Impact of settings and culture on nurses’ knowledge of and attitudes and perceptions towards people with dementia: An integrative literature review

Abstract Background Well‐trained nurses are required to support dementia patients; however, the quality of the provided dementia nursing care can be impacted by nurses’ knowledge, attitudes and perceptions towards people with dementia. Aim To obtain an overview of the current nursing practice towards people with dementia around the world. Design An integrated literature review was conducted based on Whittemore and Knafl's method. Results A total of 72 articles met the inclusion criteria. Three main themes were identified: (1) nurses’ knowledge, attitudes and perceptions towards dementia; (2) nursing experience of caring for people with dementia in acute and community care settings; and (3) dementia nursing care across health regions. Conclusion Nurses play the role of facilitators in the efficient delivery of quality care for dementia patients. A variety of attitudes and perceptions towards people with dementia were found to be triggered by the severity of dementia, religion, ethnicity and gender. Implications for practice Healthcare organisations and educational settings need to coordinate and function together to improve nurses’ knowledge and encourage positive attitudes towards people with dementia.


| BACKG ROU N D
Dementia is one of the most prevalent health-related conditions across the globe, and it is estimated that around 35.6 million people are living with dementia worldwide (American Psychiatric Association, 2012;Briggs et al., 2017). Dementia is one of the most prevalent psychiatric conditions that affects the ageing population, mostly adults above the age of 65 (Prince et al., 2015). Dementia causes multiple symptoms that are characterized by memory impairment, language problems, motor speech disorder, sensory recognition problems and general body functioning disturbance (Prince et al., 2015). The nature of the disease dictates that advanced nursing care must be provided for the successful management of dementia. People with dementia need to receive care from well-trained | 67 YAGHMOUR nurses in both acute hospital and community care settings so that patients can receive around-the-clock care (Strøm et al., 2019).
Despite the fact that nurses play a special role in attending to the special needs of dementia patients, in many cases, it has been found that dementia patients do not receive optimal care (Registered Nurses' Association of Ontario, 2018). It has been suggested that the provision of care for dementia patients extends beyond the confines of nursing education and overlaps with additional factors, such as attitudes and perceptions about this illness (Daniel et al., 2014). In 2019, authors reported that nursing students have almost no knowledge about how to provide ideal care to patients with dementia; they often struggle in dealing with the behavioural problems of patients (Strøm et al., 2019). Thus, because knowledge and attitude influence the quality of care provided, it is important to distinguish between nursing knowledge, attitudes and perceptions when considering the educational skills of nurses. Each of these three concepts has a different meaning and function. For example, knowledge is associated with cognitive expertise derived from learning, which outlines the role of modern nurses in health care (Hatamleh & Sorio, 2017). The attitude of a nursing professional relates to the individual's belief system, which may or may not be the same as widely accepted societal attitudes (Coban et al., 2015;Yaghmour et al., 2019). In addition, it is well known that societal attitudes also vary depending on the country and culture. Perceptions, on the other hand, are associated with the views, concerns and interpretation of behaviours.
It has been noted that nursing care for people with dementia is different between organisations and it varies according to nursing experience, wards and its business, nurses' knowledge and their perceptions about the disease, and their attitudes towards people with dementia and dementia care (de Witt & Ploeg, 2016;Eritz et al., 2016;Schindel Martin et al., 2016;Yaghmour et al., 2019;. Therefore, exploring the current nursing practices for people with dementia from a global perspective was significant in order to provide policymakers educational organisations and healthcare organisations with the best available evidence.
The main objective of the current paper was to carry out an integrated literature review of nurses' knowledge, attitudes and perceptions towards caring for dementia patients in different care settings, including acute care hospitals and community care settings. This is to obtain an overview of the current nursing practice towards people with dementia around the world by exploring the cultural difference impact on nurses' knowledge, attitudes and perceptions. This will help in identifying any existing gaps in knowledge and opportunities for nursing practice development in the field of mental health. This could pave the way for new reforms in mental health nursing and geriatric educational programmes.

| ME THODS
This integrative review was guided by Whittemore and Knafl's method. This method's guidelines were used to assist the data extract and analysis of the included papers (Whittemore & Knafl, 2005). An integrative method involves the inclusion of both empirical and theoretical publications. This methodological approach consists of five stages to guide the review. This includes problem identification, literature search, data evaluation, data analysis and presentation. This section provides comprehensive details of stages two and three,

What does this research add to the existing knowledge in gerontology?
• This review examined the different strategies used by nurses in caring for dementia patients and the measures that can be taken to improve their knowledge, attitudes and perceptions in both acute hospital and community care settings.
• Nurses' burnout, ward routine and work environment were found to have a negative impact on nurses' perceptions towards dementia patients.
• Nurses' perceptions towards end-of-life and holistic care are influenced by the religious and cultural practices of the person with dementia.
What are the implications of this new knowledge for nursing care with older people?
• It is suggested to include both theoretical and practical interventions to enhance nurses' knowledge and attitudes towards people with dementia.
• Nurses in administrative roles must acquire knowledge about skills to care for people with dementia, and they must support nurses in providing advanced and highquality care.
• Communication competencies and strategies to care for dementia patients have to be defined and added to core nursing competencies for dementia care.
• Nurses must be aware of people with dementia actual condition and have the proper knowledge and skill set for managing people with dementia and their specific needs.
How could the findings be used to influence policy, practice, research or education?
• Healthcare organisations and educational settings should work together to enhance nurses' knowledge and encourage positive attitudes towards people with dementia.
• Furthermore, studies adapting mixed methodologies are needed to validate the best practices and generalize the findings in the context of nursing care for dementia across the world.
• The policies and practices within community care centres and acute care hospital settings require improvement to maintain patients' expectations about care. which relate to the description of a comprehensive search strategy, explaining the methodological quality and representativeness of the primary studies (Hopia et al., 2016).

| Search strategy
A systematic search was conducted in March 2018 and updated in June 2021 using a number of scientific databases, including DelphiS, CINAHL, MEDLINE, OVID, ProQuest, EMBASE and PsychINFO, using keywords such as "nurses," "staffing," "knowledge," "attitude," "perception" and "dementia." Several truncations were used to further refine the key terms and ensure that all relevant articles related to the research question were taken. The key truncations used included "Nurs* staff" OR "register* nurse*" in combination with knowledge, educational, understand*, awareness, attitude, perception, opinion, thought, feeling, OR beliefs. Search terms like dementia, Alzheimer*, "Lewy body," Parkinson*, "mild cognitive impairment," "cognitive impairment," "cognitive decline," "memory loss," "cognitive function," OR "cognitive dysfunction" were also used during the search process (Table 1).

| Eligibility criteria
The inclusion criteria focused on defining the target sample group who were Registered Nurses, research design, publication date, language and main outcome in the articles selected for review. A summary of the inclusion/exclusion criteria is presented in Table 2. The exclusion criteria for article selection were also defined. All nursing students were excluded from the review. In addition, studies investigating patients with mental disorders other than dementia were excluded.

| Selection of studies
The screening of the articles was done by looking at duplicate articles first and then removing them. Following the removal of duplicate articles, the titles of the returned articles were examined. All articles with irrelevant titles were excluded. After the title was reviewed, the abstract of each article was reviewed. This was followed by full-text screening of the articles by comparing them with the inclusion and exclusion criteria. Two researchers were involved in the screening process, and they finalized the studies after discussion and comparing all the results. The final list of articles was selected after any arguments were resolved through discussion. In case no agreement could be reached, a third expert member of the research team was consulted. The PRISMA flow chart was followed to summarize the screening process ( Figure 1).

| Methodological quality assessment
It is important to assess the quality of the papers to be included to ensure the integrity of the overall review's findings. The quality of research evidence was assessed using the Joanna Brigs Institute (JBI) appraisal tool for qualitative and quantitative studies, control trials and the mixed-methods appraisal tool. The tool consists of 10 questions according to different research designs, and the answers need to be chosen from four options: yes, no, unclear and not applicable. This research aims to classify articles according to their quality because high-quality research papers will be reflective of the validity of the research papers. Studies were considered as having a good quality of research evidence if the score was between 50%-84%.
The papers were classified as very high-quality papers if the score was higher than 85%. In addition, papers scoring 50% or below were rated as low-quality research evidence. This per cent was set by the study researcher to insure rigorous peer-reviewed studies were included. The quality appraisal of the articles will be given in the results section.

| Data extraction
The data were extracted using a data extraction sheet. The key data extracted from the data include the following: a) author name, title and date of publication, b) setting, c) study design, d) outcome data and e) conclusion. The process of data extraction was completed by the study researcher.

Study participants Registered Nurses
Papers were included if they indicated nurses were the study's participants and that these nurses directly cared for dementia patients. This reflects the objective of this review. When studies included other healthcare professionals, nurses must have to be more than 35% of the total study's participants. However, when studies included nurses among other healthcare professionals without mentioning the quantity, the study was excluded. Nursing assistants and nursing students were excluded because they have not received full training and are often still in the process of gaining knowledge, so their knowledge may differ from that of a qualified nurse.

Settings
Acute hospital settings or communitybased practices Only residential, palliative care and/or primary health settings were included because these settings are involved in caring for dementia patients.

| Data analysis
Relevant articles were extracted using NVivo software; the articles were coded accordingly within the software. The extracted data were synthesised and analysed using a thematic analysis method. The main purpose of this form of data synthesis was to assess how the literature addresses the research question. Because the current review focused on the three outcomes of attitude, knowledge and perception, the findings related to these three areas were synthesised by looking at patterns within the dataset. According to authors, the significance of using the thematic analysis method is that it offers a flexible yet rigorous approach to establish links between the study question and test of primary studies (Nicholson et al., 2016). It involves the systematic coding of data and generating of analytical themes. In the present research, line-to-line coding was done, followed by grouping together codes based on the similarities and differences between the codes. In

| Included studies
Based on the database search process, a total of 777 articles published between 2010 and March 2021 were obtained. The articles were further screened by looking at duplicate papers. A total of 318 papers were obtained after removing duplicates. After this, the articles were assessed by reviewing the title and abstract. A total of 35 articles were excluded by title and abstract. The remaining 283 articles were reviewed based on inclusion and exclusion criteria. Finally, a total of 72 articles were included in the review. The PRISMA flowchart for the search result is given in Figure 1 above. The list of articles, along with numbering for the selected articles, is provided in   Smythe et al., 2014Smythe et al., , 2017Solli et al., 2015;Van Hoof et al., 2016), Americas (Brody et al., 2016;Chaudhury et al., 2017;Daniel et al., 2014;de Witt & Ploeg, 2016;Eritz et al., 2016;Hunter et al., 2017;Karlin et al., 2017;Schindel Martin et al., 2016;Sharpp & Young, 2016;Unroe et al., 2015), the Western Pacific region (Annear, 2020;Conway & Chenery, 2016;Digby et al., 2018;Ervin et al., 2014;Fry et al., 2017;Kable et al., 2015;Lin et al., 2018;McCann et al., 2014;Nakanishi & Miyamoto, 2016;Shannon et al., 2018;Wang, He, et al., 2017;Wang et al., 2018;Yada et al., 2014), South-East Asia (Kang et al., 2017) and finally Eastern Mediterranean countries (Bentwich et al., 2017;. Then, the reviews were summarized too

| Results of the critical appraisal
Using the JBI appraisal tool for quantitative studies (Institute TJB, 2016), 14 studies were found to rank as high quality and six good (refer to Table 3 for details). When the qualitative studies were critically appraised using the JBI checklist (Lockwood et al., 2015), 30 studies were found to be high quality and two were good-quality papers. Regarding the systematic reviews that were included, the JBI checklist (Aromataris et al., 2015) found six articles were of high quality, while two were good. The mixed-methods appraisal tool (Pluye et al., 2011) found that all eight studies that used a mixedmethod design were of a high quality. Additionally, control trials were assessed using the JBI critical appraisal tool (Aromataris et al., 2017), which found three good-quality studies and one high-quality study.
The rationale behind the inclusion of only good-quality and highquality papers is to increase the reliability and validity of these integrated reviews' findings and the study's rigour.

| Characteristics of the studies
The characteristics of selected studies and its context, such as scope, setting and participants' numbers are presented in Table 3. Nurses are unable to provide care for patients with severe dementia as result of their suffering.

| Review's findings
Most challenges were attributed to the behavioural symptoms of dementia, like agitation, irritability, physical aggression and rejection of care.
Nurses described their experience as painful and distressing as they found themselves helpless.
Getting to know patients more is one of the successful approaches in providing care and minimising patient irritations.
The important of having close relative around to aid the care process. Pain management perceived as difficult task for nurses providing care for a dementia patient.

80%
As nurses feel powerless and unable to communicate with them.
Nurses concern about the recourses available such standardised pain management tools and medication.

90%
Cluster randomised controlled trial Nurses knowledge in intervention group was higher than the control group in follow-up but not in no different in their attitudes.
Overall, knowledge and attitudes scores were significantly improved by the educational programme.
Nurses minimises the use of restrains after completing the education programme. Nurses found that caring for people with dementia is rewarding. Nurses in both countries were greatly uncertain about the care and perceived a person with dementia.
Having person with dementia disturbs the ward's routine.
In order to perform person-centred care, organisations must minimise restrains on nurses.
Some nurses believed that they are creative in providing care for the person with dementia that makes their care rewarding. Application of dementia-friendly environment proves its benefit in minimising patient's confusion. Cross-sectional Difficulty in assessing pain for dementia patients.
There were statistically significant differences between the sufficiency of pain management and barriers.

Blaser and
Berset (2019)  cross-sectional Nurses attitudes were significantly positive with nurses working in dementia-related wards.
The care setting (ward) has strong association with attitudes scores.
All other factors-such as age, gender, years of experience, nursing degree and employment- were not found to be associated with the attitudes scores (no effect found).

86%
Kohler et al. Qualitative; interviews Nurses showed that they prioritized patients with rehabilitation goals who were returning to the community ahead of others who may be awaiting a bed in residential care. Patients with comorbidities were the least concerned by nurses.
It was clear from the interviews that not all nurses perceived patients equally.
Most nurses perceived the person with dementia as unworthy (lack of value, undeserving, not good enough, inappropriate) to the ward environment.
Nurses professed that people with dementia as disturbance of the work routine and environment.
Work organisation adding pressure to nurses. Qualitative; observations and interviews Nurses trying their best to make consistent ward routine to maintain calm atmosphere and allow focusing on maintaining patient's dignity.

80%
Nurses used physical and chemical restrains on patients with dementia to keep them safe and avoid their falling. Person-centred care is challenging. Nurses referred to the importance of having a family member to support the care and some seeks help from security personnel. Nurses main concern is the patient safety and to minimise risks. Person-centred approaches minimise nurses' burnout.
Educational and practice together improve.

TA B L E 3 (Continued)
The significance of these studies is that they revealed a positive re- External facilitators (physical environment; organisational culture and structure).
Facilitating actions (forming a holistic picture; establishing trust; adjusting routines and interventions).
While facilitators did exist in the hospital setting, the findings indicate that care received by inpatients with dementia is dependent on individual registered nurses knowledge, personal attitude and ability to compensate for structural flaws. Opinion varies according to the severity of dementia, religion, ethnicity and gender.

TA B L E 3 (Continued)
this did not always translate into competency in the teams providing quality care for dementia patients (Deasey et al., 2014;Nakanishi & Miyamoto, 2016). Also, the negative attitudes of nurses towards dementia patients were found to be associated with high levels of perceived patient dependency (Deasey et al., 2014;Evripidou et al., 2019) with some nurses in acute care settings reporting feeling hesitant to attend to patient cases related to old age (Deasey et al., 2014;Digby et al., 2017). Dementia knowledge and attitudes scores were found to be significantly higher among nurses who had more experience and possessed higher educational levels (Blaser & Berset, 2019;Nakanishi & Miyamoto, 2016). This is consistent with the findings from Norway, which stated that licensed nurses with higher work experience had higher dementia care knowledge scores (Jakobsen & Sørlie, 2016).
Studies also reported about an improvement in knowledge and attitude after the provision of training. To this end, nurses' knowledge and perceptions were significantly improved when educational interventions (Brody et al., 2016;de Witt & Ploeg, 2016;Kang et al., 2017;Kohler et al., 2016;Pellfolk et al., 2010;Wang, He, et al., 2017) and training programmes ( (Brody et al., 2016). In Canada, the Gentle Persuasive Approaches educational programme was carried out to educate nurses in acute care settings, including medical, surgical, oncology, orthopaedic, intensive, emergency wards and cardiology care units; this programme was found to significantly enhance nurses' knowledge, perceptions and practices about dementia (Schindel Martin et al., 2016). Similarly, studies done in Australia, South Korea and China also revealed an improvement in attitude and knowledge towards dementia patients (Annear, 2020;Kang et al., 2017;Wang, He, et al., 2017).
Therefore, these approaches can be useful in maximizing the advancement of interprofessional collaboration, thereby improving the overall dementia care for the patient.
3.4.2 | Theme 2: Nursing experience of the factors influencing dementia care in acute and community care settings Work environment and care settings were believed to play a crucial role in the nurses' perceptions and in their dementia care delivery. A wide diversity in practices along with the skills of the nurses working in both community and acute care settings was evident with respect to dementia screening, evaluation and treatment (Daniel et al., 2014;Van Hoof et al., 2016). In community care settings, researchers have suggested the application of effective communication skills at the time of training community-based caregivers, thereby contributing to the quality care of dementia-afflicted individuals (Conway & Chenery, 2016;Eritz et al., 2016;Gwernan-Jones et al., 2020;Smythe et al., 2014Smythe et al., , 2017. Additionally, community care settings with nurses who have developed manual end-of-life care skills scored higher in terms of knowledge and attitudes (Nakanishi & Miyamoto, 2016). Contextually, at the time of assessing the barriers with respect to the development of dementia care, it was found that the lack of educational opportunity, limited access to training, staff shortages, lack of management support, time constraints and lack of funding were among the most predominant and common barriers experienced by healthcare personnel (Cooper et al., 2016;Gwernan-Jones et al., 2020;Monthaisong, 2018;Smythe et al., 2017).
Nurses' experience of care was also found to be influenced by the staff's working condition. For example, in the UK, researchers found poor staff working conditions, undertrained nurses and a negative image of the work setting had a negative impact, but despite these factors, nurses were compassionate towards dementia patients (Digby et al., 2018;Kupeli et al., 2016). A Swedish study found that nurses struggled to perform person-centred care for dementia patients, and most did not hold positive attitudes towards dementia patients (Ericson-Lidman et al., 2014); this is also confirmed by focused groups studied in Germany and Austria (Pinkert et al., 2018).
While in China, authors claimed that nurses caring for people with dementia in community care settings failed to apply person-centred care. In Australia, nurses argued that non-pharmacological interventions were not the nurses' role, claiming that they always worked under pressure (Digby et al., 2018;Ervin et al., 2014;Shannon et al., 2018). Therefore, nurse-patient communication and a conducive environment played an important role in changing the nurses' perceptions towards patients with dementia (Beck et al., 2017;Krupic et al., 2016;Rosendahl et al., 2016).
In contrast, studies conducted in acute care settings revealed poor quality of services and a lack of knowledge about dementia.
Issues like burnout and high-stress levels were common in patients.
Nurses' burnout and lack of essential knowledge of dementia incapacitate the delivery of quality services. In Japan, nurses within psychiatry wards who were working with aggressive dementia patients had high-stress levels and experienced burnout (Yada et al., 2014). However, if workplace environment stressors were reduced for nurses, the cognitive health of patients with dementia improved (Yada et al., 2014). In the UK, work pressures on nurses were influenced by different perceptions of patients with dementia (Lillekroken et al., 2015;Midtbust et al., 2018a); some indicted compassion and love while others experienced psychological stress (McPherson et al., 2016;Monthaisong, 2018;Yada et al., 2014). Thus, the work environment varied for nurses in different settings. A study evaluating dementia care experience from the perspective of nurses reported that inadequate staffing, along with few educational training opportunities, undermines the quality of care (Yous et al., 2019).
Job satisfaction was also linked to dementia care experience in both acute care settings and community care settings. Community care setting nurses from the Netherlands found that the level of nurses' job satisfaction, motivation and social support were different among those taking care of dementia patients (Adams et al., 2017).
The most significant factor that was correlated with higher job satisfaction and motivation was social support (Adams et al., 2017).
Inadequate nursing support leads to low job satisfaction in nurses taking care of dementia patients (Adams et al., 2017;Digby et al., 2017).
In both acute and community care settings, nurses may have to strive to understand the conditions of dementia patients and even struggle to adapt to the new cultural norms of offering quality care to these patients (Egede-Nissen et al., 2017;Evripidou et al., 2019). The nurses' perceptions towards dementia patients may vary depending on the severity of the dementia and even based on the patient's religion, ethnicity and gender (Tomlinson & Stott, 2015).

| Theme 3: Dementia nursing care across health regions
In the UK, the six qualitative studies mostly focused on investigating nurses' perceptions of dementia patients in both acute and community care settings (De Witt et al., 2017;Kupeli et al., 2016;Lee et al., 2017;McPherson et al., 2016;Ross et al., 2015;Smythe et al., 2017). Despite the nurses acknowledging the importance of end-of-life care, they struggled to administer good end-of-life care to dementia patients McPherson et al., 2016). In Norway, six qualitative studies were conducted in community care settings to investigate nurses' perceptions towards dementia patients and the nurses' caregiving (De Witt et al., 2017;Hansen et al., 2017;Jakobsen & Sørlie, 2016;Lillekroken et al., 2015;Skomakerstuen Ødbehr et al., 2015;Solli et al., 2015). Work pressure and nurses' burnout can be perceived by nurses to be the most significant reasons behind the mismanagement of dementia-afflicted patients (Chaudhury et al., 2017;Hunter et al., 2017;Midtbust et al., 2018b). In addition, these nurses also expressed that they felt that it is regular practice, which can assist in enhancing their knowledge together with educational interventions. This can further contribute to encouraging a positive attitude with respect to communication and personal interaction (de Witt & Ploeg, 2016;Eritz et al., 2016;Machiels et al., 2017). In the United States, four quantitative studies were conducted in both settings (Brody et al., 2016;Daniel et al., 2014;Karlin et al., 2017;Unroe et al., 2015), along with one mixed-method study (Sharpp & Young, 2016) in an acute care setting (dementia wards at the hospital), to gather a clear inference of the nurses' knowledge; this was done by investigating the nurses' attitudes towards dementia patients and towards dementia care.
The diversities in the practice and skill of the nurses led to an increase in the level of risks over time (de Witt & Ploeg, 2016;Unroe et al., 2015).
A few mixed-methods studies have been conducted within community and acute care settings to investigate nurses' knowledge of providing the required care to dementia-affected people (Cooper et al., 2016;Naughton et al., 2016;Smythe et al., 2014). However, considering the concept of communication, it can be inferred that a lack of empathy along with the aggressive behaviour of dementia patients tends to hamper the proper decision-making of nurses. One qualitative and one quantitative study in community care contributed to inferring the importance of non-verbal communication in decision-making (Krumm et al., 2014;Krupic et al., 2016;Kuehlmeyer et al., 2015;Saxell et al., 2019). A control trial study in Switzerland community care focused on nurses' knowledge (Kohler et al., 2016) and concluded that educational programmes improve the quality of care provided and could further reduce urinary incontinence issues in dementia patients. In South-East Asia, a mixed-method study was conducted in an acute care setting (medical ward) in South Korea (Kang et al., 2017), and there was a review that included South Korean nurses (Evripidou et al., 2019). It was declared that educational strategies alter self-confidence, which further leads towards improving the assessment of dementia patients (Kang et al., 2017). In Palestine, within community care settings, a significant variation in attitudes towards the autonomy and dignity of patients with dementia has been noted among 196 nurses (Bentwich et al., 2017). The researchers suggested that the nurses lacked positive perceptions of dementia patients, which further resulted in a failure to maintain autonomy and/or dignity in their care. This explains how nursing competency and the care environment can contribute to the dignity and quality of life of dementia patients (Jenkins, 2016).

| D ISCUSS I ON
The main objective of the current study was to synthesise a comprehensive body of evidence about nurses' knowledge, attitudes and practices towards dementia care. Another objective was to explore experience of care in acute care hospitals and community care settings and evaluate experience by different regions across the world.
A total of 72 articles were identified from the literature search, and these were classified into three themes. The majority of the reviews included qualitative or quantitative papers, but there were a few trials. knowledge and access to community services can broaden their understanding of safety (Kable et al., 2015). This will help in finding out how a care transition takes place from acute care to community care settings.
The third theme was related to experience of dementia care in different regions across the world. It has been found that the issue of burnout and work pressure is not limited to one setting. Studies done in Europe, the United States and Eastern Mediterranean countries reported these issues. Poor patient autonomy and violation of dignity in care were a major concern. For this reason, nurses are recommended to engage family members in the care to ensure that information about the patient's premorbid function and their likes/ dislikes could be obtained (Sagbakken et al., 2017).
Overall, the present review contributes to more knowledge about the current knowledge and attitude of nurses and how their knowledge, attitudes and perceptions is enhanced or reduced by different factors in care; it gives guidance about the areas that need more work.

| Strengths and weaknesses of the review
This review mainly aims to uncover the knowledge, attitudes and practices of nurses in dementia care. The strength of the review is that it includes 72 articles from diverse settings. In addition, not limiting the research to any specific research design was also a strength because it ensured that diverse types of papers were reviewed.
However, one major limitation of the review is that it lacked the inclusion of many randomized control trials. Because randomized control trial studies come under top quality in evidence hierarchy, including a few randomized control trial studies were important. The lack of these studies leaves a gap in the integrated review process.
Second, the review focused on the quality of each article. Hence, most of the studies were high-quality or good-quality papers, which were mostly evaluated using the JBI critical appraisal tools. The strength of the review is that no studies were found that had a quality appraisal score of less than 50%.

| Limitations of the studies
The main limitation of this study is it has been conducted by one researcher; however, all decisions and findings were discussed in supervisory meetings in order to reduce researcher's bias and maintain transparent findings and conclusion. Also, unequal data were found across the health regions and scarcity of literature available in most developing countries in Eastern Mediterranean and Asian region in particular.

| IMPLI C ATI ON S FOR P OLI C Y OR PR AC TICE CHANG E
To achieve best nursing practices and enhance dementia nursing care, researchers across the globe have acknowledged the importance of exploring and investigating nurses' knowledge, attitudes and perceptions towards people with dementia. Researchers have used different research methodologies to achieve this aim; however, there is an absence of studies in particular areas, such as in the Eastern Mediterranean and South-East Asia regions.
The current review's findings indicate that improving the practical experience of nurses enhances their knowledge of dementia, thereby leading to an improved quality of care. It is found that skill- shortages, lack of management support, time constraints and lack of funding are the factors to be addressed for improving dementia care. Additionally, leadership style influences the attitudes towards caring, thus negatively affecting the nurses' working atmosphere, which ultimately creates a somewhat negative impact on their work experiences.

| CON CLUS ION
Overall, the present review contributes to the understanding of the current knowledge and attitude of nurses and how their knowledge, attitudes and perceptions are enhanced or reduced by different factors in care; it gives guidance about the areas that need more work.
In particular, the studies found that having samples from a broader range of services can help researchers draw a more generalized understanding of how nurses may navigate through the ethical dilemmas of dealing with patients' various emotions and aggressive behaviours. Moreover, the role of working environment and leadership style in dementia care is vital for job satisfaction, which influences the care offered by nurses to people with dementia. Lastly, the issue of burnout and work pressure resulting from poor patient autonomy and violation of dignity in care is a major concern that affects nurses in all regions of the world.
Thus, future research needs to focus on educational interventions and training programmes, as these are an essential component in raising nurses' competency levels in managing patients' pain issues. In addition, evaluating nurses' knowledge and access to community services can broaden their understanding of safety and help in transitioning patients from acute care to community care settings.
Finally, nurses are advised to engage family members to ensure that the patient's care includes adjustments made for premorbid function and personal preferences.
This review mainly aims to synthesise the knowledge, attitudes and practices of nurses in dementia care. The strength of the review is that it includes 72 articles from diverse countries. In addition, not limiting the research to any specific research design was also a strength because it ensured that diverse types of studies were reviewed. This review focused on the quality of each article. Hence, most of the studies were high-quality or good-quality papers, which were mostly evaluated using the Joanna Briggs Institute critical appraisal tools. The strength of the review is that no studies were found that had a quality appraisal score of less than 50%.
It is everyone's right to have positive experiences and receive the right support when admitted to an acute or a community care facility. This study contributed to the current body of knowledge on the dementia nursing care and suggested possible areas that need more development and concerns to enhance the nursing care for people with dementia, which, in turn, can influence their well-being.

ACK N OWLED G EM ENTS
Special thanks for my PhD supervisors RB and SE for their continuous support and recommendations to improve my study.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest that are directly relevant to the content of this review.

E TH I C A L A PPROVA L
Ethical approval was not required.