET AL.
indicated a more hopeful attitude,17 compared to nursing assistants
(p = .02), or nurses over the age of 50 (p = .01) and less than 10 years
of experience (p = .02).29 Moreover, nurses over the age of 50, who
indicated less hopeful attitudes provided less person-centered care
(p < .01). In contrast, nurses under the age of 40 indicated more hopeful
attitudes, resulting in providing more person-centered care for PwD.
Although person-centered care is promoted as the golden standard
in providing quality care and promoting patient satisfaction, in this
context it appeared to be provided only when it is the most obvious
choice.27
4.1.4 Interventional studies to increase nurses’
knowledge and attitudes toward dementia care
Training programs were found to significantly enhance nurse's knowl-
edge and confidence in the provision of dementia care.30,32,36–38,41
Positive attitude changes were reported by nurses, as they perceived
that educational programs advanced their knowledge about dementia
care.41 Training programs included presentation, videos, activities,
printed handouts and observation of clinical experiences, meeting,
and workshops. Interventional studies found that nurses’ attitudes
and practices showed improvement and positive attitudinal changes
were adopted.32,36,38 Those studies indicated significant differences in
attitudes prior the training program (M = 4.21, SD = 0.29;38 M = 20.28,
SD = 6.6726) and 4 months (M = 4, 57, SD = 0, 21, p < .00138) o r 6
months (M = 28.83, SD = 5.34, F(1, 61) = 5.07, p < .0526) after the
intervention. Additionally, nurses felt increased satisfaction in caring
for PwD38 because their role as nurses was informed and enriched—
increasing their ability to realize the full value of patient interaction.39
Furthermore, after program implementation, attendees reported
gains in knowledge regarding the recognition, assessment, and com-
munication with PwD (83%, n = 540).30 Participants also considered
those gains to increase their contribution in improving the hospital
environment, patient safety, and behavioral management.30 Among
experienced nurses, knowledge and attitudes scores, as well as the
impact of training were lower30 than with younger nurses, although
they both were found to respond to early signs of dementia and to
identify potential sources of support.25 However, the effectiveness
of training programs did not extend to substantially reducing nurses’
burnout or levels of challenging patient behavior.26
5 DIS C USSIO N
5.1 Nurses’ Knowledge and attitudes
The review showed that knowledge about dementia care is limited in
relation to management, recognition, and communication strategies,
and attitudes toward PwD have been found to be somewhat negative
among nurses. This could possibly be attributed to a lack of under-
standing of person-centered care, an issue which is commonly identi-
fied in studies of dementia care. Person-centered care is “an approach
that instead of treating a person as a collection of symptoms and
behaviors to be controlled, considers the whole person, taking into
account each individual's unique qualities, abilities, interests, prefer-
57
3
ences and needs”2(p22). It has been found to be an integral part of
care,49 particularly with PwD, who may not be able to verbalize their
needs effectively and are more dependent and vulnerable than many
other patients. For instance, Fessey27 in her study found that nurses do
not choose person-centered care when a patient asks for a cup of tea,
but they do select person-centered approach if the patient is not will-
ing to take a shower. These facts indicate that nurses choose person-
centered approaches depending on the situation and that nurses do
not endorse this approach for all care needs.
One interesting finding of this review is that nurses working in com-
munity mental health or trained in dementia care were found to have
more favorable attitudes, while acute care nurses reported less hope-
ful attitudes and less awareness of person-centered care.17,25,29 This
could be attributed to the fact that nurses with less hopeful attitudes
do not have high expectations for PwD,29 thus they may not enhance
person-centered care for them, as they do not anticipate any response.
Hope is a unidimensional construct containing a comprehensive
insight that target can be achieved.50 Snyder et al.,50 found that higher
hopeful attitude leads to higher probability of goal fulfillment and pos-
itive attitudes. In contrast, a lower hopeful attitude is correlated with
low possibility of achievement, a focus of failure rather than success
and nonfavorable attitudes. Also, hope has been correlated with exter-
nal help and caring.51 Community mental health nurses were also more
confident in their abilities to recognize and provide advice on behav-
ioral and psychological problems, information, coordination, disclosure
of the diagnosis, and support services to PwD.17,25,29 This fact could be
attributed to the content of education of mental health nurses and the
emphasis given on dementia and the problems of the disease, as well
as the experience of mental health nurses who come in close contact
with PwD. Findings of this review suggest that a higher level of knowl-
edge is correlated with higher confidence level and positive attitudes.
In addition, low levels of confidence may be associated with low levels
of knowledge, as nurses having gaps in knowledge may not feel appro-
priately prepared to confront all possible complications in PwD.
Overall, nurses’ knowledge and attitudes constitute one factor that
might impact dementia patient's care. There are many other factors
as well, such as staffing adequacy, nurse manager ability and leader-
ship, work environment,52 nurses carrying out nonnursing activities
(Ausserhofer et al.),53 or nurses’ attitudes on elderly people in general
(Halvorsen et al.),54 despite the presence or absence of dementia.
5.2 Factors influencing dementia care and training
impact
Nurses’ conceptions of their role within the context of dementia may
additionally affect their attitudes. Additionally, education, age, level
of communication skills, ethical dilemmas, and psychological factors in
the provision of care (such as fear or frustration) have been identified
as potential influences on nurses’ attitudes toward PwD.27,29,35,37
Based on the results of this review, intervention studies have been
found to be effective, considering the advancement of knowledge
regarding dementia care and the positive change on nurses’ attitudes.
Nurses’ roles were defined and enriched by interventions,39 and their
attitudes experienced positive changes. Nurses’ level of knowledge
58
2 EVRIPIDOU ET AL.

was raised, as they were enabled to respond to behavioral changes development and refinement of an existing one, which could be used
and identify early stages of dementia and potential sources of sup- by most researchers to maintain the validity and consistency of results.
port, after the implementation of the program. 25 Additionally, nurses Although the focus of this review was to explore the level of knowledge
realized the importance of their interactions with patients and demon- and attitudes of nurses toward dementia care, the findings are raising
strated interest in learning about dementia.34 The use of verbal or non- concerns as to the quality of care this vulnerable group of people is
verbal communications skills could potentially facilitate better under- receiving, as PwD cannot express their needs verbally and are not able
standing of patients’ needs and help nurses to apply a more individual- not demand for better care.30
ized care and ultimately to deliver improved dementia care. Also, train-
ing programs were found to make nurses’ attitudes more positive and 5.4 Limitations
increased nurses’ satisfaction with regard to caring for older PwD.
The studies included in this review were published in English only;
Reported attitudes among nurses were also found to change after
studies in other languages or from varying contextual backgrounds
the implementation of educational interventions.26,30,36–38 Training
might confirm or contradict their findings. Furthermore, nurse's per-
in dementia care is essential for nurses in order to deliver quality
ceptions in countries where surveys have yet not been conducted may
care and ranges from basic awareness training to more comprehen-
vary from those seen in our selected studies. Moreover, the variety of
sive programs. 55 An important problem related to nurses’ knowledge
tools used for collecting the data and the heterogeneity of outcome
and attitudes, and a reason that makes caring for PwD unpopular is
measures might influence the results. The focus of the studies was on
problematic patient behavior and the difficulties in dealing with prob-
nurses’ self-assessment of their own attitudes, so more objective mea-
lems associated with this. Therefore training needs to focus on behav-
sures could possibly have different findings. Through this review, it is
ior management, as well as communication issues, since there is a ten-
not revealed that low level of knowledge and nonfavorable attitudes of
dency among nurses to avoid patients with dementia that could be very
nurses’ can impact dementia care outcomes. The findings of this review
significantly reduced after implementation of training. However, the
must be interpreted in the light of these limitations.
value of some intervention studies needs to be considered with cau-
tion, since the findings apply to single studies that cannot be general-
ized. More research is needed in multiple studies to confirm the sig-
6 CONCLUSION
nificance of educational programs and how they change attitudes or
improve knowledge.
The aim of the study was to explore nurses’ attitudes and the level
PwD should not be overlooked during hospitalization as they are
of knowledge regarding the care of PwD and it was found that
vulnerable not only to physical problems such us urinary tract or chest
nurses are lacking knowledge and their attitudes are not favorable
infections, delirium, electrolyte disorder, and pressure ulcers,56 but toward dementia care. Given the fact that the population ages, and so
also to psychological, social, and spiritual problems. The low level of the prevalence of age-related problems such as dementia increases,
knowledge and the unfavorable attitudes related to the care of PwD
the need for hospital care for these patients will continue to be
among nurses may result in patients not being properly assessed for
considerable. 60 Nurses’ low level of knowledge and nonfavorable atti-
falls and to extended hospital stays. Furthermore, they are at greater
tudes may have a negative impact on care, patient safety, symptom
risk of mortality5; therefore, nurses need to be enabled to engage in management, and many other issues associated with PwD. However,
guided and evidence-based practices with a view to correcting this. the aforementioned studies have not investigated possible relations
These negative outcomes can be avoided if nurses are exposed to com-
of lack of knowledge and negative attitudes with patient outcomes
munication skills as a part of their nursing training. Moreover, their
and this is a challenge for future research. Nurses need to be able
overall confidence level will be raised as well, considering that effective
to respond to patients’ multidimensional needs and be aware of new
communication among nurses and patients has been noted as essential
approaches to care and management in the provision of dementia
for effective treatment.57 PwD constitute a large proportion of a hos-
care. The need for training of healthcare workers on the care of PwD
pital's population58,59; hence, the need for training is significant as if
has been described as a crucial element of the Global Action Plan on
training is implemented at an early stage of nursing education, nurses
the public health response to dementia 2017–2025 published by the
may be able to apply this advanced knowledge to later stages, including
World Health Organization. Therefore, all efforts to strengthen nurs-
routine dementia care.
ing education on how to cope with a major healthcare problem of the
near future seems to be of utmost importance.
5.3 Methodological concerns
CONFLICT OF INTEREST
A variety of assessment tools were used for data collection and this
The authors report no actual or potential conflicts of interest.. This
fact reveals that a primary tool for evaluation of knowledge or atti-
research received no specific grant from any funding agency in the pub-
tudes among nurses has yet to be decided on. This suggests that the
lic, commercial, or not-for-profit sectors.
results of the surveys might not be consistent as a range of tools were
used in investigating the same variables. The lack of a single, reliable
tool for assessment of knowledge and attitudes is problematic, and ORCID
this review emphasized the need for the creation of such a tool or a Melina Evripidou RN PhD(c) http://orcid.org/0000-0003-2511-4103
EVRIPIDOU ET AL.
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How to cite this article: Evripidou M, Charalambous A, Middle-
ton N, Papastavrou E. Nurses’ knowledge and attitudes about
dementia care: Systematic literature review. Perspect Psychiatr
Care. 2019;55:48–60.
2018;1–13. https://doi.org/10.1111/ppc.12291
https://doi.org/10.1111/ppc.12291