Internal consistency and construct validity assessment of a revised Facts on Aging Quizfor Flemish nursing students: an exploratory study

Society is undergoing major demographic changes. People are reaching older ages, and as life expectancy increases, the proportion of persons older than 65 increases. It is expected that the number of very old (85 and over) persons will especially continue to increase and occupy an ever-increasing proportion of the overall population [1]. This ageing of the population has a direct impact on healthcare, since older persons tend to have disproportionately more chronic illnesses and disabilities. Moreover, as a lot of these older persons will remain at home longer, available access to non-medical and medical services in the community will be essential [2‐4]. In general, a multidisciplinary team approach using gerontology and geriatric expertise is recommended in order to provide high-quality care to the ageing population [5, 6]. To provide high-quality care, future healthcare systems are increasingly in need of more knowledgeable nurses in order to meet the specific healthcare needs of older people [5‐7]. Nurses are the primary caregivers for many older persons, and because of the uniqueness of their profession, their role is of great importance in designing, implementing and evaluating health care of older adults in primary, hospital, and long-term care [8‐10]. It is often the nurse who has close and intense interactions with the older care recipient [11, 12]. In particular, they play an important role in the early detection and diagnosis of specific nursing problems, for example, bedsores, delirium, and fall risk [13‐15]. Because older people in healthcare settings often present with a frailty profile, limited homeostasis, active multipathology, comorbidity, multipharmacology, disturbed pharmaco-kinetics, and psychosocial problems, they are in need of a different approach than adult patients with regard to the detection of healthcare problems and the maintenance and promotion of their current health care status [16, 17]. Nurses, and healthcare professionals in general, for example, often misperceive changes in cognitive and functional status as a normal consequence of aging, which may result (in)directly in negative outcomes, such as an accelerated deterioration of overall health [18]. Therefore, the health care of older patients should extend beyond the traditional medical management of illness and requires evaluation of multiple issues including physical, cognitive, affective, social and environmental components that influence an older adult’s health [17]. Although their role in providing care to the older patient is critical, studies show that some nurses and nursing students lack adequate knowledge about ageing, and do not possess the competencies or attitudes necessary for providing quality care to older persons [19‐22].

The American Association of Colleges of Nursing (AACN) in collaboration with The John A. Hartford Foundation (2000), composed a document titled ‘Older adults: recommended baccalaureate competencies and curricular guidelines for geriatric nursing care’ that provides a description of the basic nursing competencies needed to guarantee high-quality care for older people, aiming to help educators implement specific gerontology content into their baccalaureate nursing education programmes [23]. However, although many nursing education programmes have integrated geriatric nursing into their curriculum [24, 25], the majority of nurses and nursing students also have inadequate experience in geriatric care and a rather negative attitude towards the care of older persons [26‐29].

Taking into account all of the above, a valid and reliable assessment tool is needed to determine the state of gerontological knowledge nurses possess and to assess what they know about geriatric aspects of caring for older patients. Many tools have been developed for this purpose. A comprehensive literature review revealed an extensive body of literature about nursing and medical students’ knowledge of older persons and ageing [21, 22, 30, 31]. There are different measurement instruments that have been used, such as Palmore’s Facts on Aging Quizzes (FAQs)[32‐35]; the Geriatric Knowledge Self-Assessment Tool[21]; the Alzheimer’s Disease Knowledge Test[30, 36]; the UCLA Geriatrics Knowledge Test[37, 38]; and the University of Michigan Geriatrics Knowledge Test[39, 40]. Most of these instruments are designed to measure medical students’ knowledge of older persons and ageing, and are therefore more focused on the medical aspects of ageing [37, 39]. Other instruments are rarely used now, and data on their psychometric properties are meagre [21, 30]. The most widely used instruments to measure nursing students’ knowledge are the FAQs: Facts on Aging Quiz version 1 and 2 (FAQ1 and FAQ2) and Facts on Aging Mental Health Quiz (FAMHQ)[32‐34].

The Palmore’s FAQs were originally developed to encourage group discussion among healthcare workers about older persons and their care. Palmore’s quizzes have been described as being valid (e.g., face and known-groups validity) and reliable (e.g., internal consistency) when used in various groups of learners [27, 32‐34]. Laner stated that FAQ1 measures knowledge and factual learning independently from the specific content of courses being taught [35]. The FAQ1, as well as the FAMHQ, originally consisted of 25 items in ‘true’ or ‘false’ response format. FAQ1 is designed to measure knowledge about basic physical, mental, and social factors of ageing; FAMHQ focuses more on assessing knowledge about the cognitive and mental aspects of older persons and ageing. Total scores of both instruments can range from 0 to 25, with higher scores reflecting greater knowledge about ageing and mental health of older persons [32‐34].

Despite different publications and statements concerning the Palmore’s FAQs being valid and reliable, available evidence supporting these notions is still poor, and discordance appears to persist among researchers [26, 41, 42]. Several studies have re-evaluated the different versions of the FAQs and report a low internal consistency with Cronbach’s alphas varying from 0.45 to 0.66 [43‐46]. Also, the study of Miller et al. revealed a major shortcoming of the FAQ1, as most items have an underlying negative bias [41]. If the items were worded in a positive way, the respondents might have higher scores, indicating richer, more complete knowledge about ageing and gerontological care.

There also appear to be problems for the alternate versions of Palmore’s FAQs. Seufert et al. [26] and Obiekwe [44] compared the different versions of the FAQ (1 & 2), and concluded these are not actually alternate measures, despite Palmore’s earlier assertions [33]. Furthermore, Lusk et al. [43] and Norris et al. [42] tried to perform factor analysis on FAQ1, and both found unstable factor structures, many substantively incoherent and different factors, and overall low factor loadings.

The situation is similar for the FAMHQ. Actually, the literature on the psychometric properties of the FAMHQ is remarkably scarce, if not completely obscure.

The FAQ1 and FAMHQ were used as a basis for developing the revised FAQ [32‐34]. Response categories for each item were ‘true’, ‘false,’ or ‘don’t know’ [47].

In this study, we aimed to create a revised version of the FAQ that would better evaluate nursing students’ knowledge about ageing and care for older persons. The new instrument is based on the FAQ1 and FAMHQ, originally developed by Palmore [32‐34] and two additional items suggested by the expert panel. Development of the revised instrument proceeded in two phases: (1) translation, adaptation, and validation; and (2) evaluation of the revised instrument’s construct validity and internal consistency. The first phase produced a provisional instrument with 22 items from the original FAQ1, two de novo items about life expectancy and risk of physical injury, and 12 items from the original FAMHQ. The second phase was based on the results of an exploratory study in which the revised instrument was administered to 1141 first- and third-year nursing students in colleges in Flanders, Belgium. The final version of the revised and extended FAQ scale consisted of 36 items, which are answered with ‘true’, ‘false’, or ‘don’t know’. An external expert panel of educators confirmed the face validity of the revised instrument, and evaluation of its internal consistency produced a Cronbach’s alpha of 0.723. Explorative factor analysis failed to produce a simple structure. However, using the known-groups technique, we confirmed the construct validity of the revised instrument.

As expected, explorative factor analysis failed to reveal different underlying constructs. Inclusion of various factors produced a substantively incoherent model, and factor loadings were generally low. On the basis of these results and on other results reported in the literature on the factor structure of Palmore’s FAQs[42, 44], we surmise that the overall underlying concept could, therefore, be related more to general knowledge about older persons, ageing, and gerontological care. This suggested underlying concept is very broad and covers many different aspects. However, we did confirm construct validity of our revised version of the FAQ in a large sample of nursing students using the known-groups technique. With this approach, the new instrument was able to discriminate (p < 0.001) between the knowledge of first- and third-year nursing students about older persons and ageing.

Another finding regarding the new instrument’s discriminatory power was that almost all items that were incorporated from the FAMHQ, except three (items 3, 29, and 33), significantly discriminated between first- and third-year nursing students’ knowledge. By contrast, only 6 of 24 items incorporated from the FAQ1 showed similar performance. This difference might indicate that overall knowledge about older people, ageing, and gerontological care tapped into by the FAQ1 items is more or less the same for first- and third-year nursing students. By extension, knowledge about the cognitive and mental state of older persons tapped into by the FAMHQ items is likely knowledge that is gained through internship experiences and more extensive training packages that students receive in the second and third year of nursing education.

Overall knowledge about older persons and gerontological care is a difficult construct to measure and operationalize in a measurement instrument. Palmore’s research provides a useful starting point, a valuable framework in this area on which to build. Our study demonstrates the overall utility and value of Palmore’s work, despite the necessity of some adjustments for its use in Belgium, Flanders. This fact is also reflected by the numerous translations and adaptations for use in different regions [22, 27, 29, 31, 45, 50‐55]. Nevertheless, we must also note a caveat about its unrestricted use. In line with previous research on the use of Palmore’s FAQs, we agree that it is primarily suitable in non-research–based settings or in discussion groups [42‐45, 47]. This is true also for the revised (Flemish) version.

Palmore’s FAQs were originally developed to encourage healthcare workers to participate in group discussion about older persons and gerontological care. On the basis of the findings of this study, we conclude that our revised and extended version of the FAQ can also be used to evaluate nursing students’ knowledge about older persons and gerontological care in Flanders, Belgium, as reasonable reliability and validity were established. Future research, however, is needed to further evaluate and confirm the psychometric properties of this scale in different groups of students and in different settings.