https://orcid.org/0000-0003-1913-3295
Figures
Abstract
Background
There is considerable evidence indicating that nursing students demonstrate inadequate knowledge and negative attitudes toward working with older adults. This suggests nursing student’s unpreparedness to provide care for the expanding older adult population. Feelings of unpreparedness can negatively impact their motivation and confidence. However, limited evidence exists about how nursing students’ knowledge and attitudes influence their self-efficacy in caring for older adults. Knowing this can help to identify gaps and opportunities to facilitate nursing students’ confidence in caring for older adults in acute care settings.
Aim
To examine nursing students’ knowledge, attitudes, and self-efficacy and how these variables impact nursing student self-efficacy in caring for older adults in acute care settings in Ghana.
Methods
We employed explanatory sequential mixed method approach. In Phase I, we used a cross-sectional design and collected quantitative data about students’ knowledge, attitudes, and self-efficacy. Data were collected from 170 second and third-year nursing students between December 2019--March 2020. We analyzed the data using descriptive and multiple-variable linear regression. Survey results informed the selection of students for Phase II based on their scores. In Phase II, 17 nursing students were purposively selected for semi-structured interviews between November and December 2020. Interviews were transcribed and analyzed using thematic analysis. Both results were integrated and presented.
Results
Students’ mean age was 21 years (SD = 3.73). Just over half were female (54%). The majority had lived with/were currently living with older adults (83.0%). Many had low knowledge scores (71%) and a majority had positive attitudes (91%) and high self-efficacy scores (97%). Nursing students’ ages and attitudes were significantly positively associated with their self-efficacy. There was no significant association between students’ gerontology knowledge and self-efficacy. Qualitative findings showed that low knowledge scores were due to limited attention to gerontology education in the curriculum and heavy course load. Sociocultural norms in caring for older adults influenced students’ positive attitudes. This facilitated students’ interactions with older adults and increased their confidence. Higher self-efficacy scores were associated with the impact of the general nursing program, students’ perceived familiarity with the needs of older adults and routine procedural knowledge. Younger students perceived that their age and competencies were questioned by older adults, impacting their self-efficacy. Both datasets converged at integration.
Citation: Abudu-Birresborn D, Puts M, McCleary L, Chu CH, Yakong V, Cranley L (2025) An explanatory sequential mixed method study of nursing students’ self-efficacy in caring for older adults in Ghana. PLoS One 20(12): e0334404. https://doi.org/10.1371/journal.pone.0334404
Editor: Vasuki Rajaguru, Yonsei University Medical Center: Yonsei University Health System, KOREA, REPUBLIC OF
Received: March 8, 2024; Accepted: September 28, 2025; Published: December 2, 2025
Copyright: © 2025 Abudu-Birresborn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: There are ethical and legal restrictions which prevent the public sharing of data for this study. Study participants did not consent to public sharing of data for this study. Furthermore, the Research Ethics Board in accordance with the Tri-Council statement in Canada has not given permission to share participant data. Also, due to the nature of the data sets for the mixed method study, where we aligned participants data from phase one to phase two, the authors are unable to further de-identify participant data to share publicly. Thus, as per Research Ethics Board regulations, the authors are unable to publicly share participant data. Data are available upon request from the University of Toronto’s Human Research and Ethics Oversight and Compliance Office via email (ethics.review@utoronto.ca) or telephone (+1 416-946-3273), and from the Ghana Health Service Ethics Review Committee via email (ethics.research@ghs.gov.gh), for researchers who meet the criteria for access to confidential data.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interest exist.
Introduction
Researchers have explored nursing students’ knowledge, attitudes, and motivations for working with persons 60 years and above to understand and identify ways to improve students’ interest in caring for older adults [1,2]. However, students continue to rank gerontology as one of the lowest career choices of interest for practice or specialty [1,3–7]. Difficulty communicating with older adult patients, heavy workload, and inadequate knowledge about caring for older adults are among the main reasons nursing students do not prefer gerontological nursing as a career path [3,5,8–10]. Due to the growing ageing population and age-related changes in physical, functional, and cognitive health needs, older adults are increasingly seeking healthcare services [11–13]. Because of the lack of long-term care or senior nursing home facilities in Ghana, older adults seek healthcare services in acute care settings as the general population [12,14]. General nurses and midwives provide nursing care in these acute care facilities in Ghana with no specialized gerontology training and are expected to provide competent and quality care to older adult patients. The acute care setting has patients with complex health problems across the lifespan. The concerns and needs of ‘at risk’ patients such as older adults may not be optimally addressed [15].
Nursing education provides nursing students with cognitive and psychomotor skills development, enhancing their theoretical and experiential knowledge acquisition [16]. This is expected to help develop nursing students’ competencies and self-confidence for future practice. Findings of a scoping review [6] about nursing students’ preparedness to care for older adults in lower- and middle-income countries (LMICs) showed that nursing students may perceive themselves as inadequately prepared. Feeling unprepared to care for older adults can negatively impact nursing students’ motivation and self-belief or confidence to care for older adults [17].
Bandura’s self-efficacy theory guided this study. The theory suggests that a person’s perception of their self-efficacy- of how competent they are likely to be in a given task, influences their choices, commitment, and efficiency in their interactions with others and the task [18]. Self-efficacy is task specific, and persons with high sense of self-efficacy will pursue and continue with a task irrespective of how challenging that task is. They persist in being effective in their interactions and become successful in the task [18,19]. Persons with low self-efficacy will avoid a task they were not able to complete in the past and may not pursue it further [19]. Nursing students with low self-efficacy in caring for older adults will not commit to working with them. They may avoid or delay interventions resulting in serious negative outcomes [20,21]. Bandura recommended four ways to enhance and improve self-efficacy: guided mastery, vicarious learning, social persuasion, and self-regulation. These self-efficacy factors are congruent to teaching and learning gerontological nursing and may enhance students’ self-belief and interest in caring for older adults.
There is abundant literature on nursing students’ self-efficacy in areas such as cultural competency [22,23], learning motivations and academic performance [24,25], the impact of simulation practice [16,26–28], the impact of preceptorship and clinical instructor [29–31] and communication and urinary catheterization [32,33]. However, there is limited evidence about nursing students perceived self-efficacy in caring for older adults. Specifically, the association between students’ knowledge and attitudes on their self-efficacy to care for older adults is unknown in LMICs. This paper reports findings from a mixed-method study undertaken as doctoral research with the following questions: What are nursing students’ perceptions of their gerontology content knowledge levels in acute care settings in Ghana? What are students’ attitudes toward older adults in Ghana? And what are students’ understanding of their self-efficacy in caring for older adults? [34]. Understanding nursing students’ perceptions about their gerontology content knowledge, attitudes, and self-efficacy may help to recognize and identify opportunities, strategies, and gaps in gerontological nursing education and practice that can inform the development of interventions to advance gerontological nursing practice in Ghana.
Materials and methods
Study design
An explanatory sequential mixed method design was employed [35].
Quantitative survey data were first collected and analyzed, followed by the collection and analysis of qualitative interview data. The data were integrated and interpreted [35,36]. In the quantitative phase (Phase I), a cross-sectional design was used for data collection to examine nursing students’ content knowledge, attitudes toward older adults and their self-efficacy in caring for them. The findings informed the refinement of the interview guide and selection of participants for the qualitative data generation (Phase II). Phase II explored how nursing students’ content knowledge and attitudes influenced their understanding of their self-efficacy in caring for older adults. The findings were jointly tabulated and presented to explain the quantitative results and identify convergence or divergence for a broader understanding of nursing students’ self-efficacy in caring for older adults in Ghana. Fig 1 presents the study design.
Study sampling
Quantitative (Phase I).
A two-stage sampling method was employed. The first stage involved the site recruitment of participating institutions. The two broad northern and southern geographic sectors of Ghana were used as a guide for site recruitment. The inclusion criteria for site recruitment were:
- 1) A public Nurses’ and Midwives’ Training College (NMTC) offering the three-year Diploma Nursing Certificate Program. A single national curriculum guides the 3-year program by Ghana’s regulatory body of nursing education and practice [37].
- 2) Nurses’ and Midwives’ Training College affiliated with a Teaching Hospital. The five Teaching Hospitals in Ghana serve as referral points from regional hospitals and are affiliated with universities and colleges for training health professionals.
A convenience sampling of two public Nurses’ and Midwives’ Training Colleges (NMTCs) accessible to the PI, based on cost and feasibility, were recruited [38].
The second stage involved sampling participants. Participants were recruited from December 3rd, 2019 – March 11th, 2020. Second- and third-year nursing students were sampled as they had more clinical experience to provide their perspectives on their self-efficacy in caring for older adults than first-year nursing students. Information sessions about the study’s aim and purposes were conducted in the second and third-year classrooms. Students asked questions about their rights as participants, including confidentiality and whether they had the right to drop out at any time. Participation was voluntary. Those who volunteered to participate were given a package in an envelope containing coded questionnaires, two copies of the information letter/informed consent, and a thank you card. Alphanumeric codes that contained non-personal descriptors and study site locations were assigned to questionnaires and consent forms. This allowed the principal investigator (DAB) to align students’ responses in Phase I to Phase II should they agree to participate in the second phase. At the end of the consent form was an invitation to participate in phase II.
Sample size estimation (Phase I).
The target sample size was calculated using the rule of thumb estimation for sample size in multiple linear regression analysis and the eight predictors and covariates from our larger study [39,40]. Thus, N = 50 + 8k, [40], where N = sample size, k = the number of predictors and covariates. Using a reported 70% and above response rate among nursing students [1,4,41–43], the sample size was calculated and rounded to 170 second and third-year nursing students.
Study instruments
Socio-demographic Data: The selection of sociodemographic variables was based on previous research [1,41] that reported that age, gender, years of school, living with/having lived with an older adult, religion, and where they come from (region) (southern/northern sector), influence nursing students’ motivations and interest in working with older adults. All the data except for age and religion were dichotomous and were collected to describe the population and determine their impact on nursing students’ self-efficacy in caring for older adults.
Nursing Students’ Self-Efficacy: The General Self-Efficacy to Care for Older Adults (GSE-COA) scale modified from the General Self-efficacy (GSE) for the specific task of caring for older adults was used [39,44]. The 26-item scale is rated on a five-point Likert scale, with responses ranging from 1 (not very like me), 2 (not like me), 3 (not sure), 4 (like me), and 5 (very like me). Scores are summed for a total score range between 26–130. Using the middle response as a split point, 78 was used as the cut-off point [45]. Participants who had scores higher than 78 suggest high self-efficacy. Scores below 78 indicate low self-efficacy. The overall Cronbach Alpha coefficient for the modified GSE-COA scale was 0.85 and is considered high [46,47].
Knowledge about Older Patients Quiz (KOP-Q): The KOP-Q is a unidimensional scale comprising 30 true or false items [48,49]. Due to the lack of a validated survey tool to measure nursing students’ content knowledge in caring for older adults in our study context, we adapted the KOP-Q scale [50]. The modified scale comprises 15 unidimensional items. A correct response scored +1, and an incorrect response scored zero. The scores are summed for a total score range between 0–15. Scores of 7.5 and above were considered adequate, and scores lower than 7.5 were inadequate using Bloom’s cut-off point [45]. The KR-20 for the original scale was 0.70 [48]. In this study, the Kuder-Richardson-20 (KR20) reliability was 0.30, which is considered low [46].
Kogan’s Attitude Towards Old People Scale (KAOP): The KAOP [51] originally consisted of 32- items rated on a 5-point Likert scale, ranging from 1 strongly disagree to 5 strongly agree. We evaluated and adapted the scale for our study context [50]. The adapted KAOP scale consists of 22 items on a 5-point Likert Scale. Half of the statements are negative, and the other half are positive regarding attitudes toward older individuals [52]. Negative statements were reverse coded for one total positive score ranging between 22 and 110. The maximum score for a neutral response of 66 was determined as the cut-off point [45]. Higher scores above 66 indicated positive attitudes, and lower than 66 indicated negative attitudes. The Cronbach alpha coefficient of 0.65 and is considered moderately satisfactory [46].
Qualitative (Phase II).
Participants who completed the invitation to participate in Phase II were sampled purposefully from November 5h, 2020 – December 19th, 2020. Using mean scores as cut-off points, nursing students who scored above and below the mean for knowledge, attitudes, and self-efficacy were contacted via phone and recruited for Phase II [36,45]. Nursing students were sampled until data saturation, where no new information or patterns were noted from subsequent participants during analysis [53,54]. Seventeen nursing students were purposively selected to participate in Phase II.
Ethical considerations
The study was conducted following ethics approval from the University of Toronto Health Sciences Research Ethics Board (ERB) (#37347) and the Ghana Health Service Ethics Review Board (GH-ERB) (#GHS-ERC-001/06/19). Permission was sought and approved by the Regional Health Directors (RHD) and Principals of the NMTIs to recruit nursing students. Written informed consent was obtained from nursing students who participated in the study.
Inclusivity in global research
Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist).
Data collection procedures
Quantitative (Phase I).
Completed questionnaires were dropped in a sealed box left at the College reception and picked up by the principal investigator daily after school hours. Some students handed over completed questions to the PI on site. Questionnaires were examined for completeness, and data were coded and entered into SPSS IBM Version 26.
Qualitative (Phase II).
Students who completed the invitation form for Phase II and provided their; emails/phone numbers for follow-up interviews also dropped them in the sealed box. The completed invitation forms were identified, sorted, and matched with the student’s knowledge, attitudes, and self-efficacy scores using the alphanumeric codes on the questionnaires. Students were contacted, and interviews were conducted with those who agreed to participate. The PI conducted the interviews on the phone due to Covid-19 pandemic restrictions. Students were asked to locate a quiet, non-interruptive environment for the phone interviews. Interviews were audio recorded and lasted 45–60 minutes. Alphanumeric codes and pseudonyms were used to protect participants’ identities and maintain confidentiality.
Data analysis
Quantitative (Phase I).
Quantitative data analysis was conducted using SPSS IBM version 26. Missing values were examined using descriptive statistics and missing values analysis in SPSS to determine the proportion, type, and pattern of missing data. The proportion of missing data was less than 5% of all the cases and excluded from the analysis [55,56]. Descriptive and multiple linear regression analysis was conducted. Descriptive statistics examined nursing students’ knowledge, attitudes, and self-efficacy in caring for older adults. The following hypothesis guided regression analysis.
H0: Knowledge about and attitudes toward older adults is not associated with nursing students’ self-efficacy to care for older adults.
H1: Knowledge about and attitudes toward older adults are associated with nursing students’ self-efficacy to care for older adults.
Multiple regression assumptions testing
The assumptions of a multiple variable linear regression analysis (linearity, normality, independence of error, homoscedasticity, and multicollinearity) were evaluated to ensure that the data were appropriate. The linearity assumption stipulates that a linear relationship should exist between the dependent variable and independent variables [40,57]. We used scatter plots and standardized residuals and predictors to examine linearity. The scatter plot showed a linear relationship between self-efficacy, knowledge, attitudes and the socio-demographic data. The linearity line showed that standardized residual and standardized predictors were around zero suggesting a linear relationship. The linearity assumption was satisfied, see Fig 2.
Normality assumption indicate that the residuals of the dependent (outcome) variable should be normally distributed [40,57]. The assumption was assessed using histogram and Q-Q plot, see Figs 3 and 4. Visual inspection of the histogram suggested a distribution of a normal curve with a slight negative tail. Normality of the residuals were further examined with the visual inspection of the Q-Q plot. As Q-Q plot are sensitive to deviations in the tails of distribution, they are effective in identifying potential outliers if they are present in the data [57].
The Q-Q Plot shows the data points cluster around the horizontal line with the tail slightly pulled to the negative. The presence of outliers appears to violate the normality assumption [40]. Examination of the data for entry errors showed that the extreme values are legitimate data points. Using IBM SPSS explore, the distribution of the variables was examined to identify the outliers. Five cases (S003, S080, S021, S018 and S053) were identified to have extreme values. Outliers were further examined using Mahalanobis distance in regression analysis [40]. The P-value of the right tail of chi-square was calculated using 1-CDF.CHISQ(MAH_1, 8) to create a new probability variable. With the use of p < .001 criterion for Mahanalobis distances, cases S097, S015, S086, S021, S061 and S1117 had probability values of (.0000) respectively. Removal of these cases did not have any influence on the distribution of the normality curve; and were maintained. The extreme values which were due to the age variations of the participants present a true representation of the population distribution.
Independence of error was assessed using visual examination of the standardized residuals plots and the Durbin-Watsons statistic. The residuals appeared randomly scattered and did not present a funnel shape pattern. The Durbin-Watsons score ranges from 0–4, with values around 2 indicating independence of errors. In this study, the Durbin-Watson score was close to 2 supporting the assumption of independence of errors, see Table 1. Thus, the assumption of independence was satisfied, see Fig 5.
Homogeneity of error variance (homoscedasticity) assumption indicate that error variance should be constant across all levels of predictor variables [40]. This was examined using scatter plot of the standardized residuals and standardized predictors. The scatter plot showed that the variance is randomly scattered around zero suggesting homogeneity of variance. See Fig 5. The test of homogeneity of error variance was satisfied.
Multicollinearity assumption requires that two or more of the predictor variables are not correlated with each other [40]. This ensures that the individual contribution of each independent variable to the variance explained by the dependent variable can be accurately interpreted. In this study, multicollinearity was evaluated using the Variance Inflation Factor (VIF) values. The VIFs ranged from 1.07 to 1.51 which is below the accepted threshold of 10, indicating the absence of multicollinearity, see Table 2.
Results of the assessment of the assumptions of linearity, normality, independence of error, homoscedasticity and multicollinearity were all met. The normality assumption was met with some few extreme values on age pulling the tail of the curve to the negative. The extreme ages of some of the participants are a representation of the population and was maintained for analysis.
Qualitative (Phase II).
Interviews were transcribed and organized by the PI using NVivo 12. Analysis was done using thematic analysis and guided by self-efficacy theory, research questions, and existing literature [58,59]. We employed thematic analysis (TA) and used deductive and inductive approaches to coding [59,60]. Using the deductive approach, coding and recording were from general to specific terms. For example, in examining students’ knowledge, attitudes, and self-efficacy, general terms like ‘knowledge’ ‘attitudes,’ ‘confidence,’ and ‘self-efficacy’ were identified as codes when discussed by participants. Specific terms or phrases like ‘do not know’ ‘I am prepared,’ and ‘I am confident’ were determined as codes. During inductive coding, coding and recoding were from specific to general using terminology and terms from the participants’ [61]. Participants’ terms, phrases, or terminology were implied based on the study context and helped in the generation of codes. For example, in this phrase… “you know at home, the grown-ups will tell you don’t talk back to an aged person, you should bow and greet them. So, when you apply all this in the ward, sometimes it helps too”. This was coded as ‘attitude’ as the student draws on sociocultural teachings to facilitate interactions and positive behaviour toward older adult patients.
In addition, deliberate analytic decisions were made throughout the analysis process by reading, rereading, and developing analytic questions during coding and constructing shared meanings [59,62]. To illustrate, analytic questions like; how do nursing students’ experiences about working with older adults shape their understanding of their self-efficacy in caring for older adults? asked during coding helped to identify similar concepts and the meanings and assumptions participants ascribed to their responses. In answering the above analytic question, the PI recognized that students adopt various self-regulatory mechanisms, including viewing older adults as their parents/grandparents which helps them control their emotions and cope with challenging experiences when working with older adults.
Through this self-regulatory approach, students who successfully complete a task for a perceived ‘difficult’ or ‘uncooperative’ older adult viewed themselves as confident which shaped their perceived self-efficacy in caring for older adults. Thus similar responses and assumptions were grouped into categories and themes were generated [63]. Employing analytic questions highlighted how the participants’ cultural and social backgrounds influenced their views about their self-efficacy in caring for older adults in Ghana. The analytic questions also highlighted students’ positions in their responses as learners and/or caregivers of older adult relatives at home which enhanced the data interpretation process [61].
Rigour, positionality, and reflexivity
A reflexive journal of the decisions and experiences after interviews was maintained to enhance credibility. The reflexive journal allowed the PI to be conscious of assumptions and prejudices that may impact data collection. The systematic documentation of the study design, implementation activities, and processes enhanced dependability and confirmability [64,65]. Transferability was achieved through the reflexivity and positionality of the PI and the research process. The PI’s identity as a female, trained Ghanaian nurse and doctoral student was altered between insider and outsider positions during interviews [66]. The PI’s theoretical positioning, including motives, personal history, disciplinary affiliation, and a preceptor, was acknowledged which enhanced the study’s credibility [60,67]. Additionally, providing sufficient information about the context of the study and participants enhanced transferability by allowing readers of the study to decide whether the findings were relatable and transferable to their contexts.
Results
Quantitative (Phase I)
Nursing students’ knowledge about older adults, attitudes toward older adults, and self-efficacy to care for older adults were examined with frequencies and descriptive statistics. There was a 99% response rate. The results are presented in Table 3.
From Table 3, the majority of students n = 120 (71%), had a mean score of 6.5 (SD = 2.01), suggesting inadequate knowledge about the care of older adults (Table 1). Regarding students’ attitudes, most students, n = 153 (90.5%), had a mean score of 77.1 (SD = 8.61), indicating positive attitudes. Most students, n = 164 (97%), also had a mean of 107 (SD = 14.29), suggesting a high self-efficacy.
The association between knowledge about and attitudes toward older adults on nursing students’ self-efficacy in caring for older adults in acute care settings was examined using multiple variable regression analysis. The findings are shown in Table 4.
The self-efficacy model was significantly associated with nursing students’ self-efficacy in caring for older adults and accounted for 18% of the variance, see Table 1. Knowledge about older adults was not significantly associated with self-efficacy (b = −0.31, [95% CI −1.3, 0.7], p > .05). However, nursing students’ attitudes and age were significantly associated with their self-efficacy in caring for older adults respectively (b = 0.75, [95% CI 0.5,1.0], p < 0.05), (b = 0.56, [95% CI 0.0, 1.0], p < .05), see Table 4.
Qualitative findings (Phase II)
To understand and explain the findings of Phase I, nursing students’ gerontology knowledge, attitudes toward and self-efficacy in caring for older adults were explored. Three main themes; perceived content knowledge, perceived attitudes, and perceived self-efficacy and subthemes were generated and are discussed in Table 5. below.
Data integration
Data integration occurred at two points. First, during data collection with the purposive sampling of students based on their scores in Phase I, to identify issues or factors to explain the quantitative results. The second integration occurred after data analysis of both quantitative and qualitative phases. The findings were compared to identify convergence or divergence. No point of divergence was noted in the integration of quantitative and qualitative data. Convergence occurred as qualitative findings identified issues and factors that supported and explained the quantitative results, providing a broader understanding of nursing students’ self-efficacy in caring for older adults in Ghana, see Table 6.
Discussion
We examined the association between nursing students’ knowledge and attitudes on their self-efficacy in caring for older adults in acute care settings in Ghana. Specifically, we examined students’ perceptions of their content knowledge and attitudes and explored their understanding of their self-efficacy in caring for older adults. Results showed that nursing students’ gerontology knowledge was insufficient and not statistically significant to self-efficacy. Students demonstrated positive attitudes toward older adults, however, they exhibited ageist perceptions and demonstrated compassionate ageism. Students’ attitudes and ages were significantly positively associated with self-efficacy. Students exhibited a high sense of self-efficacy, attributed to the broad skills and confidence they acquired in the general nursing program and routine procedural clinical knowledge.
The lack of statistically significant association between nursing students’ knowledge and self-efficacy was congruent with previous studies among nursing students in areas like managing pediatric pain, evidence-based practice, using patient simulation and caring for older adults in a nursing home [27,47,68,69]. The performance of the KOP-Q in our study population may explain our study outcome. The KOP-Q had a low KR20 reliability which might have impacted our finding. The low reliability was not surprising. This is because the reduction of the items from the original scale and the unrelated multiple concepts often measured in knowledge scales likely accounted for the low KR-20 reliability [46]. Other factors including guessing, which might have impacted the reliability of the KOP-Q are discussed in detail elsewhere [50]. However, the face and content validity of the KOP-Q were achieved through expert and participant validity assessment [70]. The expert of four panel in gerontological nursing education and practice in Canada and Ghana, allowed for the identification and inclusion of the appropriate items for the development of the survey instrument [71]. The readability, interpretation and comprehension of the items were further enhanced through cognitive interviewing and pilot testing of the survey instrument [71,72]. Although the KOP-Q had a low KR-20 reliability, the findings are valid as they measured substantive acute care gerontology content. The finding of insufficient content knowledge levels is consistent with previous reviews and empirical quantitative findings in LMICs [6,7,10,46,50,73–76]. The insufficient knowledge levels were further corroborated in the qualitative results of this study. Future researchers in LMICs should consider refining the KOP-Q to improve its reliability in LMICs, including Africa. This is because there are limited alternative validated survey tools for measuring gerontology knowledge in acute care settings in LMICs. The Palmore’s Facts on Aging Quiz, has widely been used for measuring knowledge about older adults and could likely be an alternative to KOP-Q [77]. However, the Facts on Aging Quiz has been criticized for measuring perceptions and includes items not specific to acute care settings [49].
Prior scholars suggested that sociodemographic data, years in school, living with/having lived with an older adult, impacted students’ interest and willingness to care for older adults [1,41]. However, these predictors did not yield statistically significant association between students’ self-efficacy and their knowledge. Our qualitative findings revealed that other factors, including nursing students’ knowledge of routine clinical nursing care, age, students’ procedural knowledge of performing tasks like bed bathing, feeding and their familiarity with the needs of older adults shaped their perceived self-belief and knowledge about caring for older adults. Some researchers noted interests in working with older adults, is also impacted by the work environment and working experience [1,41,78]. Future researchers should consider other contextual variables influencing students’ self-efficacy in caring for older adults.
Previous studies corroborate our study’s finding of positive attitudes toward older adults [2,74]. Researchers argued that nursing students who lived with older adult relatives had more positive attitudes toward older adults [2,74]. Similarly in our study, many students had lived with or were living with older adults due to the extended family structure. Living with older adults plays a crucial role in the socialization of students and might have shaped students’ positive attitudes. Students also presented ageist perceptions (frail, weak, and acting like a child) and compassionate ageism. Coined by Binstock, compassion ageism occurs when younger people perceive older adults as needing help and more vulnerable than they are [79,80]. Comparable findings among nursing and other healthcare professional students are reported in earlier studies as determinants of ageism [81,82]. Research on ageism and its impact on the quality of nursing care for older adults has largely been conducted in high-income countries [81,83] with limited evidence in LMICs. Further research is required to understand ageism and how it influences the nursing care of older adults in LMICs, especially in sub-Saharan Africa.
Results of previous studies, congruent with our study findings showed a positive association between students’ age and attitudes toward older adults and their self-efficacy [47,84]. In this study, interviews revealed that sociocultural expectations facilitated students’ interactions with and made them comfortable in working with older adults which increased their self-efficacy. However, younger students noted that their competencies were questioned by older adults which impacted their self-efficacy negatively. Another underlying assumption regarding the discomfort of older adults receiving care from younger nursing students could be gender. In a recent systematic review, authors argued that gaps exist in the nurse-patient relationship with older adults because of gender barriers, which can result in discomfort [85]. Potential researchers could explore the association of gender and how it shapes nursing student’s self-efficacy in caring for older adults in acute care settings in LMICs including Ghana.
Students’ high self-efficacy scores were due to their perceived clinical routine knowledge, familiarity with the needs of older adults and the overall impact of the general nursing program. Students’ clinical routine knowledge was based on their perceived general nursing competencies, not specific to gerontological nursing competencies. Previous evidence similar to our study finding linked perceived high self-efficacy with perceived competency in carrying out a task [86–88]. Although insufficient in gerontology content knowledge, students’ clinical and personal knowledge from their experiences can facilitate interaction, comfort, and confidence in working with older adults [89,90]. However, this personal knowledge may also present worrying concerns about students’ views regarding the care for older adults as requiring minimal specialized skills and suggesting an ingrained societal view about the care of older adults. Given that self-efficacy is a task-specific construct, our findings were likely influenced by students’ situational and individual factors, which might have impacted their higher scores and simplistic views about caring for older adults without related content knowledge levels [27,68,69,91,92].
Additionally, the totality of the general nursing program enhanced students’ views about their self-efficacy. Students drew information from multiple courses, including, medical-surgical nursing, therapeutic communication, mental health, and basic and advanced nursing which enhanced their confidence in caring for older adults. However, information from these courses did not seem to influence students’ gerontology content knowledge scores, as their mean knowledge scores were low. This raises a crucial question about how these courses support students’ gerontological learning and their self-efficacy in caring for older adults. And highlights the crucial need for adequate integrated and standalone gerontology content in nursing education to increase students’ knowledge and confidence and advance gerontological nursing practice [89,93,94]. Furthermore, educators can consider simulation and scenario-based approaches as a potential strategy for teaching nursing students’ crucial skills and competencies for working with older adults to enhance their confidence [95,96].
Limitation and strengths
The recruitment of two institutions was a limitation, which may impact the generalizability of the findings [97]. Therefore, this study should be replicated with more nursing training institutions for generalization across Ghana. The modified KOP-Q had a low KR20 reliability in our study population, which might have impacted the knowledge scores. However, it measured substantive gerontology content appropriate for our study. Qualitative findings provided a broader understanding of students’ gerontology knowledge gaps. Nonetheless, future research should test additional psychometric properties of the modified KOP-Q with a larger sample size to enhance its KR20 reliability. Another limitation was the impact of the COVID-19 pandemic on the qualitative data collection. Interviews were conducted via telephone, limiting body language and other nonverbal cues that could enhance data interpretation.
Implications for education, research, practice, and policy
Our findings highlight broader policy and systemic barriers in LMICs and suggest a critical need for greater focus on gerontological nursing education and practice. The insufficient knowledge gaps suggest a foundational need in nursing students gerontological knowledge to bridge these gaps. It behooves on nursing education programs to intensify gerontological nursing education to adequately position nursing students in readiness for the increasing older adult population and epidemiological shift from acute infectious diseases to multiple long term chronic conditions such as multimorbidity in LMICs [98]. The findings draw attention to the need for educational interventions including curricula revisions to reflect current trends.
In addition, the aging policy in Ghana aims to provide incentives and attract healthcare professionals to gerontological practice, however, there is little evidence to suggest its implementation [99]. Government and policy makers should be committed to attracting healthcare professionals, through the development of policies and creating funding opportunities to support educational programs in gerontology and the provision of resources to facilitate research and clinical gerontological nursing practice. The findings also suggest a need to improve the nursing care of older adults in acute care settings, particularly in LMICs with limited specialized personnel or care facilities for older adults. Specialized units for older adults or Acute Care for Elderly (ACE) have shown to improve patient outcomes such as reduced functional decline and falls, increased home discharge, and improved patient and staff satisfaction [100,101]. Recognizing that the creation of specialized wards may be a long-term goal due to resource constraints, integrating interim, age-appropriate compassionate care for older adults in acute care settings is both necessary and possible.
In addition, acute care settings can benefit from specialized trained personnel in gerontological nursing to support and facilitate appropriate quality care for older adults and socialize nursing students adequately in caring for older adults. Furthermore, providing practicing nurses with the opportunities for continuous professional programs in caring for older adults can be a first step to improving geriatric care and the student gerontology experience. This can be achieved as a requirement for the renewal of licensed Personal Identification Numbers (PINs). Furthermore, ensuring the availability of resources can promote positive working environments and experiences for nurses and nursing students alike and lead to positive patient outcomes. Findings also emphasize a need for increased research to refine and develop validated survey tools appropriate for ageing research. To facilitate understanding of the challenges and needs of older adults and develop interventions to improve positive outcomes.
Conclusion
Nursing students perceived high self-efficacy, their positive attitudes toward and insufficient content knowledge about caring for older adults, indicate a significant opportunity to advance gerontological nursing education and practice in Ghana. This study has identified sources of students’ insufficient knowledge and perceived self-efficacy that can guide policy changes and inform teaching and learning strategies to improve quality and positive patient outcomes in caring for older adults in acute care settings in Ghana.
Supporting information
S1 Checklist. Inclusivity in global research questionnaire.
https://doi.org/10.1371/journal.pone.0334404.s001
(DOCX)
Acknowledgments
We thank the Principals and Research committees of participating institutions, and study participants who contributed to this study. We particularly thank Mr. Mohammed Hardi, Mr. John Akoto, Madams Baaba De-graft and Faustina Yariga for facilitating and contributing to the administrative processes of this study.
References
- 1. Rathnayake S, Athukorala Y, Siop S. Attitudes toward and willingness to work with older people among undergraduate nursing students in a public university in Sri Lanka: A cross sectional study. Nurse Educ Today. 2016;36:439–44. pmid:26507448
- 2. Wanko Keutchafo EL, Kerr J. Cameroonian nursing students’ attitudes towards older adults. International Journal of Africa Nursing Sciences. 2020;13:100215.
- 3. Haron Y, Levy S, Albagli M, Rotstein R, Riba S. Why do nursing students not want to work in geriatric care? A national questionnaire survey. Int J Nurs Stud. 2013;50(11):1558–65. pmid:23664143
- 4. Yildirim D, Keçeci A, Bulduk S. How do Turkish nursing students plan their career after the graduation?: a questionnaire survey. Asia Pacific Educ Rev. 2010;12(3):373–80.
- 5. Xiao LD, De Bellis A, Habel L, Kyriazopoulos H. The experiences of culturally and linguistically diverse family caregivers in utilising dementia services in Australia. BMC Health Serv Res. 2013;13:427. pmid:24148155
- 6. Abudu-Birresborn D, McCleary L, Puts M, Yakong V, Cranley L. Preparing nurses and nursing students to care for older adults in lower and middle-income countries: A scoping review. Int J Nurs Stud. 2019;92:121–34. pmid:30807890
- 7. Liu Y-E, Norman IJ, While AE. Nurses’ attitudes towards older people: a systematic review. Int J Nurs Stud. 2013;50(9):1271–82. pmid:23265870
- 8. Shen J, Xiao LD. Factors affecting nursing students’ intention to work with older people in China. Nurse Educ Today. 2012;32(3):219–23. pmid:21543142
- 9. de Guzman AB, Cruz AAR, Cruz ALG, Cruz RED, Cuarto JMNL. The Filipino Nursing Students’ Dilemmas in Geriatric Care. Educational Gerontology. 2009;35(8):673–86.
- 10. Rejeh N, Heravi-Karimooi M, Vaismoradi M. Iranian nursing students’ perspectives regarding caring for elderly patients. Nurs Health Sci. 2011;13(2):118–25. pmid:21401841
- 11. Yawson AE, Ackuaku-Dogbe EM, Seneadza NAH, Mensah G, Minicuci N, Naidoo N, et al. Self-reported cataracts in older adults in Ghana: sociodemographic and health related factors. BMC Public Health. 2014;14:949. pmid:25216928
- 12. de-Graft Aikins A, Addo J, Ofei F, Bosu W, Agyemang C. Ghana’s burden of chronic non-communicable diseases: future directions in research, practice and policy. Ghana Med J. 2012;46(2 Suppl):1–3. pmid:23661810
- 13. de-Graft Aikins A, Unwin N, Agyemang C, Allotey P, Campbell C, Arhinful D. Tackling Africa’s chronic disease burden: from the local to the global. Global Health. 2010;6:5. pmid:20403167
- 14. Karikari G, Huber L, Lohrmann DK, Ozdogan Z. Medical students perspectives and consideration of geriatrics for future practice. An exploratory study of a public medical school in Ghana. Gerontol Geriatr Educ. 2021;42(3):423–36. pmid:32008471
- 15. Levett-Jones T, Hoffman K, Dempsey J, Jeong SY-S, Noble D, Norton CA, et al. The “five rights” of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically “at risk” patients. Nurse Educ Today. 2010;30(6):515–20. pmid:19948370
- 16. Cardoza MP, Hood PA. Comparative Study of Baccalaureate Nursing Student Self-Efficacy Before and After Simulation. Comput Inform Nurs. 2012;30(3):142–7.
- 17. N. Iroegbu M. Self Efficacy and Work Performance: A Theoretical Framework of Albert Bandura's Model, Review of Findings, Implications and Directions for Future Research. PBS. 2015;4(4):170.
- 18. Gibson SK. Social Learning (Cognitive) Theory and Implications for Human Resource Development. Advances in Developing Human Resources. 2004;6(2):193–210.
- 19. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1–26. pmid:11148297
- 20. Masoudi Alavi N. Self-efficacy in nursing students. Nurs Midwifery Stud. 2014;3(4):e25881. pmid:25741520
- 21. Stump GS, Husman J, Brem SK. The Nursing Student Self-Efficacy Scale: development using item response theory. Nurs Res. 2012;61(3):149–58. pmid:22551989
- 22. Long T. Influence of international service learning on nursing students’ self efficacy towards cultural competence. J Cult Divers. 2016;23(1):28–33. pmid:27188018
- 23. Quine A, Hadjistavropoulos HD, Alberts NM. Cultural self-efficacy of Canadian nursing students caring for aboriginal patients with diabetes. J Transcult Nurs. 2012;23(3):306–12. pmid:22477719
- 24. Hassankhani H, Mohajjel Aghdam A, Rahmani A, Mohammadpoorfard Z. The Relationship between Learning Motivation and Self Efficacy among Nursing Students. Res dev med edu. 2015;4(1):97–101.
- 25. Sarikoc G, Oksuz E. Academic motivations and academic self-efficacy of nursing students. Journal of Clinical and Analytical Medicine. 2017;8(1):47–51.
- 26. Akhu-Zaheya LM, Gharaibeh MK, Alostaz ZM. Effectiveness of Simulation on Knowledge Acquisition, Knowledge Retention, and Self-Efficacy of Nursing Students in Jordan. Clinical Simulation in Nursing. 2013;9(9):e335–42.
- 27. Shinnick MA, Woo MA. Does Nursing Student Self-efficacy Correlate with Knowledge When Using Human Patient Simulation? Clinical Simulation in Nursing. 2014;10(2):e71–9.
- 28. Saied H. The impact of simulation on pediatric nursing students’ knowledge, self-efficacy, satisfaction, and confidence. Journal of Education and Practice. 2017;8(11):95–102.
- 29. Rowbotham M, Owen RM. The effect of clinical nursing instructors on student self-efficacy. Nurse Educ Pract. 2015;15(6):561–6. pmid:26482402
- 30. Soudagar S, Rambod M, Beheshtipour N. Factors associated with nurses’ self-efficacy in clinical setting in Iran, 2013. Iran J Nurs Midwifery Res. 2015;20(2):226–31. pmid:25878701
- 31. Rambod M, Sharif F, Khademian Z. The Impact of the Preceptorship Program on Self-efficacy and Learning Outcomes in Nursing Students. Iran J Nurs Midwifery Res. 2018;23(6):444–9. pmid:30386394
- 32. Skoglund K, Holmström IK, Sundler AJ, Hammar LM. Previous work experience and age do not affect final semester nursing student self-efficacy in communication skills. Nurse Educ Today. 2018;68:182–7. pmid:29945098
- 33. Chan JCY. Using medical incidents to teach: effects of vicarious experience on nursing students’ self-efficacy in performing urinary catheterization. J Nurs Educ. 2015;54(2):80–6. pmid:25602584
- 34.
Abudu-Birresborn D. Nursing students’ self-efficacy to care for older adults in acute care settings in Ghana: A mixed method study. Canada: University of Toronto; 2022.
- 35.
Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 4th ed. Los Angeles: SAGE Publications Inc; 2014.
- 36. Creswell JW, Zhang W. The application of mixed methods designs to trauma research. J Trauma Stress. 2009;22(6):612–21.
- 37.
Nursing and Midwifery Council. Revised Curriculum For the Training of Nurses and Midwives in Ghana. Ghana, Accra. 2016.
- 38.
Polit DF, Beck CA. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Wolters Kluwer/ Lippincott Williams & Wilkins; 2012.
- 39.
Abudu-Birresborn D. Nursing students’ self-efficacy to care for older adults in acute care settings in Ghana: A mixed method study. 2022.http://hdlhandlenet/10755/22845
- 40.
Tabachnick B, Fidell L. Using multivariate statistics: Pearson new international edition. London: Pearson; 2014.
- 41. Zhang S, Liu Y-H, Zhang H-F, Meng L-N, Liu P-X. Determinants of undergraduate nursing students’ care willingness towards the elderly in China: Attitudes, gratitude and knowledge. Nurse Educ Today. 2016;43:28–33. pmid:27286941
- 42. Hweidi IM, Al-Obeisat SM. Jordanian nursing students’ attitudes toward the elderly. Nurse Educ Today. 2006;26(1):23–30. pmid:16115699
- 43. Xiao LD, Shen J, Paterson J. Cross-cultural comparison of attitudes and preferences for care of the elderly among Australian and Chinese nursing students. J Transcult Nurs. 2013;24(4):408–16. pmid:24014491
- 44. Abudu-Birresborn D, Brennenstuhl S, Puts M, McCleary L, Nyagre VY, Chu CH, et al. Modification and adaptation of the general self-efficacy scale to determine nursing students’ belief in their capability to care for older adults. International Journal of Africa Nursing Sciences. 2023;19:100595.
- 45. Bloom BS. Learning for Mastery. Instruction and Curriculum. Regional Education Laboratory for the Carolinas and Virginia, Topical Papers and Reprints, Number 1. Evaluation comment. 1968;1(2):n2.
- 46. Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Research in Science Education. 2018;48(6):1273–96.
- 47. Zhang H, Sun H. Knowledge, attitude and self-efficacy of elderly caregivers in Chinese nursing homes: a cross-sectional study in Liaoning Province. BMJ Open. 2019;9(11):e029869. pmid:31722938
- 48. Dikken J, Hoogerduijn JG, Kruitwagen C, Schuurmans MJ. Content Validity and Psychometric Characteristics of the “Knowledge about Older Patients Quiz” for Nurses Using Item Response Theory. J Am Geriatr Soc. 2016;64(11):2378–83. pmid:27627575
- 49. Dikken J, Hoogerduijn JG, Lagerwey MD, Shortridge-Baggett L, Klaassen S, Schuurmans MJ. Measurement of nurses’ attitudes and knowledge regarding acute care older patients: Psychometrics of the OPACS-US combined with the KOP-Q. Geriatr Nurs. 2017;38(5):393–7. pmid:28189336
- 50. Abudu-Birresborn D, Brennenstuhl S, Puts M, McCleary L, Yakong V, Chu CH, et al. Evaluating knowledge and attitudes scales for the care of older adults among nursing students in Ghana. BMC Nurs. 2023;22(1):47. pmid:36805691
- 51. Kogan N. Attitudes toward old people: the development of a scale and an examination of correlates. J Abnorm Soc Psychol. 1961;62:44–54. pmid:13757539
- 52.
Allen M. The SAGE Encyclopedia of Communication Research Methods. 2017.
- 53. Fusch P, Ness L. Are We There Yet? Data Saturation in Qualitative Research. TQR. 2015.
- 54.
Gray JR, Grove SK, Sutherland S. The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. Eight ed. Elsevier, Inc.; 2017.
- 55.
Derrick BA. How can I deal with missing data in my study? Australian and New Zealand Journal of Public Health. 2001;25(5):464–9.
- 56.
Little RJA, Rubin DB. Statistical analysis with missing data. John Wiley & Sons; 2014.
- 57.
UCLA. Statistical Consulting Group. Introduction to Regression with SPSS Lesson 2: SPSS Regression Diagnostics. 2020.https://statsidreuclaedu/spss/seminars/introduction-to-regression-with-spss/introreg-lesson2/
- 58.
Green TN. Qualitative methods for health research. Sage; 2018.
- 59. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019;11(4):589–97.
- 60. Caelli K, Ray L, Mill J. ‘Clear as Mud’: Toward Greater Clarity in Generic Qualitative Research. International Journal of Qualitative Methods. 2003;2(2):1–13.
- 61.
Coffey A, Atkinson P. Concepts and coding, Chapter. 2, in Making Sense of Qualitative Data. Sage; 1996. p. 26–53.
- 62. Eakin JM, Gladstone B. “Value-adding” Analysis: Doing More With Qualitative Data. International Journal of Qualitative Methods. 2020;19.
- 63.
Hollway W, Jefferson T. Analysing data produced with defended subjects, Doing Qualitative Research Differently. Doing Qualitative Research Differently. Sage. 2000. p. 55–82.
- 64. Krefting L. Rigor in qualitative research: the assessment of trustworthiness. Am J Occup Ther. 1991;45(3):214–22. pmid:2031523
- 65. Morrow SL. Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology. 2005;52(2):250–60.
- 66. Coar L, Sim J. Interviewing one’s peers: methodological issues in a study of health professionals. Scand J Prim Health Care. 2006;24(4):251–6. pmid:17118866
- 67. Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84. pmid:20014004
- 68. Stanley M, Pollard D. Relationship between knowledge, attitudes, and self-efficacy of nurses in the management of pediatric pain. Pediatr Nurs. 2013;39(4):165–71. pmid:24027950
- 69.
Tang L, Juang R, H S. College Nursing Students Knowledge of and Self-efficacy in Evidence-based Practice in Taiwan. In: Bero L, Montgomery P, Robinson K, Pigott T, Krause K. Bringing Evidence-Based Decision-Making to New Heights. Abstracts of the 2010 Joint Colloquium of The Cochrane and Campbell Collaborations. John Wiley & Sons; 2010.
- 70. Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Front Public Health. 2018;6:149. pmid:29942800
- 71.
Dillman DA, Smyth JD, Melani L. Internet, mail, and mixed-mode surveys: The tailored design method. 2009.
- 72. Izumi S, Vandermause R, Benavides-Vaello S. Adapting cognitive interviewing for nursing research. Res Nurs Health. 2013;36(6):623–33. pmid:24142451
- 73. Ghimire S, Shrestha N, Callahan KE, Nath D, Baral BK, Lekhak N, et al. Undergraduate nursing students’ knowledge of aging, attitudes toward and perceptions of working with older adults in Kathmandu Nepal. Int J Nurs Sci. 2019;6(2):204–10. pmid:31406893
- 74. Birimoglu Okuyan C, Bilgili N, Mutlu A. Factors affecting nursing students’ intention to work as a geriatric nurse with older adults in Turkey: A cross-sectional study. Nurse Educ Today. 2020;95:104563. pmid:33032122
- 75. de Guzman AB, Jimenez BCB, Jocson KP, Junio AR, Junio DE, Jurado JBN, et al. Filipino Nursing Students’ Behavioral Intentions Toward Geriatric Care: A Structural Equation Model (SEM). Educational Gerontology. 2013;39(3):138–54.
- 76. Atakro CA. Gerontological nursing in Ghana: Preferences and perceptions of nursing students. Gerontol Geriatr Educ. 2022;43(4):482–98. pmid:35380940
- 77. Palmore EB. The Facts on Aging Quiz: Part Two. The Gerontologist. 1981;21(4):431–7.
- 78. Fox MT, McCague H, Sidani S, Butler JI. The Relationships Between the Geriatric Practice Environment, Nursing Practice, and the Quality of Hospitalized Older Adults’ Care. J Nurs Scholarsh. 2018;50(5):513–21. pmid:30051573
- 79. Binstock RH. The aged as scapegoat. The Gerontologist. 1983;23(2):136–43.
- 80. Palmore EB. Ageism comes of age. The Gerontologist. 2003;43(3):418–20.
- 81. Burnes D, Sheppard C, Henderson CR Jr, Wassel M, Cope R, Barber C, et al. Interventions to Reduce Ageism Against Older Adults: A Systematic Review and Meta-Analysis. Am J Public Health. 2019;109(8):e1–9. pmid:31219720
- 82. Ozaydin T, Kocoglu-Tanyer D, Akın B. Normative solidarity and compassion as determinants of ageism in nursing students: An analysis of mediation and moderation. Collegian. 2023;30(2):400–6.
- 83. Kagan SH, Melendez-Torres GJ. Ageism in nursing. J Nurs Manag. 2015;23(5):644–50. pmid:24238082
- 84. Li J, He Z, Luo Y, Zhang R. Perceived transcultural self-efficacy of nurses in general hospitals in Guangzhou, China. Nursing Research. 2016;65(5).
- 85. Xiarchi LM, Nässén K, Palmér L, Cowdell F, Lindberg E. Gender influences on caring, dignity and well-being in older person care: A systematic literature review and thematic synthesis. Nurs Philos. 2024;25(1):e12467. pmid:37901941
- 86. Albagawi B, Hussein FM, Alotaibi JS, Albougami AS, Amer MF, Alsharari AF. Self-efficacy and clinical competence of fourth-year nursing students: A self-reported study. Int J Adv Appl Sci. 2019;6:65–70.
- 87. Kim KH, Lee AY, Eudey L, Dea MW. Improving Clinical Competence and Confidence of Senior Nursing Students through Clinical Preceptorship. IJN. 2014;1(2).
- 88. Lauder W, Watson R, Topping K, Holland K, Johnson M, Porter M, et al. An evaluation of fitness for practice curricula: self-efficacy, support and self-reported competence in preregistration student nurses and midwives. J Clin Nurs. 2008;17(14):1858–67. pmid:18578760
- 89. Potter G, Clarke T, Hackett S, Little M. Nursing students and geriatric care: the influence of specific knowledge on evolving values, attitudes, and actions. Nurse Educ Pract. 2013;13(5):449–53. pmid:23465846
- 90. Dahlke SA, Phinney A, Hall WA, Rodney P, Baumbusch J. Orchestrating care: nursing practice with hospitalised older adults. Int J Older People Nurs. 2015;10(4):252–62. pmid:25534507
- 91. Karabacak Ü, Serbest Ş, Kan Öntürk Z, Eti Aslan F, Olgun N. Relationship between student nurses’ self-efficacy and psychomotor skills competence. Int J Nurs Pract. 2013;19(2):124–30. pmid:23577969
- 92.
Bandura A, Walters RH. Social learning theory. Englewood Cliffs, NJ: Prentice-Hall; 1977.
- 93. Garbarino JT, Lewis LF. The impact of a gerontology nursing course with a service-learning component on student attitudes towards working with older adults: A mixed methods study. Nurse Educ Pract. 2020;42:102684. pmid:31931303
- 94. O’Meara A. Prescriptions for excellence in gerontological nursing education. Geriatric Nursing. 2008.
- 95. Haugland VL, Reime MH. Scenario-based simulation training as a method to increase nursing students’ competence in demanding situations in dementia care. A mixed method study. Nurse Educ Pract. 2018;33:164–71. pmid:30224221
- 96. Cummings CL, Connelly LK. Can nursing students’ confidence levels increase with repeated simulation activities? Nurse Educ Today. 2016;36:419–21. pmid:26599594
- 97. Jager J, Putnick DL, Bornstein MH. More than just convenient: the scientific merits of homogeneous convenience samples. Monogr Soc Res Child Dev. 2017;82(2):13–30. pmid:28475254
- 98.
World Health Organization. Ageing and Life-course: Health Systems that meet the needs of older people. 2016. wwww.hoint/ageing/health-systems/en/
- 99.
Government of Ghana. National Ageing Policy: Ageing with Security and Dignity. Ministry of Employment and Social Welfare. 2010.
- 100. Fox MT, Persaud M, Maimets I, O’Brien K, Brooks D, Tregunno D, et al. Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis. J Am Geriatr Soc. 2012;60(12):2237–45. pmid:23176020
- 101. Brennan MJ, Knee AB, Leahy EJ, Ehresman MJ, Courtney H-A, Coffelt P, et al. An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System. J Hosp Med. 2019;14(9):527–33. pmid:31112495