Investigation of Differences in First Year Nursing Students Comprehension,
Application and Critical Thinking Skills when Caring for Individuals with
Alzheimer ’s Disease and Other Dementias
Prepared for
Health Association Nova Scotia
2 Dartmouth Rd.,
Bedford, Nova Scotia
B4A 2K7
Prepared by
Shelley Cobbett, Adele LeBlanc, Sandra Redmond, Lisa Doucet,
Nancy Edgecombe, and Heather Helpard.
Dalhousie University School of Nursing
Halifax and Yarmouth Sites,
Nova Scotia
1
Investigation of Differences in First Year Nursing Students Comprehension,
Application and Critical Thinking Skills when Caring for Individuals with
Alzheimer ’s Disease and Other Dementias
Background
The number of Canadians living with cognitive impairment including dementia is
747,000 and anticipated to reach 1.4 million persons by 2031 (Alzheimer’s Society of
Canada, 2012). Along with this demographic shift, it important to recognize that
educational opportunities for nurses to gain knowledge about Alzheimer’s disease and
other dementias are variable and sporadic (Page, 2013). Lacking adequate understanding,
nurses are at risk to follow misconceptions, assumptions, and discriminatory attitudes that
lead to inadequate caregiver practices, foster social isolation, and discourage
independence (Veselinova, 2013).
Purpose
The purpose of this quasi-experimental research design is to investigate if there
are differences in comprehension, application and critical thinking skills among first year
nursing students that have taken the Alzheimer Disease and other Associated Dementias
Care Course (ADODCC) and those that have not taken the ADODCC.
Research Design
A non-equivalent control group design tested the research hypothesis among first
year nursing students (N=196) at two geographically separated campuses’ of Dalhousie
University School of Nursing. Students were in two groups: Group 1, the control group,
enrolled in the required course in the nursing curriculum (Nursing 1030: Human
Development and Health I: Adults and Health Aging) and Group 2, the experimental
group, took the ADODCC simultaneously with Nursing 1030. Both groups received preand post- tests related to comprehension, application and critical thinking skills
associated with providing care to individuals who have Alzheimer’s disease and/or other
dementias. Demographic data was collected to describe the level of dispersion in the data
between the two groups using measures of variability. Paired sample t-tests were used to
test the relationship between the pre-test and post-test scores within each group; a split
plot ANOVA was used as a test of ‘within subjects’ effects. Qualitative data was
collected from the ADODCC participants related to their experiences taking the course
and their perceptions of the theory and/or application of information that they have
acquired. Student data was collected after each module and at the end of all of the
2
modules as a final evaluation of the entire course. Qualitative data was collected from the
facilitators in relation to resources utilized to implement the ADODCC course integrated
within the required nursing course and their perception of the strengths, areas for
improvement and other comments directly related to the course and its facilitation in an
online environment.
Hypothesis: There is a difference in first year nursing students’ comprehension,
application and critical thinking skills related to the theory and application of nursing
care for those clients with Alzheimer’s disease and other dementias that take Dalhousie’s
School of Nursing required course (Nursing 1030) as compared to those students that
take the ADODCC while simultaneously taking Nursing 1030.
Findings and Discussion
Quantitative Data Analysis and Results
Sample: The initial sample consisted of 197 first year nursing students with an
age range of 18 to 50 (mean: 21.59; s.d. 4.89). There were 179 female students and 16
male students, with one participant not selecting a gender category. In relation to
previous education, 142 participants had a previous university degree, 88 had previous
post secondary education, 20 participants indicated that they had previously taken either a
workshop or an education session related to dementia, and two participants indicated that
they had previously taken the ADODCC course. Seventy-two participants indicated that
they have a family member or loved one with Alzheimer’s disease or dementia while 44
participants indicated that they had previously provided care to someone with
Alzheimer’s disease or dementia. In order to have a complete data set, participants
needed to complete both the pretest and the post test (see Appendix A); final sample size
was 23 for the experimental group and 106 for the control group.
Control Group Demographics: Five male and 101 females (N=106) comprised
the control group with an age range of 18 to 50 (mean: 21.48; s.d. 5.27). Twenty-five
participants have a previous university degree and 43 indicated that they had previous
post secondary education. One participant indicated that they had previously taken the
ADODCC with an additional seven participants indicating that they had taken either a
workshop or an education session related to dementia. Forty-one participants have a
family member or loved one with dementia and 25 participants indicated that they had
provided care to someone with Alzheimer’s disease or dementia.
Experimental Group Demographics: Two male and 21 (N=23) females
comprised the control group with an age range of 18 to 45 (mean: 20.22; s.d. 5.56). Two
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participants have a previous university degree and eight indicated that they had previous
post secondary education. Two participants have previously taken the ADODCC with an
additional three participants indicating that they had taken either a workshop or an
education session related to dementia. Seven participants have a family member or loved
one with dementia and six participants indicated that they had provided care to someone
with Alzheimer’s disease or dementia.
Pre- and Post- test Results: Pre- and post- test data are normally distributed in
the control group as well as the post-test results in the experimental group. The pretest
data in the experimental group has the mode to the right of the mean. Data distribution
can be seen in the plots in Table 1.
Table 1: Pre- and Post- Test Data Distribution
25
25
20
15
Count
Count
20
15
10
10
5
2.00
5
4.00
6.00
8.00
2.00
Control Group Pre Te st Score
8.00
8
6
Count
6
Count
6.00
Control Group Postte st Score
8
4
4
2
2
4.00
4.00
5.00
6.00
Expe rim e ntal Group Pre-Tes t Score
7.00
6.00
7.00
8.00
9.00
Expe rim e ntal Group Post Test Score
4
Results of the pre- and post- tests for the experimental and the control group are
displayed in Table 2. The ranges, means and standard deviations differed for both groups
among both tests.
Group
N
Control group Pretest
Control group Post test
106
106
Mark Range (% out
of 100)
20% - 90%
20% - 90%
Experimental group
23
40% - 70%
Pretest
Experimental group Post 23
50% - 100%
test
Table 2: Pre- and Post- Test Descriptive Results
Mean
(%)
54.06
58.68
Standard
deviation
15.96
13.81
49.13
9.00
73.91
13.71
There were no statistically significant differences in the pretest scores between the
control and the experimental groups (f = .780, p=.598). Both groups demonstrated
statistically significant differences in the pretest as compared to the post-test; however,
the experimental group differences were much larger and more highly significant. The
control group paired sample t-test result was t(105) = -2.636, p=.01 whereas the
experimental group paired t-test results was t(22) = -7.605, p<.0001. To test within
subject effects, a split plot ANOVA was conducted and resulted in an f-value of 24.628,
d.f. 127, p<.001 at an alpha of 0.05. The plot in Diagram 1 visually depicts the
differences in pre- and post- test scores for the two groups.
Diagram 1:
Estimated Marginal Means of
MEASURE_1
Estimated Marginal
Means
7.50
Group
7.00
Experimental
Grp
6.50
Control Grp
6.00
5.50
5.00
4.50
1
2
Pre_Post_Scores
5
Data analysis supports rejection of the null hypothesis that there is no difference
in first year nursing students’ comprehension, application and critical thinking skills
related to the theory and application of nursing care for those clients with Alzheimer’s
disease and other dementias that take Dalhousie’s School of Nursing required course
(Nursing 1030) as compared to those students that take the ADODCC while
simultaneously taking Nursing 1030. Analysis of the results indicates that while all
students enrolled in the required nursing course (Nursing 1030) had higher
comprehension, application and critical thinking skills in relation to the theory and
application of nursing care for those clients with Alzheimer’s disease and other
dementias, there was a statistically significant difference in these abilities in the students
in the experimental group (that had taken the ADODCC in addition to the content in
Nursing 1030) as compared to the control group.
Qualitative Data Analysis and Discussion
Student Perception of Learning:
Qualitative data from both the module specific and final course evaluations,
indicated that this course consistently met students expectations. The qualitative data
supported the quantitative data. All students indicated that the course met their
expectations, with all students rating the course as good (eight students) or excellent (15
students). Please see Appendix B for further details.
Students consistently commented that participation in the course significantly
improved their knowledge and skills. They expressed a greater appreciation for the depth
of knowledge required to provide quality care for clients with dementia. One student
stated, “It’s not for the faint of heart.” Students commented that this was new information
and could see its applicability to a wide variety of practice areas: “All my new learning I
will bring them with me wherever I go.” Even students who had previously worked with
clients with Alzheimer’s disease commented that the course challenged them. “It made
me rethink dementia care.”
Core curriculum concepts associated with the BScN curriculum, such as patient
safety, therapeutic communication, person-centered care, critical thinking, reflective
practice were described in the students’ evaluation narratives. Students commented that
the course content was relevant to their practice and the content was clearly presented and
well organized. These qualitative findings were also supported in the quantitative data
with sixteen students (70%) indicating on their final evaluation that all the content
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presented was easy to understand and the remaining 30% noted that most of the content
was understandable.
In addition to critical cognitive domain learning, affective learning was also
evident in the students’ evaluations. There was a valuing of compassion, ethical practice
and empathy: “One thing that stood out… persons with dementia do not lose their ability
to feel emotions, so be mindful of that…” and “Enabling freedom and restoring dignity
by the simplest things that I would have never thought of before”. There was a greater
appreciation of the meaning behind the behavior and students recognized that how
caregivers understood client behaviours greatly impacted on the quality of care received.
Positive changes in the affective domain of learning can often be challenging to obtain
when content is delivered online.
Course Design and Modes of Learning
The first eight modules of the ADODCC, were taught as part of a core first year
winter term nursing course. Students were given one hour of scheduled course time
towards completion of the modules for 8 consecutive weeks and were expected to
complete at least two hours of additional work on each module outside of class time. In
order to receive a mark for the Dalhousie course, students who had not previously taken
ADODCC were required to register for the course and received a course manual.
In regards to the hard copy participant manual, all students indicated its considerable
value to their learning –“Everything in the participant manual was clear and very easy to
understand. It was interesting to read and comprehendible.” Students particularly noted
the value of the case studies and relevant clinical examples.
In addition to weekly module readings from the ADODCC course manual,
students were expected to complete module specific online learning activities; at least one
of these weekly activities were submitted to the course facilitators for review. Several
students commented that they were confused at times about which online activities were
requirements (BbLearn). Students noted technical challenges that impacted on their
ability to meet course expectations (quiz function and uploading online journals). Overall
narratives emphasized the value students placed on the online learning activities. Both
tabular feedback and written feedback highlighted the importance of providing a diversity
of learning experiences (videos, demonstrations, guest speakers, case studies/scenarios,
reflective exercises, discussion board posting, journal sharing and self-assessments).
When asked how to improve the course, the most frequent suggestion was to increase the
number of videos, demonstrations and real life case examples.
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One student was in the unique position that she had taken the course in the faceto-face methodology and also in the online version. This student’s feedback as part of
one of the earlier module feedback indicated a preference for the face-to-face approach.
“As I have taken this course in another format, I feel that an issue as relevant as this one
should be presented in a classroom format. A lot of the content and important discussion
is lost in this manner [online]”. However, in the final evaluation only two students
specifically noted that they would have appreciated the course being taught in a
classroom setting.
The final module of the course involved working in small groups to complete a
clinical project and the presentation of this project to their peers. This part of the course
occurred during the students’ five week spring intersession course (May to June).
Although it is possible through the use of online tools (e.g. BbCollaborate) to have
students present online, for the pilot project, students presented within a classroom
setting. Students overwhelmingly found the final project to be valuable, with 22 students
indicating it enhanced their learning. Students conceptualized the project as a “capstone”
experience helping to consolidate learning and demonstrate ongoing application of the
content taught beyond the course. Remarks included: “It really helped pull everything
together…”; “…it was a summary of what we learned and how we can put our
knowledge to good use.” There was recognition of the value of group work to produce
the project, as well as presenting the work to their peers. Comments concerning the final
project indicated there was a sense of pride and ownership of their new knowledge – “It
gave an opportunity to show what we know”; “It allowed me to share with my classmates what I learned.”
In addition, student comments related to the presentation reaffirmed their
commitment to embraced and promote quality, client-centred care and family care for
those with dementia, regardless of their future practice setting. The following comment
demonstrated this valuing of using creative approaches and focusing on health
promoting/strength based caring with this population – “Our final project definitely
helped my understanding and how to improve their health and well-being. It helped
because you have to think outside of the box…”
In regards to improving their experience, several students noted that they would
have liked to have less evaluation components. It is unclear if they mean content
evaluation or program evaluation. Because this was a pilot project, there were numerous
program evaluations throughout the course, including feedback after completion of each
of the eight modules and overall feedback at the completion of the course as well as a
narrative reflections required as part of the spring intersession course, in which the final
project presentation was embedded. Course content evaluations (quizzes, reflections,
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case studies) were part of each of the modules of the program. Students were required to
complete these activities to demonstrate understanding or application of course content.
As this program was integrated into pre-existing BScN courses, it was important that
course professors were able to justify marks being given for ADODCC participation.
Implications for Future Practice
In their final evaluation of the program, students identified the content areas they
hypothesized would be most significant for their future nursing practice. Many responded
that all topics presented would be important. Many students were unable to pinpoint a
specific topic and listed multiple areas of priority. The most commonly identified were
patient safety, promoting independence, care planning/co-ordination, therapeutic
communication, promoting a therapeutic environment, understanding and effective
behavioral and emotional management and family caregiving. These concepts are
consistent with those introduced and reinforced in the Dalhousie University Bachelor of
Science in Nursing curriculum across care areas.
Overall Student Comments and Suggestions
In addition to specific suggestions concerning course content and delivery, a
number of students had overall suggestions. For example, one student suggested this
program should be a separate course while another student took this idea further,
recommending that all nursing students within the province should have access to the
course.
The student comments overwhelmingly illustrated significant support for the
incorporation of the Alzheimer’s and Other Dementias Care Course as part of nursing
education, as well as the delivery methods used in this pilot. Students indicated that
learning from the program occurred both in the cognitive and affective learning domains.
The respondents viewed the course positively, with minimal suggestions for
improvement. One student comment captured well those of many of their peers “Well
done; very enjoyable and meaningful experience. Looking forward to using all newly
acquired knowledge in the future.”
Faculty Feedback
As part of the pilot evaluation, feedback was obtained from the two Dalhousie
Yarmouth-based nursing faculty members who constructed the BbLearn Site that served
as the online learning platform of the ADODCC and facilitated the course activities and
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academic evaluation components. Both individuals had completed the ADODCC
training and the associated facilitator course.
In order to estimate the resources required for course development and ongoing
student support and monitoring, the facilitators were requested to keep an activity log.
The majority of faculty time involved online course development, with 52 hours being
devoted to the BbLearn site development and to securing learning resources. The faculty
members were clear that their responsibility was to deliver the ADODCC as developed;
however, at times, reference materials (e.g. videos) referred to in the manual were not
available in a format that could be used online. Significant time was needed to find,
evaluate and in some cases obtain copyright permission for already developed learning
materials. For example, permission was obtained from SCIE to link to their e-learning
materials and the Alzheimer Society Ontario was contacted about the students completing
their e-modules. Time was also invested in incorporating online tools that facilitated
interactivity with the content and other students.
Once the online learning platform that complimented the course manual was
developed, the facilitators dedicated twelve (12) hours in total to support the twenty-three
participants to complete the first eight modules of the course. This time was divided
between reviewing the required submitted learning activity to gauge whether or not the
submission was “satisfactory” or “unsatisfactory” and to trouble shoot technical problems
and address student questions related to course content or processes. Considerably more
time would have been needed if individual student submissions were graded. As part of
the pilot, if students submitted a satisfactory completed activity by the deadline, they
were given the associated points.
Course facilitators identified the following strengths of the online ADDODC
pilot: asynchronous online delivery that required minimal instructor resourcing to
manage the course after the initial set up, the ability to use learning activities outlined in
the already developed course manual as a foundation for online activities, the
purposefully and thoughtfully balancing of interactive exercises and individual reflective
activities to address affective and cognitive learning and support various learning style
preferences, and the face-to-face presentation of final projects that increased
accountability for a high quality product and allowed students to highlight their
achievement with their peers. Facilitators also identified areas for improvement. These
suggestions included: the simplifying and/or streamlining of technology (e.g. successive
release dates for activities within each module), increasing the clarity of module
expectations in terms of required elements or activities, and to consider the possibility to
use asynchronous on-line sharing for the final project so that the entire ADODCC could
be delivered as part of N1030.
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Conclusion
The findings from this study supports that the addition of ADODCC as part of the
Dalhousie BScN first year curriculum can positively impact the attitude, knowledge and
skills of future registered nurses when caring for individuals and their families who are
experiencing cognitive impairment related to Alzheimer’s Disease and related disorders.
In regards to the pre- and post- tests, student in both the control and experimental groups
had higher comprehension, application and critical thinking skills in relation to care of
clients with dementias at post-test. However, there was statistically significant difference
in these abilities in students in the experiential group (that had taken ADODCC in
addition to the content in Nursing 1030).
Both quantitative and qualitative data from module specific and final course
feedback, supported the conclusion that students perceived the ADODCC course as
relevant, well organized and clearly presented. The students highly valued the interactive
nature of the online learning requirements, particular those activities which had direct
application to their future clinical practice (ex. care planning, assisting families through
transition, nutritional interventions, leisure activity promotion, co-construction of
therapeutic conversations). The asynchronous on-line delivery of the first eight course
modules was well received.
From a human resource perspective, the translation of in-class activities to an
online format did take creativity and an initial time commitment. However, once the
BbLearn website was developed, course facilitation workload was manageable,
particularly when submitted activities were monitored for the obtainment of an
acceptable standard (satisfactory vs. unsatisfactory) rather than graded.
Based on the research findings, a recommendation has been proposed to
incorporate ADODCC into a first year nursing course of the Dalhousie BScN Program.
Additional recommendations include: ADODCC be considered for other schools within
the Faculty of Health Professions and the Faculty of Medicine; additional faculty take
ADODCC and the facilitator’s course; and, the inclusion of the ADODCC course fee as
part of student university fees. Externally, it is recommended that HANS explore the
inclusion of this course into all nursing programs in Nova Scotia; create an electronic
manual rather than a hard copy to ensure currency and regular updates less than 5 years
apart; and, provincially promote an online delivery option to promote dialogue between
learners at different sites across the province.
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References
Alzheimer’s Society of Canada (2012). A new way of looking at the impact of dementia
in Canada. Retrieved from http://www.alzheimer.ca/en/niagara/Get-involved/Raise-yourvoice/A-new-way-of-looking-at-dementia
Page, S. S., & Hope, K. K. (2013). Towards new ways of working in dementia:
Perceptions of specialist dementia care nurses about their own level of knowledge,
competence and unmet educational needs. Journal of Psychiatric & Mental Health
Nursing, 20(6), 549-556. doi:10.1111/jpm.12029
Veselinova, C. (2013). Dementia awareness: Providing person-centred care. Nursing &
Residential Care, 15(9), 622-626.
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Appendix A: Not available until Phase II of the Research Project is completed
Appendix B: Alzheimer’s Disease and Other Dementias Care Course Participant
Evaluation
Participant Final Course Evaluation
1. Did the course improve your knowledge and skills?
No
0
To some extent
1
Yes
7
2. Did you find this course met your expectations?
Not at all
Somewhat
0
0
To a great extent
15
Yes
23
3. Did you find the content easy to understand?
Not at all
Some
Most
0
0
7
All
16
4. Did you find the Participant Manual Easy to Use?
Not at all
Some
Most
0
0
5
All
18
5. Please complete the following table:
Useful
Videos
22
Role plays
10
Demonstrations
15
Guest Speakers
22
Case
23
studies/Scenarios
Reflective Exercise
21
Participation Self
22*
Assessment
Other: (too many
evaluations/quizzes)
Not useful
0
4
2
1
0
Not used
1
19
6
0
0
1
1
2*
1
* One student answered both Useful and Not used for this question
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6. Did the opportunity to do a Final Project give you the opportunity to demonstrate
what you had learned from the course?
Not really
Somewhat
Yes
0
1
22
9. Overall, how would you rate this course?
Poor
0
Fair
0
Good
8
Excellent
15
Participant Session (Module) Evaluation
1. The material in this session was presented clearly.
Module
1
2
3
4
5
6
7
8
Strongly
agree
64%
56.52%
77.27%
60.87%
63.64%
50%
47.83%
54.55%
Agree
Disagree
36%
43.48%
22.73%
39.13%
36.36%
41.67%
47.83%
40.91%
0
0
0
0
0
0
0
0
Strongly
disagree
0
0
0
0
0
4.17%
4.35%
4.55%
Unanswered
0
0
0
0
0
4.17%
0
0
2. The exercises and activities helped me to understand the material presented.
Module
1
2
3
4
5
6
7
8
Strongly
agree
56%
43.48%
59.09%
69.57%
63.64%
50%
47.83%
50%
Agree
Disagree
40%
56.52%
40.91%
30.44%
36.36%
45.83%
47.83%
45.46%
4%
0
0
0
0
0
2
0
Strongly
disagree
0
0
0
0
0
4.17%
4.35%
4.55%
Unanswered
0
0
0
0
0
0
0
0
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