Assessing the Confidence and Competency of Nurses in the Management of Pharmacotherapy in Older Patients: a Cross-sectional Study

Assessing the Confidence and Competency of Nurses in the Management of Pharmacotherapy in Older Patients: a Cross-sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the Confidence and Competency of Nurses in the Management of Pharmacotherapy in Older Patients: a Cross-sectional Study CarmenMaria Vitiello, Rita Manuela Bruno, Myriam Letizia Li Vigni, and 16 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8348146/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Nurses are on the frontline in drug treatment of older persons, which impacts on patients’ safety and well-being. Aim of the study was to assess nurses’ confidence and competency in geriatric pharmacotherapy. Methods After literature search, a questionnaire was developed and then refined with a Delphi procedure and cognitive interviews. In a cross-sectional study design, nurses attending an educational event in six Italian cities answered the questionnaire, exploring participants’ general characteristics and scoring confidence (range 0-40) and competency (range 0-100). Satisfactory competency was defined by a score in the top tertile. Results Out of 174 participants, 24, 67, and 83 were from Northern (NI), Central (CI), and Southern Italy (SI), respectively. The mean±SD confidence score was 23.9±4.8. Working in a Geriatrics setting and being employed in a hospital were independent predictors of higher confidence. The competency score (mean: 61.9±11.0) was independent of confidence (r= -0.026; p=0.729). Multivariable predictors of satisfactory competency scoring were: participants’ geographic location in NI (OR 3.3, 95% CI 1.0-10.9) or CI (OR 4.3, 95% CI 1.9-9.9) vs. SI, previous Geriatrics education (OR 2.2, 95% CI 1.0-4.7), and familiarity with bibliographic search engines (OR 1.55, 95% CI 0.99-2.43). Years since graduation were inversely associated with satisfactory scoring (OR 0.95, 95% CI 0.91-0.98). Conclusions This sample of Italian nurses showed moderate confidence and competency in managing drug therapy in older persons. Education, and not experience, was associated with satisfactory scoring. Efforts should be made to enhance training in Geriatrics and the utilization of tools for continuing education. Aged Competency Confidence MEN Study Nurses Pharmacotherapy Figures Figure 1 Background The management of pharmacotherapy in older persons is challenging in several aspects. Age-associated pharmacokinetic and pharmacodynamic changes may significantly modify the effects of drugs in late life [ 1 , 2 ]. Multimorbidity and other factors lead to polypharmacy, usually defined as the routine assumption of five or more drugs [ 3 , 4 ], which in turn reduces treatment adherence and increases the risk of interactions and adverse drug events [ 5 ]. Most medicines commonly used at an advanced age have been approved based on clinical trials that did not include complex and frail older adults, resulting in a lack of evidence for treatment efficacy and safety in this population [ 6 ]. Certain drugs largely prescribed to older persons are to be considered inappropriate, particularly in the presence of severe disability or cognitive impairment [ 7 , 8 ]. Although deprescription is increasingly considered a valuable option [ 9 ], uncertainty remains on its timing, modalities, and outcomes [ 10 ]. On the other hand, care must also be taken to prevent older patients from being denied potentially appropriate treatments [ 7 , 10 ]. End-of-life status requires a profound revision of the drug regimen [ 11 , 12 ]: yet the boundaries between terminal illness and advanced disease are not always clear, again raising the question of treatment appropriateness [ 13 ]. Medication errors are frequent and may potentially lead to adverse outcomes [ 14 ]. Before this complex scenario, the nurses' role in managing therapy in older persons is increasingly important [ 15 ]. Far from being simple executors of physicians’ orders, with the only responsibility of applying prescriptions carefully and without errors, nurses are extensively involved in most phases of the therapeutic process [ 16 ]. Some specific tasks, such as detailing and adapting the therapeutic scheme to patient and family, evaluating and promoting therapeutic adherence, or deciding whether and when to administer pro re nata drugs, are commonly accomplished by nurses. In some cases, such as in long-term care facilities, nurses are on the frontline in judging the effectiveness of therapeutic interventions or the possible occurrence of adverse drug events (ADE) [ 17 ]. As an example, the evaluation of the therapeutic and adverse effects of antipsychotic drugs prescribed to institutionalized patients with dementia-related behavioral disorders relies more on nurses, who see the patients continuously, than on the prescribing physician. Over the years, in Italy as in other countries, regulations have affirmed the autonomy of the nurses from other healthcare professionals [ 18 , 19 ]. In parallel with their professional role, the criminal liability of nurses has also increased. The Italian Supreme Court ruled that physicians and nurses share responsibility in drug management and that nurses, to avoid potentially incurring joint criminal liability, must intervene in case of perceived errors and report doubts about congruity, interpretation, or pertinence of the prescribed therapy [ 20 ]. Because nurses have such a relevant and demanding role in the management of geriatric pharmacotherapy, we deemed it important to evaluate their confidence and competency in dealing with such a complex task, and to assess the relationship between confidence and competency. To this purpose, we designed the Medications, Elderly, and Nursing (MEN) study. As a first step, we developed and validated a questionnaire, which was then submitted to a national sample of Italian nurses. Methods The study protocol follows Helsinki declaration and was approved by the Ethics Committee of the University of Florence (n. 226, July 27, 2022). Written informed consent was obtained from participants. Questionnaire development and validation The development of an appropriate tool for data collection was accomplished by a team of geriatricians (MDB, SET), nurses (LR, CV), and a pharmacist (PF). Three members (MDB, LR, PF) were professors of the corresponding disciplines at the University of Florence. The following four steps were considered: literature review, creating a first draft, refining the draft with a Delphi procedure, and assessing its content validity with cognitive interviews. To identify pertinent tools, we searched the literature in the period May - June 2020, applying on Pubmed the following search string without time limits: (drugs OR medications OR pharmacotherapy OR polypharmacy) AND (elderly OR older adults) AND (nurse knowledge OR nurse competency OR competency). Other titles were identified through cross-referencing and other sources. Two authors independently examined all the retrieved records and read the full text of the articles of interest. Disagreements were resolved by consensus. Content areas and items emerging from the literature review were shared among the team members. The first draft was developed by the team with the following fundamentals: 1) it must allow anonymous, in-person completion, because web-based approaches to data collection were considered unsatisfactory; 2) it should ideally be directed to expert nurses working with older persons in different settings (acute care hospitals, rehabilitation facilities, nursing homes, and community services) as well as to freshmen nurses; 3) it should include a first section to characterize the participants in terms of education, professional activity, and familiarity with tools for continuing education, a second one evaluating nurses’ confidence (self-efficacy) in handling drug therapy in older persons, and a third one assessing their competency on several geriatric pharmacotherapy issues; 4) the last two sections must allow the calculation of summary scores to quantify the constructs of interest. A panel of six experts, representing the three disciplines involved (Geriatrics: CP, SV; Nursing: YL, EZ; Pharmacy/Pharmacology: EC, EL) and external to the University of Florence, evaluated the draft using an iterative Delphi procedure [ 21 , 22 ]. Comments and changes were processed by a facilitator (MDB) and then returned to the panel members for further rounds until optimal convergence and final agreement. Finally, content validation of the draft in terms of relevance, comprehensiveness, and comprehensibility of questions and answers was assessed with cognitive interviews. An interview protocol was previously set up, in agreement with the COSMIN methodology [ 23 ], applying the retrospective probing procedure and the immediate retrospective approach [ 24 , 25 ]. A stratified purposeful sampling [ 26 ] procedure was conducted to enroll expert nurses working in hospital wards, expert nurses working in community services or nursing homes, and freshmen nurses within six months of graduation, all in the network of the Azienda Ospedaliero-Universitaria Careggi and the Azienda USL Toscana Centro. Interviews were conducted by three investigators (MLLV, CV, SET) and audio recorded. After each participant had completed the questionnaire, probe queries designed to elicit specific information about the questions, response options, and instructions of the questionnaire were administered. If discrepancies in the interpretation of some items were evident, suggestions for rewording were sought. Transcripts were analyzed independently by three researchers and subsequently compared; disagreements were solved by consensus. In case of relevant criticisms, the questionnaire was promptly modified and re-tested in subsequent interviews, until no new discrepancies arose. Data collection To obtain in-person administration of the questionnaire, an educational event on drug therapy in older persons was organized, which took place concurrently in six different Italian cities (Milan and Ferrara in Northern Italy, Florence and Rome in Central Italy, and Naples and Catanzaro in Southern Italy) on March 8, 2024. Participants were nurses working in hospitals, long-term care facilities, or community services, who voluntarily applied to attend the course and were physically present in a conference hall at each location on the event date. Speakers and moderators of the course were distributed in the six sites, which were Internet-connected to allow the synchronized administration of the test, followed by the sharing of the lectures. The questionnaire was distributed after participants' registration and was completed in the classrooms, before the beginning of the lectures. None of the attendees refused to complete the questionnaire. Statistical analysis Data were entered and analyzed centrally at the University of Florence, using IBM SPSS Statistics v. 29®. The reliability (internal consistency) of the second section of the questionnaire was examined with Cronbach's alpha. Interval variables were reported as mean ± SD when normally distributed or as median [IQR] otherwise; categorical variables were expressed as percentages. The bivariate associations of potential predictors, represented by selected variables from the first section, with the two outcomes of confidence and competency, were analyzed separately. Student’s t-test for independent samples and ANOVA (with a for trend test when appropriate) were used to compare means; Pearson’s r coefficient was calculated to examine correlations between interval variables. Given the small sample of nurses that eventually participated in the survey (see Results), categories with a limited number of answers were ultimately collapsed. Pearson’s correlation was used to examine the association between nurses’ confidence and their competency scores. Additional analyses were performed to identify the predictors of a satisfactory competency score, i.e., categorizing the continuous score into tertiles and then contrasting the top tertile with the bottom and the intermediate ones combined. These analyses were restricted to participants with no missing values in the variables that had reached statistical significance in the analyses based on the score as a continuous variable. Bivariate predictors of a satisfactory score were screened with the Chi-square test for categorical variables and the Mann–Whitney U test for interval ones. Variables with at least a trend for association with a satisfactory score (p ≤ 0.1) were then entered in logistic regression models, from which the redundant variables were backward deleted to identify the independent predictors. The goodness-of-fit of the models was tested with the Hosmer-Lemeshow test. Protection against type I error was set at α < 0.05. Results Findings from the literature review As shown by the flow chart of the literature search (Fig. 1 ), 7,916 titles were found in PubMed and three others from cross-referencing. From the 7,919 articles screened, 7,900 were excluded based on reading the title and abstract, while the remaining 19 were maintained. Of them, 12 were found unsuitable, and seven proved pertinent after reading the full text, as they described tools of interest (27–33). Agreement between the two investigators performing the literature review was 100% both in the screening phase and in the subsequent full-text analysis. Please insert Fig. 1 approximately here The tools proposed in the few articles retrieved were not completely adherent to our aim, as they focused mainly on medication errors [ 33 ], targeted only nurses in a specific setting, such as primary care [ 33 ], residential aged-care facilities [ 27 ], homecare [ 30 ], and ICU [ 32 ], or were designed for Internet administration [ 30 ]. However, the literature search offered some useful hints. In particular, we valued the 5-point Likert scale format for the confidence section [ 30 ], the content areas of drug interactions, ADE, and polypharmacy [ 31 ], and the “clinical scenario” format for the competency section [ 30 , 31 ]. First draft of the questionnaire The first section of the tool included 18 questions that, while always guaranteeing anonymity, characterized the participants in terms of demographics, education, area of professional activity, familiarity with, and time dedicated to continuing professional education. The second section evaluated the respondents’ confidence in geriatric pharmacotherapy and explored possible related educational needs, as a manifestation of poor confidence. It asked the participant to express his/her agreement with 10 statements on a 5-point Likert scale, ranging from “strongly agree” to “strongly disagree”. To prevent stereotyped answers, the statements were formulated in opposite directions (e.g., “ I find everything related to drug therapy for older persons stressful ” and “ Checking whether an older patient takes the therapy correctly is a task that I accomplish scrupulously ”), so that expressing agreement sometimes meant difficulty or discomfort and other times confidence or ease. For analytical purposes, the score assigned to the statements indicating difficulty was subsequently reversed; a summary score was therefore calculated, representing confidence progressively increasing from 0 to 40. The last section included 25 questions exploring nurses’ competency in issues such as polypharmacy, drug adherence, ADE, handling therapy in the presence of sensory or cognitive deficits, inappropriate drugs, delirium, and the role of the caregiver. Acknowledging that the participants would be professionals with at least some clinical expertise and not students, 10 questions asked participants how they would behave in each clinical scenario, based on their professional experience. For example: “ Mr. Mario comes to the clinic after hospitalization. While waiting for the medical examination, would you consider it appropriate to evaluate how Mario takes the drug therapy? If so, how would you proceed? ”. Each question might have several acceptable answers out of the five proposed, for a total of 50; the number of acceptable answers was not known to the participants. To score this section of the questionnaire, we first calculated the proportion of correct answers out of 50 and then subtracted from this quantity the proportion of wrong answers out of the total number of answers provided. The result of this calculation, ranging from − 1 to 1, was multiplied by 50 and added to 50 to obtain a score ranging from 0 (worst performance) to 100 (best performance), according to the following formula: Score = [(correct answers/50) - (wrong answers/total answers given)] x 50 + 50. Delphi procedure In the Delphi procedure, the multidisciplinary team approved the general architecture of the questionnaire, and in particular the unusual structure and scoring system of its third section. No requests were made to add or delete any items. In the first Delphi round, it was suggested to collect the participants’ age in classes and not as a continuous variable to better preserve anonymity, to use a non-binary definition of gender, to propose a more detailed identification of the service where the respondent worked, and to specify that “knowledge of scientific English” referred to “article reading and comprehension”. In the second round, it was proposed to add to the first section a question asking whether the respondent had some formal training in Geriatrics. Other minor formal changes were also introduced to make questions and answers more understandable even by non-Italian mother language participants. All these changes were eventually approved in the third round: in its final version, the first part of the questionnaire included 19 questions, whereas the second and third sections maintained 10 and 25 items, respectively. Cognitive interviews Fifteen nurses participated in the cognitive interviews. The sample was evenly distributed in the three strata of nurses working in hospital wards, nurses working in community services or nursing homes, and freshmen nurses within six months of graduation. The interview duration ranged between 32 and 55 minutes (median [IQR]: 40 [ 37 , 43 ]). The time required to complete the questionnaire was 20 [ 19 , 22 ] minutes. Overall, the participants judged the questionnaire well-structured and understandable. The first three interviewees suggested adding a question on crushable drugs to the third section, whereas two others considered poorly pertinent a question on the side effects of anti-inflammatory drugs. The researchers' team agreed on crushable drugs as an important issue: a question on this theme was added in a revised version of the tool, while removing the question on anti-inflammatory drugs’ side effects to maintain the number of 25 questions and 50 correct answers. No other proposals to add or delete items were made in the 12 subsequent interviews. Suggestions sporadically made for minor rephrasing of a limited number of questions or answers were rejected by the researchers as irrelevant or potentially pejorative. At the end of the cognitive interviewing phase, the questionnaire was considered ready for use. The original Italian version of the questionnaire, as well as its authors’ English translation, is available on request. Reliability analysis Because no changes were proposed to the second section of the questionnaire, the answers provided by the 15 participants to the cognitive interviews were considered suitable for reliability analysis. Cronbach's alpha was 0.739, supporting the internal consistency of the tool (34 Tavakol, 2011). Field data collection A total of 174 nurses answered the questionnaire. Their characteristics are reported in Table 1 . Most of the respondents participated in the educational event in the two sites in Southern Italy and were younger than 35 years. Half of them had some kind of postgraduate academic qualification, and approximately one-third had attended Geriatrics classes at some point during their education. Nearly one-third of the sample worked in a Geriatrics ward or a nursing home. On average, the recruited nurses declared intermediate confidence in the scientific English and bibliographic search engines. Table 1 General characteristics of the 174 participants. Variable N (%) Median [IQR] Age (years) < 35 78 (44.8) 35–44 28 (16.1) 45–54 40 (23) 55+ 28 (16.1) Men 1 40 (23.0) Geographic area North 24 (13.8) Centre 67 (38.5) South 83 (47.7) Years after graduation 12.5 [ 7 – 26 ] Achieved postgraduate degree 88 (50.6) Received formal Geriatrics education 2 57 (32.8) Employed in a Geriatrics ward or a NH 50 (28.7) Workplace 3 Hospital Others 116 (67.8) 55 (32.2) Educational resources available in the workplace 3 102 (58.6) Confidence with scientific English, range 1–5 3 [ 2 – 4 ] Confidence with bibliographic search engines, range 1–5 1 3 [ 2 – 4 ] Time spent in continuing educ. (hrs/week) 4 1[ 1 – 3 ] Because of missing values, the total number of observations was lower than 174 for the following variables: 1 n = 173, 2 n = 170, 3 n = 171, 4 n = 167. Abbreviation. NH: Nursing Home. Please insert Table 1 approximately here Confidence On average, the reported level of confidence was moderate, with a mean ± SD score of 23.9 ± 4.8 within an IQR of [21.0, 27.0]. As shown in Table 2 , nurses working in a Geriatrics ward or a nursing home achieved a higher confidence score compared to those working in other settings. Nurses employed in a hospital showed greater confidence than those who worked in other services. Table 2 Bivariate predictors of the confidence score. ANOVA or Student’s t-test for categorical predicting variables and Pearson’s correlation for interval ones. N = 174 unless otherwise specified. Variable Mean score (SD) r p value Age (years) 0.939* < 35 13.6 (4.6) 35–44 14.0 (5.7) 45–54 14.2 (5.1) 55+ 13.9 (4.8) Gender 1 0.357 Men 14.5 (5.0) Women 13.7 (4.7) Geographic area North 13.8 (6.1) 0.898 Centre 13.7 (5.2) South 14.0 (4.0) Years after graduation 0.08 0.295 Postgraduate degree 0.966 Yes 13.9 (5.0) No 13.9 (4.6) Formal Geriatrics education 2 0.521 Yes 14.2 (4.5) No 13.7 (4.9) Employed in a Geriatrics ward or a NH 0.045 Yes 15.3 (3.7) No 13.5 (4.9) Workplace 3 < 0.001 Hospital Others 14.8 (4.1) 11.9 (5.6) Educational resources in the workplace 3 0.163 Yes 14.3 (4.9) No 13.3 (4.6) Confidence with scientific English 0.063 0.411 Confidence with bibliographic search engines 1 0.117 0.124 Time spent in continuing educ. (hrs/week) 4 0.035 0.658 Non-missing observations: 1 n = 173, 2 n = 170, 3 n = 171, 4 n = 167. * For trend value. Abbreviation as in Table 1 . In an ANOVA model adjusted for age and sex, working in a Geriatrics ward or a nursing home and being employed in a hospital facility were independent predictors of higher confidence (p < 0.001 for both variables). Please insert Table 2 approximately here Competency Overall, the participants showed moderate competency, as demonstrated by a mean score of 61.9 ± 11.0 within an IQR of [54.2, 70.7]; none achieved the full score. As reported in Table 3 , the score decreased progressively with increasing age and time after graduation, and differed across regions, with the highest value obtained in Central Italy and the lowest in Southern Italy. Other variables positively associated with the competency score were a formal Geriatrics education, increasing confidence in the scientific English and bibliographic search engines, and the time spent in continuing education. Table 3 Bivariate predictors of the competency score. ANOVA or Student’s t-test for categorical predictors and Pearson’s correlation for interval ones. N = 174 unless otherwise specified. Variable Mean score (SD) r p value Age (years) 0.001* < 35 63.2 (10.9) 35–44 63.7 (11.7) 45–54 62.6 (9.9) 55+ 61.9 (11) Gender 1 0.950 Men 62.0 (10.5) Women 61.9 (12.6) Geographic area North 62.6 (10.7) 0.015 Centre 64.6 (10.6) South 59.5 (10. 9) Years after graduation -0.075 0.021 Postgraduate degree 0.117 Yes 63.2 (10.9) No 60.6 (11) Formal Geriatrics education 1 0.005 Yes 65.2 (10.0) No 60.2 (11.2) Employed in a Geriatrics ward or a NH 0.405 Yes No 61.1 (10.4) Workplace 3 62.1 (11.1) 0.533 Hospital Others Educational resources in the workplace 3 61.6 (11.0) 0.223 Yes 62.7 (11.2) No Confidence with scientific English 0.172 0.023 Confidence with bibliographic search engines 1 0.155 0.042 Time spent in continuing educ. (hrs/week) 4 0.159 0.041 Non-missing observations: 1 n = 173, 2 n = 170, 3 n = 171, 4 n = 167. * For trend value. Abbreviation as in Table 1 . Please insert Table 3 approximately here Confidence vs. competency The confidence and competency scores were not associated (r= -0.026; p = 0.729). Predictors of satisfactory competency scoring The cut-off identifying the top tertile, representing satisfactory competency scoring, was 68.1. As reported in Table 4 , in the 163 participants with complete data in the core variables, the only bivariate predictors of satisfactory competency scoring were age, geographic area, previous formal Geriatrics education, greater confidence with the scientific English and bibliographic search engines, and a shorter time interval from graduation. Additionally, satisfactory performance was associated with a slightly, non-significantly longer time dedicated to continuous professional education. Table 4 Bivariate associations of satisfactory competency score (top tertile, N = 55 vs. intermediate and bottom tertiles, N = 108) in 163 participants with complete data. Variables selected are those reaching statistical significance in the analyses reported in Table 3 . N (%) and chi-square test for categorical variables, median [IQR] and Mann-Whitney test for interval ones. Variable Top tertile, N (%) or median [IQR] Intermediate / bottom tertiles, N (%) or median [IQR] p value Age (years) 0.005§ < 35 30 (41.1) 43 (58.9) 35–44 11 (40.7) 16 (59.3) 45–54 12 (33.3) 24 (66.7) 55+ 2 (7.4) 25 (92.6) Geographic area 0.035 North 8 (38.1) 13 (61.9) Centre 28 (44.4) 35 (55.6) South 19 (24.1) 60 (75.9) Years after graduation 10 [ 8 , 18 ] 16 [ 8 , 28 ] 0.021 Formal Geriatrics education 0.001 Yes 27 (25.2) 80(74.8) No 28 (50.0) 28 (50.0) Confidence with scientific English 3 [ 3 , 4 ] 3 [ 2 , 4 ] 0.015 Confidence with bibliographic search engines 3 [ 3 , 4 ] 3 [2,3.8] 0.003 Time spent in continuous education (hrs/week) 1 [1,2.8] 1 [ 1 , 5 ] 0.052 * For trend value. Please insert Table 4 approximately here The candidate predictors resulting from these preliminary analyses were then entered into logistic regression models to identify those independently associated with satisfactory scoring. Because a person’s age and the years since graduation are strongly related and potentially collinear, different models were built (Table 5 , Models 1 and 2), where these two variables were entered alternatively or simultaneously (Model 3, not shown). In Models 1 and 2, the odds of achieving satisfactory scoring were 4- to 5-fold greater in participants from Northern and Central Italy compared to Southern Italy and 2-fold greater in those with vs. without formal Geriatrics education. A younger age (Model 1) or achieving graduation more recently (Model 2) were conditions independently associated with satisfactory scoring, which was also associated with increasing confidence in scientific English (Model 1) or bibliographic research engines (Model 2). When age and time from graduation were entered in Model 3, the first variable was backward deleted and, therefore, the coefficients in the final parsimonious model were identical to those in Model 2. The time dedicated to continuous professional education was backward deleted as redundant from all models. The goodness-of-fit was satisfactory in all the models. Table 5 Logistic regression models of factors associated with satisfactory competency score (top tertile vs. intermediate and bottom tertiles combined) in 163 participants with complete data. OR (95% CI) p-value Model 1 * Age (years) < 35 35–44 45–54 55+ 11.2 (2.2–58.1) 12.4 (2.1–72.1) 5.9 (1.1–31.3) Ref. 0.023 Geographic area North Centre South 5.2 (1.4–18.8) 4.2 (1.9–9.6) Ref. 0.001 Formal Geriatrics education (Yes vs. No) 2.0 (0.93–4.34) 0.075 Confidence with scientific English (1-point increase) 1.4 (0.93–2.1) 0.100 Model 2 ** Geographic area North Centre South 3.3 (1.0-10.9) 4.3 (1.9–9.9) Ref. 0.002 Formal Geriatrics education (Yes vs. No) 2.2 (1.0-4.7) 0.048 Time from graduation (1-year increase) 0.95 (0.91–0.98) 0.005 Confidence with bibliographic search engines (1-point increase) 1.55 (0.99–2.43) 0.055 * Time dedicated to continuous professional education and confidence with bibliographic research engines backward deleted as redundant. ** Time dedicated to continuous professional education and confidence with scientific English backward deleted as redundant. Please insert Table 5 approximately here Because participants from Southern Italy had significantly lower and seemingly independent odds of achieving a satisfactory score, supplementary analyses were performed in the 163 participants with complete data (79 from Southern Italy, 84 from Northern and Central Italy combined) to better interpret this association. Compared with participants from Northern and Central Italy combined, those from Southern Italy were predominantly males and younger, had a shorter time interval from graduation, more frequently achieved some postgraduate degree, received formal Geriatrics education in only a slightly lower proportion, and reported better confidence with the scientific English and bibliographic search engines (supplementary Table S1 ). Discussion Building on the scarce existing literature [ 27 – 33 ], we drafted a questionnaire to gather information on the confidence and competency of nurses in the management of drug therapy in older persons. The tool was subsequently validated according to the opinions of a multidisciplinary panel of experts and a group of nurses representative of those who would eventually fill in the questionnaire. We then applied the tool in the field, enrolling a national sample of Italian nurses, whose level of confidence in the management of pharmacotherapy in older patients was intermediate and positively and independently associated with working in a Geriatrics setting and in a hospital facility. Overall, participants’ competency in handling therapy was modest. Satisfactory competency scoring was predicted by participants’ geographic location, previous formal Geriatrics education, and confidence with resources for continuing professional education. The level of competency appeared to fade with time, expressed as either chronological age or time after graduation. A quarter of a century ago, a study reported that drug therapy and drug interactions were ranked as the highest educational needs by nurses working in nursing facilities in the United States [ 35 ]. Attention to this issue remains very high, as medication management has recently been considered a crucial component of the curriculum for Bachelor of Science in nursing studies, developed in response to a nursing mandate in long-term care [ 36 ]. Thus, understanding nurses' learning needs and their level of competency has been lengthy, and remains, important because these factors impact patients’ well-being and safety [ 37 ], especially in light of the increasing role and autonomy of nurses. Specifically, nurses may greatly contribute to the chain of medication safety in some settings, such as homecare and nursing homes [ 38 ]: because of their frequent patient contact and their education to observe changes in the patient’s state, they are indeed very well positioned to recognize, and possibly prevent, early potential drug-related problems, despite their limited medical and pharmacological knowledge. The bibliographic search conducted as a first step of our work confirmed that a general problem of nurses' poor knowledge of drug therapy exists across several countries and requires an extensive and rigorous investigation. Yet, this topic received less attention than one would expect. Moreover, the tools proposed in the few articles retrieved were not completely adherent to the MEN study's broad goal. This compelled us to develop a new tool. In doing this, we took advantage of some examples in the literature: we appreciated and applied extensively the “clinical scenario” format found in other studies [ 30 , 31 ] because it seemed appropriate to approach professionals who may have years of clinical experience. No more recent pertinent studies were found in the updated search after the MEN study data collection was completed. Previous studies have generally shown that nurses’ confidence and competency in handling pharmacotherapy, with patients of any age and in different clinical settings, are suboptimal [ 28 , 32 , 39 , 40 ]. Disappointing results were confirmed by the few investigations specific to the geriatric field [ 27 , 30 ]. Thus, despite several methodological differences, our findings compare well to those from previous studies. For example, Sino et al. assessed the nurses’ level of self-efficacy on drug-related issues by proposing statements regarding participants’ attitudes towards administering drugs and calculating the proportion of agreement with these statements [ 30 ], whereas we calculated a summary score expressing nurses' overall confidence. Like previous studies, we found that confidence and competency were poorly related. In a group of 110 UK community nurses, Sodha et al. assessed self-rated knowledge and actual ability to solve medicine-related issues in five clinical scenarios involving patients of any age: although prescribing nurses declared a greater level of confidence compared to non-prescribing ones, they still lacked the necessary degree of knowledge [ 41 ]. Our study also highlights differences associated with the geographic area of enrollment. Participants from Central and Northern Italy had significantly and independently greater odds of scoring in the top tertile than those from Southern Italy, although the latter were younger and better educated, and reported also greater familiarity with resources for continuing professional education, than the former. Although residual confounding cannot be excluded, other explanations might be invoked. Indeed, our findings echo the well-documented inequalities in the performance of the Italian National Health System across regions, whose reasons are complex and difficult to disentangle. Based on the data from the Italian Health Ministry, the Svimez Report 2023 [ 42 ] showed that none of the regions from Southern Italy dispense services in the best two quality quartiles, and, conversely, as many as five of the seven regions with the worst performances are in Southern Italy. The competency of healthcare professionals can be expected to be strictly and mutually interlaced with the performance of the service itself, and the lower level of competencies exhibited by our participants from Southern Italy probably reflects these dynamics. It should also be pointed out that, according to standardized evaluations, the quality of the educational programs is lower in Southern Italy: among the academic programs in the medical field ranking in the top 20 positions of the 2024 CENSIS report, only one was based in Southern Italy [ 43 ]. We found that competency was boosted by receiving specific training in Geriatrics or being confident with resources for continuous professional education, whereas it decreased progressively with increasing time after graduation. Taken together, these findings emphasize that education and training are superior to accumulating years of experience in achieving satisfactory performance. However, given the cross-sectional design of this study, it cannot be ascertained whether this result indicates that education on these issues is improving across students’ cohorts, or rather that competency fades progressively with time in the same individual. Important components of education are reflexivity and self-assessment [ 44 ], which imply the ability to recognize one’s own educational needs. Professionals unable to self-assess may fail to recognize their limited competencies, make no efforts to improve them, and show unjustified confidence. At the same time, awareness of their medication errors has been shown to decrease self-esteem in a sample of nurses [ 45 ]. This may also explain the lack of association between confidence and competency in our study. This study has several strengths. In the absence of a gold standard, a new tool was drafted by a team combining the three specialties of Nursing, Geriatrics, and Pharmacy/Pharmacology. The panel conducting the Delphi procedure had a similar multidisciplinary composition and included experts from different institutions across Italy, favoring the national applicability of the questionnaire. To evaluate content validity, we applied a rigorous procedure for cognitive interviewing, in agreement with current guidelines [ 23 ], and enrolled participants representative of the target population. Three independent researchers analyzed the interviews, and the tool was modified and re-tested accordingly. The questionnaire quantified both nurses’ confidence and competency, thus allowing exploring their mutual relationships, as well as the associations with potential predictors from the first section. The internal consistency of the second section was satisfactory. The “clinical scenario” format of many questions in the third section should be better received by expert professionals. Finally, the time required to complete the questionnaire was acceptable. To enhance the representativeness of our field data collection, the sample involved professionals working in diverse facilities and wards across the country. The in-person administration prevented the risks inherent in online surveys, such as unknown response rates, unclear representativeness of the target population, and uncertainty about whether the respondents received help from outside information sources and colleagues. In the third section of the questionnaire, the presence of more than one acceptable answer allowed the respondents to choose all the options closer to their habitual behavior. The scoring system facilitated summarizing competency in a single number while correcting the total number of right answers for the number of wrong answers. Study limitations should be acknowledged, both in the development and validation of the tool and in the field data collection. The tool developed could not be validated against an accepted gold standard because none exists, and validation was limited to experts’ opinions. Unlike the panel in the Delphi procedure, the participants in the cognitive interviews all came from the same geographic area: this might limit the generalizability of the findings of this step of the study. The applicability of the tool in other countries has not been evaluated. The sample was small and unevenly distributed across the different geographic areas. Participants were self-selected because they attended an educational event on the same topic that was investigated. Although participation was open to nurses from out-of-hospital services, most participants came from hospital facilities. We could not ascertain whether the level of competency expressed by our participants truly corresponded to different levels of professional performance and to different patients’ outcomes. Our analyses assumed that each participant had his/her training in the same part of Italy where he/she was enrolled, but this assumption might not always be true. Finally, broad differences in education and professional classification of nurses exist between Italy and other countries: therefore, the generalizability of our results to other countries is uncertain. Conclusions Using a newly developed and validated questionnaire, we found that, irrespective of their perceived confidence and educational needs, the competency in geriatric pharmacology of our Italian national sample of nurses was limited and decreased with time since graduation, especially if they had not received formal Geriatrics training and were poorly familiar with tools for continuing professional education. These findings may have important implications. Since nurses have a central role in the management of drug therapy in older persons, implementing a geriatric curriculum in academic nursing programs and promoting professional education in Geriatrics after graduation may contribute to enhancing nurses’ competency on this topic. This, in turn, should improve the safety of older, frail persons with multimorbidity and polypharmacy. It is also clear that efforts should be made to reduce the geographic gap in nurses’ competency across Italy. Abbreviations ADE: Adverse Drug Events ANOVA: Analysis Of Variance CI: Central Italy COSMIN: COnsensus‐based Standards for the selection of health Measurement INstruments IQR: InterQuartile Range MEN: Medications. Elderly, and Nursing NI: Northern Italy OR: Odds Ratio SD: Standard Deviation SI: Southern Italy SPSS: Statistical Package for Social Sciences USL: Unità Sanitaria Locale (Local Healthcare Unit) Declarations Ethical approval. The study protocol was approved by the Ethics Committee of the University of Florence (n. 226, July 27, 2022). Written informed consent was obtained from participants. Consent for publication. Not applicable. Availability of data and materials. Data and materials generated and/or analysed during the current study are not publicly available because we may wish to extend the study to different areas of the country. However, they may be available upon a reasonable request. Competing interest. The authors declare no conflicts of interest. Funding. This study was partially supported by MDB’s institutional funds (UNIFI ex 60% 2023). Supplementary information. The online version contains supplementary material (supplementary Table S1). Authors’ contributions. AC: Data curation, Writing – review & editing. AS: Resources, Writing – review & editing. CMV: Conceptualization, Acquisition of subjects, Data curation, Writing – review & editing. CP: Methodology, Writing – review & editing. EC: Analysis and interpretation of data, Writing – review & editing. EL: Analysis and interpretation of data, Writing – review & editing. EZ: Analysis and interpretation of data, Writing – review & editing. GC: Data curation, Writing – review & editing. LR: Methodology, Writing – review & editing. MDB: Conceptualization, Methodology, Resources, Writing – original draft. MLLV: Acquisition of subjects, Data curation, Writing – review & editing. MP: Data curation, Writing – review & editing. PA: Resources, Writing – review & editing. PF: Data curation, Methodology, Writing – review & editing. RMB: Conceptualization, Formal analysis, Writing – original draft. SET: Conceptualization, Acquisition of subjects, Data curation, Writing – review & editing. SV: Methodology, Writing – review & editing. TR: Data curation, Writing – review & editing. YL: Methodology, Writing – review & editing. Acknowledgments. All those who contributed significantly to the work have been listed. 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Supplementary Files ONLINEAPPENDIX.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 08 Jan, 2026 Editor invited by journal 18 Dec, 2025 Editor assigned by journal 16 Dec, 2025 Submission checks completed at journal 16 Dec, 2025 First submitted to journal 12 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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09:16:34","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":178265,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8348146/v1/b6a10f90760dbd05d07beaad.html"},{"id":100124960,"identity":"65437460-4281-4131-b021-89cc79d3d6f7","added_by":"auto","created_at":"2026-01-13 09:16:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57235,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-chart of the literature search.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8348146/v1/3ccf497bb5a9fa3fb00a961a.png"},{"id":100382059,"identity":"8da4cf38-22a6-4f47-b334-453f5c367d37","added_by":"auto","created_at":"2026-01-16 10:40:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1361910,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8348146/v1/07425bce-9a09-44ad-83ef-376919a54152.pdf"},{"id":100124957,"identity":"f95036dd-5099-4f3f-9077-21b519ed32dd","added_by":"auto","created_at":"2026-01-13 09:16:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17783,"visible":true,"origin":"","legend":"","description":"","filename":"ONLINEAPPENDIX.docx","url":"https://assets-eu.researchsquare.com/files/rs-8348146/v1/e6534d3e91b3d12c93aee985.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the Confidence and Competency of Nurses in the Management of Pharmacotherapy in Older Patients: a Cross-sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe management of pharmacotherapy in older persons is challenging in several aspects. Age-associated pharmacokinetic and pharmacodynamic changes may significantly modify the effects of drugs in late life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Multimorbidity and other factors lead to polypharmacy, usually defined as the routine assumption of five or more drugs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], which in turn reduces treatment adherence and increases the risk of interactions and adverse drug events [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Most medicines commonly used at an advanced age have been approved based on clinical trials that did not include complex and frail older adults, resulting in a lack of evidence for treatment efficacy and safety in this population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Certain drugs largely prescribed to older persons are to be considered inappropriate, particularly in the presence of severe disability or cognitive impairment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although deprescription is increasingly considered a valuable option [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], uncertainty remains on its timing, modalities, and outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. On the other hand, care must also be taken to prevent older patients from being denied potentially appropriate treatments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. End-of-life status requires a profound revision of the drug regimen [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]: yet the boundaries between terminal illness and advanced disease are not always clear, again raising the question of treatment appropriateness [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Medication errors are frequent and may potentially lead to adverse outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBefore this complex scenario, the nurses' role in managing therapy in older persons is increasingly important [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Far from being simple executors of physicians\u0026rsquo; orders, with the only responsibility of applying prescriptions carefully and without errors, nurses are extensively involved in most phases of the therapeutic process [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some specific tasks, such as detailing and adapting the therapeutic scheme to patient and family, evaluating and promoting therapeutic adherence, or deciding whether and when to administer \u003cem\u003epro re nata\u003c/em\u003e drugs, are commonly accomplished by nurses. In some cases, such as in long-term care facilities, nurses are on the frontline in judging the effectiveness of therapeutic interventions or the possible occurrence of adverse drug events (ADE) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As an example, the evaluation of the therapeutic and adverse effects of antipsychotic drugs prescribed to institutionalized patients with dementia-related behavioral disorders relies more on nurses, who see the patients continuously, than on the prescribing physician.\u003c/p\u003e \u003cp\u003eOver the years, in Italy as in other countries, regulations have affirmed the autonomy of the nurses from other healthcare professionals [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In parallel with their professional role, the criminal liability of nurses has also increased. The Italian Supreme Court ruled that physicians and nurses share responsibility in drug management and that nurses, to avoid potentially incurring joint criminal liability, must intervene in case of perceived errors and report doubts about congruity, interpretation, or pertinence of the prescribed therapy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause nurses have such a relevant and demanding role in the management of geriatric pharmacotherapy, we deemed it important to evaluate their confidence and competency in dealing with such a complex task, and to assess the relationship between confidence and competency. To this purpose, we designed the Medications, Elderly, and Nursing (MEN) study. As a first step, we developed and validated a questionnaire, which was then submitted to a national sample of Italian nurses.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The study protocol follows Helsinki declaration and was approved by the Ethics Committee of the University of Florence (n. 226, July 27, 2022). Written informed consent was obtained from participants.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire development and validation\u003c/h2\u003e \u003cp\u003eThe development of an appropriate tool for data collection was accomplished by a team of geriatricians (MDB, SET), nurses (LR, CV), and a pharmacist (PF). Three members (MDB, LR, PF) were professors of the corresponding disciplines at the University of Florence. The following four steps were considered: literature review, creating a first draft, refining the draft with a Delphi procedure, and assessing its content validity with cognitive interviews.\u003c/p\u003e \u003cp\u003eTo identify pertinent tools, we searched the literature in the period May - June 2020, applying on Pubmed the following search string without time limits:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e(drugs OR medications OR pharmacotherapy OR polypharmacy) AND (elderly OR older adults) AND (nurse knowledge OR nurse competency OR competency).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther titles were identified through cross-referencing and other sources. Two authors independently examined all the retrieved records and read the full text of the articles of interest. Disagreements were resolved by consensus. Content areas and items emerging from the literature review were shared among the team members.\u003c/p\u003e \u003cp\u003eThe first draft was developed by the team with the following fundamentals: 1) it must allow anonymous, in-person completion, because web-based approaches to data collection were considered unsatisfactory; 2) it should ideally be directed to expert nurses working with older persons in different settings (acute care hospitals, rehabilitation facilities, nursing homes, and community services) as well as to freshmen nurses; 3) it should include a first section to characterize the participants in terms of education, professional activity, and familiarity with tools for continuing education, a second one evaluating nurses\u0026rsquo; confidence (self-efficacy) in handling drug therapy in older persons, and a third one assessing their competency on several geriatric pharmacotherapy issues; 4) the last two sections must allow the calculation of summary scores to quantify the constructs of interest.\u003c/p\u003e \u003cp\u003eA panel of six experts, representing the three disciplines involved (Geriatrics: CP, SV; Nursing: YL, EZ; Pharmacy/Pharmacology: EC, EL) and external to the University of Florence, evaluated the draft using an iterative Delphi procedure [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Comments and changes were processed by a facilitator (MDB) and then returned to the panel members for further rounds until optimal convergence and final agreement. Finally, content validation of the draft in terms of relevance, comprehensiveness, and comprehensibility of questions and answers was assessed with cognitive interviews. An interview protocol was previously set up, in agreement with the COSMIN methodology [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], applying the retrospective probing procedure and the immediate retrospective approach [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A stratified purposeful sampling [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] procedure was conducted to enroll expert nurses working in hospital wards, expert nurses working in community services or nursing homes, and freshmen nurses within six months of graduation, all in the network of the Azienda Ospedaliero-Universitaria Careggi and the Azienda USL Toscana Centro. Interviews were conducted by three investigators (MLLV, CV, SET) and audio recorded. After each participant had completed the questionnaire, probe queries designed to elicit specific information about the questions, response options, and instructions of the questionnaire were administered. If discrepancies in the interpretation of some items were evident, suggestions for rewording were sought. Transcripts were analyzed independently by three researchers and subsequently compared; disagreements were solved by consensus. In case of relevant criticisms, the questionnaire was promptly modified and re-tested in subsequent interviews, until no new discrepancies arose.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eTo obtain in-person administration of the questionnaire, an educational event on drug therapy in older persons was organized, which took place concurrently in six different Italian cities (Milan and Ferrara in Northern Italy, Florence and Rome in Central Italy, and Naples and Catanzaro in Southern Italy) on March 8, 2024. Participants were nurses working in hospitals, long-term care facilities, or community services, who voluntarily applied to attend the course and were physically present in a conference hall at each location on the event date. Speakers and moderators of the course were distributed in the six sites, which were Internet-connected to allow the synchronized administration of the test, followed by the sharing of the lectures. The questionnaire was distributed after participants' registration and was completed in the classrooms, before the beginning of the lectures. None of the attendees refused to complete the questionnaire.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were entered and analyzed centrally at the University of Florence, using IBM SPSS Statistics v. 29\u0026reg;. The reliability (internal consistency) of the second section of the questionnaire was examined with Cronbach's alpha.\u003c/p\u003e \u003cp\u003eInterval variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD when normally distributed or as median [IQR] otherwise; categorical variables were expressed as percentages. The bivariate associations of potential predictors, represented by selected variables from the first section, with the two outcomes of confidence and competency, were analyzed separately. Student\u0026rsquo;s t-test for independent samples and ANOVA (with a for trend test when appropriate) were used to compare means; Pearson\u0026rsquo;s r coefficient was calculated to examine correlations between interval variables. Given the small sample of nurses that eventually participated in the survey (see Results), categories with a limited number of answers were ultimately collapsed.\u003c/p\u003e \u003cp\u003ePearson\u0026rsquo;s correlation was used to examine the association between nurses\u0026rsquo; confidence and their competency scores.\u003c/p\u003e \u003cp\u003eAdditional analyses were performed to identify the predictors of a satisfactory competency score, i.e., categorizing the continuous score into tertiles and then contrasting the top tertile with the bottom and the intermediate ones combined. These analyses were restricted to participants with no missing values in the variables that had reached statistical significance in the analyses based on the score as a continuous variable. Bivariate predictors of a satisfactory score were screened with the Chi-square test for categorical variables and the Mann\u0026ndash;Whitney U test for interval ones. Variables with at least a trend for association with a satisfactory score (p\u0026thinsp;\u0026le;\u0026thinsp;0.1) were then entered in logistic regression models, from which the redundant variables were backward deleted to identify the independent predictors. The goodness-of-fit of the models was tested with the Hosmer-Lemeshow test.\u003c/p\u003e \u003cp\u003eProtection against type I error was set at α\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFindings from the literature review\u003c/h2\u003e \u003cp\u003eAs shown by the flow chart of the literature search (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 7,916 titles were found in PubMed and three others from cross-referencing. From the 7,919 articles screened, 7,900 were excluded based on reading the title and abstract, while the remaining 19 were maintained. Of them, 12 were found unsuitable, and seven proved pertinent after reading the full text, as they described tools of interest (27\u0026ndash;33). Agreement between the two investigators performing the literature review was 100% both in the screening phase and in the subsequent full-text analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePlease insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e approximately here\u003c/h2\u003e \u003cp\u003eThe tools proposed in the few articles retrieved were not completely adherent to our aim, as they focused mainly on medication errors [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], targeted only nurses in a specific setting, such as primary care [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], residential aged-care facilities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], homecare [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and ICU [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], or were designed for Internet administration [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, the literature search offered some useful hints. In particular, we valued the 5-point Likert scale format for the confidence section [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], the content areas of drug interactions, ADE, and polypharmacy [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and the \u0026ldquo;clinical scenario\u0026rdquo; format for the competency section [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFirst draft of the questionnaire\u003c/h3\u003e\n\u003cp\u003eThe first section of the tool included 18 questions that, while always guaranteeing anonymity, characterized the participants in terms of demographics, education, area of professional activity, familiarity with, and time dedicated to continuing professional education.\u003c/p\u003e \u003cp\u003eThe second section evaluated the respondents\u0026rsquo; confidence in geriatric pharmacotherapy and explored possible related educational needs, as a manifestation of poor confidence. It asked the participant to express his/her agreement with 10 statements on a 5-point Likert scale, ranging from \u0026ldquo;strongly agree\u0026rdquo; to \u0026ldquo;strongly disagree\u0026rdquo;. To prevent stereotyped answers, the statements were formulated in opposite directions (e.g., \u0026ldquo;\u003cem\u003eI find everything related to drug therapy for older persons stressful\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eChecking whether an older patient takes the therapy correctly is a task that I accomplish scrupulously\u003c/em\u003e\u0026rdquo;), so that expressing agreement sometimes meant difficulty or discomfort and other times confidence or ease. For analytical purposes, the score assigned to the statements indicating difficulty was subsequently reversed; a summary score was therefore calculated, representing confidence progressively increasing from 0 to 40.\u003c/p\u003e \u003cp\u003eThe last section included 25 questions exploring nurses\u0026rsquo; competency in issues such as polypharmacy, drug adherence, ADE, handling therapy in the presence of sensory or cognitive deficits, inappropriate drugs, delirium, and the role of the caregiver. Acknowledging that the participants would be professionals with at least some clinical expertise and not students, 10 questions asked participants how they would behave in each clinical scenario, based on their professional experience. For example: \u0026ldquo;\u003cem\u003eMr. Mario comes to the clinic after hospitalization. While waiting for the medical examination, would you consider it appropriate to evaluate how Mario takes the drug therapy? If so, how would you proceed?\u003c/em\u003e\u0026rdquo;. Each question might have several acceptable answers out of the five proposed, for a total of 50; the number of acceptable answers was not known to the participants. To score this section of the questionnaire, we first calculated the proportion of correct answers out of 50 and then subtracted from this quantity the proportion of wrong answers out of the total number of answers provided. The result of this calculation, ranging from \u0026minus;\u0026thinsp;1 to 1, was multiplied by 50 and added to 50 to obtain a score ranging from 0 (worst performance) to 100 (best performance), according to the following formula:\u003c/p\u003e \u003cp\u003e \u003cem\u003eScore = [(correct answers/50) - (wrong answers/total answers given)] x 50\u0026thinsp;+\u0026thinsp;50.\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eDelphi procedure\u003c/h3\u003e\n\u003cp\u003eIn the Delphi procedure, the multidisciplinary team approved the general architecture of the questionnaire, and in particular the unusual structure and scoring system of its third section. No requests were made to add or delete any items. In the first Delphi round, it was suggested to collect the participants\u0026rsquo; age in classes and not as a continuous variable to better preserve anonymity, to use a non-binary definition of gender, to propose a more detailed identification of the service where the respondent worked, and to specify that \u0026ldquo;knowledge of scientific English\u0026rdquo; referred to \u0026ldquo;article reading and comprehension\u0026rdquo;. In the second round, it was proposed to add to the first section a question asking whether the respondent had some formal training in Geriatrics. Other minor formal changes were also introduced to make questions and answers more understandable even by non-Italian mother language participants. All these changes were eventually approved in the third round: in its final version, the first part of the questionnaire included 19 questions, whereas the second and third sections maintained 10 and 25 items, respectively.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCognitive interviews\u003c/h2\u003e \u003cp\u003eFifteen nurses participated in the cognitive interviews. The sample was evenly distributed in the three strata of nurses working in hospital wards, nurses working in community services or nursing homes, and freshmen nurses within six months of graduation. The interview duration ranged between 32 and 55 minutes (median [IQR]: 40 [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]). The time required to complete the questionnaire was 20 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] minutes.\u003c/p\u003e \u003cp\u003eOverall, the participants judged the questionnaire well-structured and understandable. The first three interviewees suggested adding a question on crushable drugs to the third section, whereas two others considered poorly pertinent a question on the side effects of anti-inflammatory drugs. The researchers' team agreed on crushable drugs as an important issue: a question on this theme was added in a revised version of the tool, while removing the question on anti-inflammatory drugs\u0026rsquo; side effects to maintain the number of 25 questions and 50 correct answers. No other proposals to add or delete items were made in the 12 subsequent interviews. Suggestions sporadically made for minor rephrasing of a limited number of questions or answers were rejected by the researchers as irrelevant or potentially pejorative.\u003c/p\u003e \u003cp\u003eAt the end of the cognitive interviewing phase, the questionnaire was considered ready for use. The original Italian version of the questionnaire, as well as its authors\u0026rsquo; English translation, is available on request.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReliability analysis\u003c/h2\u003e \u003cp\u003eBecause no changes were proposed to the second section of the questionnaire, the answers provided by the 15 participants to the cognitive interviews were considered suitable for reliability analysis. Cronbach's alpha was 0.739, supporting the internal consistency of the tool (34 Tavakol, 2011).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eField data collection\u003c/h2\u003e \u003cp\u003eA total of 174 nurses answered the questionnaire. Their characteristics are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most of the respondents participated in the educational event in the two sites in Southern Italy and were younger than 35 years. Half of them had some kind of postgraduate academic qualification, and approximately one-third had attended Geriatrics classes at some point during their education. Nearly one-third of the sample worked in a Geriatrics ward or a nursing home. On average, the recruited nurses declared intermediate confidence in the scientific English and bibliographic search engines.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral characteristics of the 174 participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian [IQR]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e55+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMen\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCentre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYears after graduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.5 [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAchieved postgraduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eReceived formal Geriatrics education\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEmployed in a Geriatrics ward or a NH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWorkplace\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (67.8)\u003c/p\u003e \u003cp\u003e55 (32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEducational resources available in the workplace\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (58.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eConfidence with scientific English, range 1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eConfidence with bibliographic search engines, range 1\u0026ndash;5\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime spent in continuing educ. (hrs/week)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBecause of missing values, the total number of observations was lower than 174 for the following variables: \u003csup\u003e1\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;173, \u003csup\u003e2\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;170, \u003csup\u003e3\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;171, \u003csup\u003e4\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;167.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviation. NH: Nursing Home.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePlease insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e approximately here\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eConfidence\u003c/h2\u003e \u003cp\u003eOn average, the reported level of confidence was moderate, with a mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD score of 23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 within an IQR of [21.0, 27.0]. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, nurses working in a Geriatrics ward or a nursing home achieved a higher confidence score compared to those working in other settings. Nurses employed in a hospital showed greater confidence than those who worked in other services.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate predictors of the confidence score. ANOVA or Student\u0026rsquo;s t-test for categorical predicting variables and Pearson\u0026rsquo;s correlation for interval ones. N\u0026thinsp;=\u0026thinsp;174 unless otherwise specified.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean score (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.939*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.6 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.0 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.2 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.8 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.898\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.0 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears after graduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal Geriatrics education\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.2 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed in a Geriatrics ward or a NH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.3 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8 (4.1)\u003c/p\u003e \u003cp\u003e11.9 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational resources in the workplace\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.3 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with scientific English\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with bibliographic search engines\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime spent in continuing educ. (hrs/week)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.658\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNon-missing observations: \u003csup\u003e1\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;173, \u003csup\u003e2\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;170, \u003csup\u003e3\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;171, \u003csup\u003e4\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;167.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* For trend value.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviation as in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn an ANOVA model adjusted for age and sex, working in a Geriatrics ward or a nursing home and being employed in a hospital facility were independent predictors of higher confidence (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both variables).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePlease insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e approximately here\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eCompetency\u003c/h2\u003e \u003cp\u003eOverall, the participants showed moderate competency, as demonstrated by a mean score of 61.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0 within an IQR of [54.2, 70.7]; none achieved the full score. As reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the score decreased progressively with increasing age and time after graduation, and differed across regions, with the highest value obtained in Central Italy and the lowest in Southern Italy. Other variables positively associated with the competency score were a formal Geriatrics education, increasing confidence in the scientific English and bibliographic search engines, and the time spent in continuing education.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate predictors of the competency score. ANOVA or Student\u0026rsquo;s t-test for categorical predictors and Pearson\u0026rsquo;s correlation for interval ones. N\u0026thinsp;=\u0026thinsp;174 unless otherwise specified.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean score (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.2 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.7 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.6 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.9 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.950\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.0 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.9 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.6 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.6 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.5 (10. 9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears after graduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.2 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.6 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal Geriatrics education\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.2 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.2 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed in a Geriatrics ward or a NH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.405\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.1 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational resources in the workplace\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.6 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.7 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with scientific English\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with bibliographic search engines\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime spent in continuing educ. (hrs/week)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNon-missing observations: \u003csup\u003e1\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;173, \u003csup\u003e2\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;170, \u003csup\u003e3\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;171, \u003csup\u003e4\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;167.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* For trend value.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviation as in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePlease insert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e approximately here\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eConfidence vs. competency\u003c/h2\u003e \u003cp\u003eThe confidence and competency scores were not associated (r= -0.026; p\u0026thinsp;=\u0026thinsp;0.729).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of satisfactory competency scoring\u003c/h2\u003e \u003cp\u003eThe cut-off identifying the top tertile, representing satisfactory competency scoring, was 68.1. As reported in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, in the 163 participants with complete data in the core variables, the only bivariate predictors of satisfactory competency scoring were age, geographic area, previous formal Geriatrics education, greater confidence with the scientific English and bibliographic search engines, and a shorter time interval from graduation. Additionally, satisfactory performance was associated with a slightly, non-significantly longer time dedicated to continuous professional education.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate associations of satisfactory competency score (top tertile, N\u0026thinsp;=\u0026thinsp;55 vs. intermediate and bottom tertiles, N\u0026thinsp;=\u0026thinsp;108) in 163 participants with complete data. Variables selected are those reaching statistical significance in the analyses reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. N (%) and chi-square test for categorical variables, median [IQR] and Mann-Whitney test for interval ones.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTop tertile,\u003c/p\u003e \u003cp\u003eN (%) or median [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntermediate / bottom tertiles,\u003c/p\u003e \u003cp\u003eN (%) or median [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u0026sect;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (58.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (59.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (92.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (61.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears after graduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal Geriatrics education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with scientific English\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with bibliographic search engines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 [2,3.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime spent in continuous education (hrs/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [1,2.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* For trend value.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePlease insert Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e approximately here\u003c/h2\u003e \u003cp\u003eThe candidate predictors resulting from these preliminary analyses were then entered into logistic regression models to identify those independently associated with satisfactory scoring. Because a person\u0026rsquo;s age and the years since graduation are strongly related and potentially collinear, different models were built (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Models 1 and 2), where these two variables were entered alternatively or simultaneously (Model 3, not shown). In Models 1 and 2, the odds of achieving satisfactory scoring were 4- to 5-fold greater in participants from Northern and Central Italy compared to Southern Italy and 2-fold greater in those with vs. without formal Geriatrics education. A younger age (Model 1) or achieving graduation more recently (Model 2) were conditions independently associated with satisfactory scoring, which was also associated with increasing confidence in scientific English (Model 1) or bibliographic research engines (Model 2). When age and time from graduation were entered in Model 3, the first variable was backward deleted and, therefore, the coefficients in the final parsimonious model were identical to those in Model 2. The time dedicated to continuous professional education was backward deleted as redundant from all models. The goodness-of-fit was satisfactory in all the models.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression models of factors associated with satisfactory competency score (top tertile vs. intermediate and bottom tertiles combined) in 163 participants with complete data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModel 1 *\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003cp\u003e55+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.2 (2.2\u0026ndash;58.1)\u003c/p\u003e \u003cp\u003e12.4 (2.1\u0026ndash;72.1)\u003c/p\u003e \u003cp\u003e5.9 (1.1\u0026ndash;31.3)\u003c/p\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003cp\u003eNorth\u003c/p\u003e \u003cp\u003eCentre\u003c/p\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2 (1.4\u0026ndash;18.8)\u003c/p\u003e \u003cp\u003e4.2 (1.9\u0026ndash;9.6)\u003c/p\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal Geriatrics education (Yes vs. No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (0.93\u0026ndash;4.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with scientific English (1-point increase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4 (0.93\u0026ndash;2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 2 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic area\u003c/p\u003e \u003cp\u003eNorth\u003c/p\u003e \u003cp\u003eCentre\u003c/p\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 (1.0-10.9)\u003c/p\u003e \u003cp\u003e4.3 (1.9\u0026ndash;9.9)\u003c/p\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal Geriatrics education (Yes vs. No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 (1.0-4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from graduation (1-year increase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.91\u0026ndash;0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence with bibliographic search engines (1-point increase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.55 (0.99\u0026ndash;2.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Time dedicated to continuous professional education and confidence with bibliographic research engines backward deleted as redundant.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e** Time dedicated to continuous professional education and confidence with scientific English backward deleted as redundant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePlease insert Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e approximately here\u003c/h2\u003e \u003cp\u003eBecause participants from Southern Italy had significantly lower and seemingly independent odds of achieving a satisfactory score, supplementary analyses were performed in the 163 participants with complete data (79 from Southern Italy, 84 from Northern and Central Italy combined) to better interpret this association. Compared with participants from Northern and Central Italy combined, those from Southern Italy were predominantly males and younger, had a shorter time interval from graduation, more frequently achieved some postgraduate degree, received formal Geriatrics education in only a slightly lower proportion, and reported better confidence with the scientific English and bibliographic search engines (supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBuilding on the scarce existing literature [\u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], we drafted a questionnaire to gather information on the confidence and competency of nurses in the management of drug therapy in older persons. The tool was subsequently validated according to the opinions of a multidisciplinary panel of experts and a group of nurses representative of those who would eventually fill in the questionnaire. We then applied the tool in the field, enrolling a national sample of Italian nurses, whose level of confidence in the management of pharmacotherapy in older patients was intermediate and positively and independently associated with working in a Geriatrics setting and in a hospital facility. Overall, participants\u0026rsquo; competency in handling therapy was modest. Satisfactory competency scoring was predicted by participants\u0026rsquo; geographic location, previous formal Geriatrics education, and confidence with resources for continuing professional education. The level of competency appeared to fade with time, expressed as either chronological age or time after graduation.\u003c/p\u003e \u003cp\u003eA quarter of a century ago, a study reported that drug therapy and drug interactions were ranked as the highest educational needs by nurses working in nursing facilities in the United States [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Attention to this issue remains very high, as medication management has recently been considered a crucial component of the curriculum for Bachelor of Science in nursing studies, developed in response to a nursing mandate in long-term care [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Thus, understanding nurses' learning needs and their level of competency has been lengthy, and remains, important because these factors impact patients\u0026rsquo; well-being and safety [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], especially in light of the increasing role and autonomy of nurses. Specifically, nurses may greatly contribute to the chain of medication safety in some settings, such as homecare and nursing homes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]: because of their frequent patient contact and their education to observe changes in the patient\u0026rsquo;s state, they are indeed very well positioned to recognize, and possibly prevent, early potential drug-related problems, despite their limited medical and pharmacological knowledge.\u003c/p\u003e \u003cp\u003eThe bibliographic search conducted as a first step of our work confirmed that a general problem of nurses' poor knowledge of drug therapy exists across several countries and requires an extensive and rigorous investigation. Yet, this topic received less attention than one would expect. Moreover, the tools proposed in the few articles retrieved were not completely adherent to the MEN study's broad goal. This compelled us to develop a new tool. In doing this, we took advantage of some examples in the literature: we appreciated and applied extensively the \u0026ldquo;clinical scenario\u0026rdquo; format found in other studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] because it seemed appropriate to approach professionals who may have years of clinical experience. No more recent pertinent studies were found in the updated search after the MEN study data collection was completed.\u003c/p\u003e \u003cp\u003ePrevious studies have generally shown that nurses\u0026rsquo; confidence and competency in handling pharmacotherapy, with patients of any age and in different clinical settings, are suboptimal [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Disappointing results were confirmed by the few investigations specific to the geriatric field [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Thus, despite several methodological differences, our findings compare well to those from previous studies. For example, Sino et al. assessed the nurses\u0026rsquo; level of self-efficacy on drug-related issues by proposing statements regarding participants\u0026rsquo; attitudes towards administering drugs and calculating the proportion of agreement with these statements [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], whereas we calculated a summary score expressing nurses' overall confidence.\u003c/p\u003e \u003cp\u003eLike previous studies, we found that confidence and competency were poorly related. In a group of 110 UK community nurses, Sodha et al. assessed self-rated knowledge and actual ability to solve medicine-related issues in five clinical scenarios involving patients of any age: although prescribing nurses declared a greater level of confidence compared to non-prescribing ones, they still lacked the necessary degree of knowledge [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study also highlights differences associated with the geographic area of enrollment. Participants from Central and Northern Italy had significantly and independently greater odds of scoring in the top tertile than those from Southern Italy, although the latter were younger and better educated, and reported also greater familiarity with resources for continuing professional education, than the former. Although residual confounding cannot be excluded, other explanations might be invoked. Indeed, our findings echo the well-documented inequalities in the performance of the Italian National Health System across regions, whose reasons are complex and difficult to disentangle. Based on the data from the Italian Health Ministry, the Svimez Report 2023 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] showed that none of the regions from Southern Italy dispense services in the best two quality quartiles, and, conversely, as many as five of the seven regions with the worst performances are in Southern Italy. The competency of healthcare professionals can be expected to be strictly and mutually interlaced with the performance of the service itself, and the lower level of competencies exhibited by our participants from Southern Italy probably reflects these dynamics. It should also be pointed out that, according to standardized evaluations, the quality of the educational programs is lower in Southern Italy: among the academic programs in the medical field ranking in the top 20 positions of the 2024 CENSIS report, only one was based in Southern Italy [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe found that competency was boosted by receiving specific training in Geriatrics or being confident with resources for continuous professional education, whereas it decreased progressively with increasing time after graduation. Taken together, these findings emphasize that education and training are superior to accumulating years of experience in achieving satisfactory performance. However, given the cross-sectional design of this study, it cannot be ascertained whether this result indicates that education on these issues is improving across students\u0026rsquo; cohorts, or rather that competency fades progressively with time in the same individual. Important components of education are reflexivity and self-assessment [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], which imply the ability to recognize one\u0026rsquo;s own educational needs. Professionals unable to self-assess may fail to recognize their limited competencies, make no efforts to improve them, and show unjustified confidence. At the same time, awareness of their medication errors has been shown to decrease self-esteem in a sample of nurses [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This may also explain the lack of association between confidence and competency in our study.\u003c/p\u003e \u003cp\u003eThis study has several strengths. In the absence of a gold standard, a new tool was drafted by a team combining the three specialties of Nursing, Geriatrics, and Pharmacy/Pharmacology. The panel conducting the Delphi procedure had a similar multidisciplinary composition and included experts from different institutions across Italy, favoring the national applicability of the questionnaire. To evaluate content validity, we applied a rigorous procedure for cognitive interviewing, in agreement with current guidelines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and enrolled participants representative of the target population. Three independent researchers analyzed the interviews, and the tool was modified and re-tested accordingly. The questionnaire quantified both nurses\u0026rsquo; confidence and competency, thus allowing exploring their mutual relationships, as well as the associations with potential predictors from the first section. The internal consistency of the second section was satisfactory. The \u0026ldquo;clinical scenario\u0026rdquo; format of many questions in the third section should be better received by expert professionals. Finally, the time required to complete the questionnaire was acceptable. To enhance the representativeness of our field data collection, the sample involved professionals working in diverse facilities and wards across the country. The in-person administration prevented the risks inherent in online surveys, such as unknown response rates, unclear representativeness of the target population, and uncertainty about whether the respondents received help from outside information sources and colleagues. In the third section of the questionnaire, the presence of more than one acceptable answer allowed the respondents to choose all the options closer to their habitual behavior. The scoring system facilitated summarizing competency in a single number while correcting the total number of right answers for the number of wrong answers.\u003c/p\u003e \u003cp\u003eStudy limitations should be acknowledged, both in the development and validation of the tool and in the field data collection. The tool developed could not be validated against an accepted gold standard because none exists, and validation was limited to experts\u0026rsquo; opinions. Unlike the panel in the Delphi procedure, the participants in the cognitive interviews all came from the same geographic area: this might limit the generalizability of the findings of this step of the study. The applicability of the tool in other countries has not been evaluated. The sample was small and unevenly distributed across the different geographic areas. Participants were self-selected because they attended an educational event on the same topic that was investigated. Although participation was open to nurses from out-of-hospital services, most participants came from hospital facilities. We could not ascertain whether the level of competency expressed by our participants truly corresponded to different levels of professional performance and to different patients\u0026rsquo; outcomes. Our analyses assumed that each participant had his/her training in the same part of Italy where he/she was enrolled, but this assumption might not always be true. Finally, broad differences in education and professional classification of nurses exist between Italy and other countries: therefore, the generalizability of our results to other countries is uncertain.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUsing a newly developed and validated questionnaire, we found that, irrespective of their perceived confidence and educational needs, the competency in geriatric pharmacology of our Italian national sample of nurses was limited and decreased with time since graduation, especially if they had not received formal Geriatrics training and were poorly familiar with tools for continuing professional education. These findings may have important implications. Since nurses have a central role in the management of drug therapy in older persons, implementing a geriatric curriculum in academic nursing programs and promoting professional education in Geriatrics after graduation may contribute to enhancing nurses\u0026rsquo; competency on this topic. This, in turn, should improve the safety of older, frail persons with multimorbidity and polypharmacy. It is also clear that efforts should be made to reduce the geographic gap in nurses\u0026rsquo; competency across Italy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADE: Adverse Drug Events\u003c/p\u003e\n\u003cp\u003eANOVA: Analysis Of Variance\u003c/p\u003e\n\u003cp\u003eCI: Central Italy\u003c/p\u003e\n\u003cp\u003eCOSMIN: COnsensus‐based Standards for the selection of health Measurement INstruments\u003c/p\u003e\n\u003cp\u003eIQR: InterQuartile Range\u003c/p\u003e\n\u003cp\u003eMEN: Medications. Elderly, and Nursing\u003c/p\u003e\n\u003cp\u003eNI: Northern Italy\u003c/p\u003e\n\u003cp\u003eOR: Odds Ratio\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003eSI: Southern Italy\u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for Social Sciences\u003c/p\u003e\n\u003cp\u003eUSL: Unità Sanitaria Locale (Local Healthcare Unit)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval.\u0026nbsp;\u003c/strong\u003eThe study protocol was approved by the Ethics Committee of the University of Florence (n. 226, July 27, 2022).\u0026nbsp;Written informed consent was obtained from participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u0026nbsp;\u003c/strong\u003eData and materials generated and/or analysed during the current study are not publicly available because we may wish to extend the study to different areas of the country. However, they may be available upon a reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest.\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u003c/strong\u003e This study was partially supported by MDB’s institutional funds (UNIFI ex 60% 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary information.\u003c/strong\u003e The online version contains supplementary material (supplementary Table S1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions.\u003c/strong\u003e \u003cstrong\u003eAC:\u003c/strong\u003e Data curation, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003eAS:\u003c/strong\u003e Resources, Writing – review \u0026amp; editing. \u0026nbsp; \u003cstrong\u003eCMV:\u003c/strong\u003e Conceptualization, Acquisition of subjects, Data curation, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003eCP:\u003c/strong\u003e Methodology, Writing – review \u0026amp; editing. \u0026nbsp; \u003cstrong\u003eEC:\u0026nbsp;\u003c/strong\u003eAnalysis and interpretation of data, Writing – review \u0026amp; editing.\u003cstrong\u003e\u0026nbsp; EL:\u0026nbsp;\u003c/strong\u003eAnalysis and interpretation of data, Writing – review \u0026amp; editing. \u003cstrong\u003eEZ:\u0026nbsp;\u003c/strong\u003eAnalysis and interpretation of data, Writing – review \u0026amp; editing. \u003cstrong\u003eGC:\u003c/strong\u003e Data curation, Writing – review \u0026amp; editing. \u0026nbsp; \u003cstrong\u003eLR:\u003c/strong\u003e Methodology, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003eMDB:\u003c/strong\u003e Conceptualization, Methodology, Resources, Writing – original draft.\u0026nbsp;\u003cstrong\u003eMLLV:\u003c/strong\u003e Acquisition of subjects, Data curation, Writing – review \u0026amp; editing. \u0026nbsp; \u003cstrong\u003eMP:\u003c/strong\u003e Data curation, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003ePA:\u003c/strong\u003e Resources, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003ePF:\u003c/strong\u003e Data curation, Methodology, Writing – review \u0026amp; editing. \u0026nbsp; \u003cstrong\u003eRMB:\u003c/strong\u003e Conceptualization, Formal analysis, Writing – original draft. \u0026nbsp;\u003cstrong\u003eSET:\u003c/strong\u003e Conceptualization, Acquisition of subjects, Data curation, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003eSV:\u003c/strong\u003e Methodology, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003eTR:\u003c/strong\u003e Data curation, Writing – review \u0026amp; editing. \u0026nbsp;\u003cstrong\u003eYL:\u003c/strong\u003e Methodology, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments.\u003c/strong\u003e All those who contributed significantly to the work have been listed. 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Nurs Times. 1994;90:27\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aged, Competency, Confidence, MEN Study, Nurses, Pharmacotherapy","lastPublishedDoi":"10.21203/rs.3.rs-8348146/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8348146/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses are on the frontline in drug treatment of older persons, which impacts on patients’ safety and well-being. Aim of the study was to assess nurses’ confidence and competency in geriatric pharmacotherapy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter literature search, a questionnaire was developed and then refined with a Delphi procedure and cognitive interviews. In a cross-sectional study design, nurses attending an educational event in six Italian cities answered the questionnaire, exploring participants’ general characteristics and scoring confidence (range 0-40) and competency (range 0-100). Satisfactory competency was defined by a score in the top tertile.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 174 participants, 24, 67, and 83 were from Northern (NI), Central (CI), and Southern Italy (SI), respectively. The mean±SD confidence score was 23.9±4.8. Working in a Geriatrics setting and being employed in a hospital were independent predictors of higher confidence. The competency score (mean: 61.9±11.0) was independent of confidence (r= -0.026; p=0.729). Multivariable predictors of satisfactory competency scoring were: participants’ geographic location in NI (OR 3.3, 95% CI 1.0-10.9) or CI (OR 4.3, 95% CI 1.9-9.9) vs. SI, previous Geriatrics education (OR 2.2, 95% CI 1.0-4.7), and familiarity with bibliographic search engines (OR 1.55, 95% CI 0.99-2.43). Years since graduation were inversely associated with satisfactory scoring (OR 0.95, 95% CI 0.91-0.98).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis sample of Italian nurses showed moderate confidence and competency in managing drug therapy in older persons. Education, and not experience, was associated with satisfactory scoring. Efforts should be made to enhance training in Geriatrics and the utilization of tools for continuing education.\u003c/p\u003e","manuscriptTitle":"Assessing the Confidence and Competency of Nurses in the Management of Pharmacotherapy in Older Patients: a Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:16:28","doi":"10.21203/rs.3.rs-8348146/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-08T10:19:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-18T10:54:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-17T01:28:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T01:28:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-12-12T17:45:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"690e6a39-0a13-493c-9fde-75003c64fed2","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-13T09:16:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 09:16:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8348146","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8348146","identity":"rs-8348146","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}