Analysis of the factors related to the knowledge, attitudes, and practices of nurses towards intensive care unit-acquired weakness: a cross-sectional survey

Abstract

Background

Intensive care unit (ICU)-acquired weakness (ICU-AW) is a common neuromuscular complication among patients in the ICU. The short-term consequences include muscle weakness, prolonged mechanical ventilation, and prolonged hospitalization, and the long-term consequences include increased patient comorbidities, increased hospitalization costs, and a higher disease burden. However, few studies have examined ICU nurses’ KAP regarding ICU-acquired weakness, particularly in the context of Chinese tertiary hospitals. Therefore, it is important to understand the level of knowledge, attitudes, and practices of ICU-AW among ICU nurses.

Objective

This is an exploratory cross-sectional study conducted without prespecified directional hypotheses. Through this study, we aim to understand the knowledge, attitudes, and practices of ICU nurses with respect to ICU-AW. The findings will provide a reference for hospitals to manage or prevent ICU-AW.

Methods

From January 2023 to February 2023, a survey involving 208 ICU nurses (recruited through convenience sampling) in Shiyan area was conducted. The survey included a general information questionnaire and the ICU-AW Knowledge and Attitudes Practices Questionnaire.

Results

The mean scores for knowledge, attitude, and practice were 32.29 ± 4.50, 34.64 ± 4.81, and 30.41 ± 7.47, respectively. The multiple linear regression showed that hospital level and nurses’ marital status independently related to the knowledge and practices of ICU nurses around ICU-AW (both P < 0.05). The linear regression equation was as follows: Y = 91.736 − 6.373 × hospital level − 4.119 × marital status (F = 11.349, R² = 0.101, adjusted R² = 0.092).

Conclusion

The overall knowledge and practice levels of ICU nurses with respect to ICU-AW was moderate, and was associated with hospital level and marital status. The findings of this exploratory study provide preliminary evidence and testable hypotheses for subsequent prospective or interventional studies.

Clinical trial number

Not applicable

Introduction

Intensive care unit (ICU)-acquired weakness (ICU-AW) is a type of acquired neuromuscular dysfunction. ICU-AW mainly manifests as hypokinesia, decreased reflexes, and even ventilator dependence [1–4]. The pathogenesis of ICU-AW is still unclear, but its prevalence is reported to be as high as 33%–82% among patients in the ICU [5, 6]. In addition, up to 36% of patients continue to experience muscle weakness after discharge from the ICU [7]. ICU-AW leads to a series of complications, such as a prolonged recovery period, increased hospitalization costs, decreased quality of survival, and increased mortality rates [8–11]. In addition, from the perspective of nursing and hospital management, owing to the lack of tools available to screen ICU-AW, most patients undergo rehabilitation after the occurrence of ICU-AW, which reduces the quality of nursing services and increases the cost of nursing care [12, 13].

Healthcare professionals working in the ICU need to focus not only on the patient’s existing health problems, but also on the possible complications that the patient may encounter. It is vital to enhance the quality of life of patients while ensuring their survival. Few studies have evaluated the knowledge and understanding of healthcare professionals around ICU-AW, despite it being a common type of neuromuscular dysfunction among ICU patients. Zhao et al. showed that the level of knowledge and the attitudes toward ICU-AW were associated with age, years of ICU experience, professional rank and title, and receipt of ICU-AW training [14]. Unlike previous studies, this research differs in the selection of the study area. The study by Zhao et al. did not focus on the Shiyan area, while this research targets 26 hospitals in this region, which can reflect regional specificity. In addition, this study includes nurses from hospitals of different levels (tertiary and secondary), and ultimately aims to develop a customized education program related to ICU-AW for the Shiyan area. Through a survey of pediatric ICUs, Huang et al. found that the level of knowledge and the attitudes around ICU-AW were associated with sex, level of education, and hospital level classification, amongst other factors [15]. It has also been shown that daily neuromuscular electrical stimulation and early physical activity preserve muscle strength, prevent ICU-AW, and reduce mechanical ventilation and ICU length of stay [16, 17]. ICU nurses are the specific implementers of ICU-AW prevention, treatment, and care. Therefore, their level of knowledge and their attitudes and practices are of great importance for the early identification and intervention of ICU-AW, as well as for improving patients’ clinical outcomes [18].

In recent years, a limited number of relevant survey studies have been conducted in China, providing important basic data for this field [14]. However, most of the existing studies focus on tertiary grade A hospitals in large first-tier cities, and the applicability of their research conclusions to regional medical centers (such as Shiyan area in this study) with differences in medical resources, population structure and nursing practice models remains to be verified. As a central city in the adjacent areas of Hubei, Henan, Shaanxi and Chongqing, Shiyan has a representative medical system. At present, there is a lack of systematic evaluation data on the KAP level of adult ICU nurses in this field specifically in Shiyan area. Moreover, Zhao et al. conducted a representative study on two tertiary hospitals, identifying core factors associated with nurses’ ICU-AW KAP under high-resource conditions and providing a reference for specialized training. However, existing research suffers from sample limitations, focusing predominantly on resource-rich tertiary hospitals while neglecting nurses in secondary hospitals—the backbone of regional medical systems. Secondary hospitals undertake grassroots critical care triage and treatment, where nurses face distinct clinical scenarios and resource constraints compared to tertiary settings: lacking dedicated ICU-AW training systems and MDT teams, they have limited access to cutting-edge guidelines; additionally, they shoulder both intensive and general ward duties, resulting in heavier workloads and lower specialization. Guided by the Health Belief Model and Social Ecological Model, these organizational differences are likely to shape ICU-AW KAP characteristics among secondary hospital nurses that differ significantly from those in tertiary hospitals. Shiyan, a mountainous economic transition city in central China, has a hierarchical medical system of “tertiary leadership and secondary support,” providing an ideal setting for comparing nurse ICU-AW KAP across hospital levels. Thus, this study adopted an exploratory cross-sectional design without prespecified directional hypotheses, which recruited ICU nurses from multiple tertiary and secondary hospitals in Shiyan to investigate ICU-AW KAP status, analyze inter-hospital differences and related factors, and provide empirical evidence for optimizing hierarchical training and promoting high-quality intensive care resource sinking.

Methods

Study design

This was an exploratory cross-sectional study. No directional hypotheses were prespecified prior to data collection and analysis.

Participants

Convenience sampling of ICU nurses was used to conduct this cross-sectional survey study across 26 general hospitals (10 secondary hospitals (10/26) and 16 tertiary hospitals (16/26)) in Shiyan area, China, from January 2023 to February 2023. In this study, an online survey method was adopted (by distributing the Wenjuanxing link through the internal WeChat groups for nurses in hospitals). Based on the principle of determining the sample size according to the rule of thumb [19], the sample size was 5–10-times the independent variable, the questionnaire in this study consists of 3 dimensions with 31 items. According to the rule of calculating the sample size as 5–10 times the number of variables, the minimum required sample size is 155 (derived from 31*5). Adding a 20% allowance for invalid data, the minimum required sample size becomes 186. A total of 206 questionnaires were distributed, and 206 were retrieved. Among them, 206 were valid, resulting in a valid recovery rate of 100%.

The inclusion criteria were 1) working registered nurses across all types of ICU (general ICU and specialized ICUs, such as the neurosurgical ICU); 2) ≥ 1 year of ICU work; and 3) informed consent and voluntary participation. The exclusion criteria were (1) nurses in training, rotation, and further training; and (2) nurses who could not participate in the survey due to completion of further training, sickness/personal leave, marriage/maternity leave, or other reasons.

Survey tool

The general information questionnaire was designed by the researchers, including age, sex, and 10 other dimensions. The ICU nurses’ ICU-AW Knowledge, Attitudes, and Practices Questionnaire was developed by Wu Li et al. [20] The questionnaire includes 31 items across three domains encompassing knowledge, attitudes, and practices, with a total score of 31–125 points. Among them, the knowledge dimension is divided into two aspects: subjective knowledge and objective knowledge. The subjective knowledge section consists of 6 items, with three response options: “Unaware”, “Partially aware”, and “Aware”, scored as 1 point, 2 points, and 3 points respectively. The objective knowledge section includes 9 items, with three response options: “Correct”, “Uncertain”, and “Incorrect”, scored as 3 points, 2 points, and 1 point respectively. Notably, Items 8, 11, 13, and 15 are reverse-scored. The total score of this dimension ranges from 15 to 45 points, where a higher score indicates a better mastery of ICU-AW knowledge among the participants. Both the attitude dimension and practice dimension comprise 8 items each, adopting a 5-point Likert scale for scoring. Responses are graded as “Strongly agree” (5 points) down to “Strongly disagree” (1 point). The total score for each of these two dimensions ranges from 8 to 40 points, with a higher score reflecting more positive attitudes and practices toward ICU-AW among ICU nurses. The knowledge dimension has six entries with a total possible score of 15–45 points. The attitude and practices dimensions each have eight entries, both of which are scored on a 5-point Likert scale. Therefore, the total possible score for each of these dimensions ranges from 8 to 40. The scores were divided into grades: total score ≥ full score × 0.85 was considered good, total score < full score × 0.60 was considered poor, and scores in between these values were considered moderate [21]. The questionnaire had a Cronbach’s α value of 0.96, a content validity index of 0.92, and a retest reliability of 0.87 [20]. Before the formal survey, a pre-survey involving 20 participants was conducted in this study, and the results showed that the Cronbach’s α coefficient was 0.93. In addition, previous studies have reported that the Cronbach’s α coefficient of the ICU-AW Knowledge, Attitudes, and Practices Questionnaire is 0.858, and its content validity is 0.873, indicating that the questionnaire has good reliability and validity [14, 20].

Survey process

The survey was anonymous and completed remotely. After obtaining approval from the nursing department of each hospital, standardized questionnaires were administered, and the nurses provided their anonymized responses. Mandatory fields were set in the online questionnaires to avoid invalid responses. Before the start of the study, the research purpose, content, voluntary nature of participation, and privacy protection measures (e.g., anonymous questionnaire completion, data used solely for research analysis) were explained to nurses through the hospital nursing departments; an informed consent pop-up window was set on the homepage of Wenjuanxing, and only by clicking “Agree” could nurses enter the questionnaire to fill it out. All nurses were informed that they could withdraw from the study at any time, and such withdrawal would not affect their work performance evaluation, which fully protects the rights and interests of participants. After the survey, two independent researchers conducted a double check on the completed and retrieved questionnaires in accordance with the inclusion and exclusion criteria. Subsequently, the data from the questionnaires were exported and imported into statistical analysis software.

Statistical analysis

IBM SPSS Statistics for Windows, Version 26.0, IBM Corp., Armonk, NY, USA was used for the statistical analysis. Shapiro–Wilk test should be conducted for continuous data. Normally distributed quantitative data are expressed as the mean ± standard deviation, while non-normally distributed data are expressed as the median with quartiles. Counting data are expressed as frequencies and percentages. The groups were compared using the t-test or analysis of variance. Related factors were identified by multiple linear regression analysis after adjusting for confounding factors, such as sex, level of education, and form of employment. Differences were considered statistically significant at P < 0.05.

Ethical review

This study was approved by the Medical Ethics Committee of Shiyan Taihe Hospital (2023KS15). We confirm that all methods have been carried out in accordance with the relevant guidelines and regulations.

Results

Demographic characteristics

A total of 206 questionnaires were distributed, and 206 were retrieved. Among them, 206 were valid, resulting in a valid recovery rate of 100%. Among the study participants, there were 34 males (accounting for 16.50%) and 172 females (accounting for 83.50%); 150 participants (accounting for 72.82%) had a bachelor’s degree or above, and 56 participants (accounting for 27.18%) had an associate degree or below; 142 participants (68.93%) were from Tertiary hospitals, and 56 participants (27.18%) were from Secondary hospitals. The overall characteristics are shown in Table 1.

Table 1.

Different characteristics around ICU nurse (n = 206)

Items	N(%)
Age(y)
≤ 26	53(25.73)
>26 ~ 32	94(45.63)
>32	59(28.64)
Hospital Level
Tertiary Hospital	142(68.93)
Secondary Hospital	64(31.07)
Professional Ranks and Titles
Senior nurse	11(5.34)
Intermediate nurse	69(33.50)
Junior nurse	126(61.17)
Marital Status
Married	136(66.02)
Unmarried/Divorced	70(33.98)
Years of Experience(y)
≤ 5	65(31.55)
>5 ~ 10	75(36.41)
>10	66(32.04)
Years of ICU nursing experience(y)
≤ 3	75(36.41)
>3 ~ 8	55(26.70)
>8	76(36.89)
ICU Category
General ICU	123(59.71)
Medical-surgical ICU	83(40.29)

Status of ICU nurses’ knowledge, attitudes, and practices around ICU-AW

ICU nurses’ KAP level around ICU-AW differed significantly by age, hospital level, title, marital status, years of work, years of ICU nursing experience, and ICU category (all P < 0.05). Among these factors, Tertiary hospital affiliation, senior professional titles, married marital status, extended overall work experience, and prolonged ICU work experience were identified as related factors for knowledge levels; Senior professional titles, married marital status, ICU type, extended overall work experience, and prolonged ICU work experience were found to be related to attitude levels; while practice levels were associated with nurses’ age, hospital level, prolonged ICU work experience, and ICU type. (Table 2).

Table 2.

Knowledge, attitudes, and practices scores of ICU nurses with ICU-AW

Items	Knowledge	Attitude	Practice	Total score
Age(y)
≤ 26	2.13 ± 0.30	4.20 ± 0.63	3.88 ± 0.97	32.20 ± 4.69
>26 ~ 32	2.12 ± 0.30	4.33 ± 0.60	3.62 ± 0.95	31.81 ± 4.52
>32	2.22 ± 0.29	4.45 ± 0.56	4.01 ± 0.83	33.67 ± 4.01
F	2.303	2.430	3.563	3.314
P	0.103	0.091	0.030*	0.038*
Hospital Level
Tertiary Hospital	2.21 ± 0.29	4.37 ± 0.59	3.95 ± 0.89	33.22 ± 4.27
Secondary Hospital	2.03 ± 0.29	4.23 ± 0.61	3.47 ± 0.95	30.71 ± 4.46
t	3.927	1.530	3.523	3.847
P	<0.001**	0.127	0.001**	<0.001**
Professional Title
Senior nurse	2.35 ± 0.20	4.50 ± 0.45	3.88 ± 1.01	34.06 ± 4.05
Intermediate nurse	2.17 ± 0.31	4.51 ± 0.55	3.89 ± 0.90	33.28 ± 4.43
Junior nurse	2.12 ± 0.29	4.21 ± 0.61	3.75 ± 0.95	31.85 ± 4.46
F	3.057	6.390	0.561	3.092
P	0.049*	0.002**	0.572	0.048*
Marital Status
Married	2.18 ± 0.30	4.42 ± 0.55	3.84 ± 0.90	32.95 ± 4.24
Unmarried/Divorced	2.09 ± 0.30	4.14 ± 0.66	3.73 ± 1.01	31.45 ± 4.77
t	2.050	3.056	0.807	2.219
P	0.042*	0.003**	0.421	0.028*
Years of Experience(y)
≤ 5	2.12 ± 0.29	4.16 ± 0.60	3.77 ± 0.99	31.72 ± 4.73
>5 ~ 10	2.11 ± 0.31	4.36 ± 0.62	3.71 ± 0.95	32.07 ± 4.36
>10	2.24 ± 0.28	4.46 ± 0.54	3.93 ± 0.86	33.58 ± 4.18
F	4.240	4.638	0.993	3.312
P	0.016*	0.011*	0.372	0.038*
Years of ICU nursing experience(y)
≤ 3	2.13 ± 0.29	4.24 ± 0.58	3.71 ± 1.00	31.83 ± 4.56
>3 ~ 8	2.08 ± 0.28	4.20 ± 0.60	3.59 ± 0.93	31.18 ± 4.21
>8	2.23 ± 0.30	4.52 ± 0.58	4.04 ± 0.82	33.97 ± 4.19
F	4.176	6.430	4.480	7.823
P	0.017*	0.002**	0.012*	0.001**
ICU Category
General ICU	2.14 ± 0.31	4.26 ± 0.62	3.66 ± 0.96	31.84 ± 0.72
Medical-surgical ICU	2.17 ± 0.29	4.43 ± 0.56	4.02 ± 0.86	33.34 ± 3.94
t	-0.517	-1.982	-2.804	-2.477
P	0.606	0.049*	0.006**	0.014*

Note: ICU: intensive care unit. ^* indicates P < 0.05, ^** indicates P < 0.01

ICU nurses’ knowledge, attitudes, and practices scores around ICU-AW

The score of the attitude dimension (34.64 ± 4.81) was categorized as “good” relative to the standardized score (86.59 ± 12.02). The knowledge and practice scores were considered “moderate” (Table 3; Fig. 1). The three items with the highest scores are “Early mobilization of ICU patients is the most effective intervention to prevent or mitigate ICU-AW” (Knowledge Dimension), “Healthcare providers should receive formal training in ICU-AW care” (Attitude Dimension), and “Providing early functional exercises for patients with team assistance” (Attitude Dimension). And the lowest scores for the three dimensions were for the items “Important risk factors for ICU-AW” (knowledge), “Nurses should take responsibility for assessing ICU-AW care” (attitude), and “Assessing patients for ICU-AW” (practices) (Table 4).

Table 3.

Number (percentage) of ICU nurses with each score (good, moderate, or poor) for knowledge, attitudes, and practices around ICU-AW (n = 206)

Score and Grade	Score	Standard Score	Good	Moderate	Poor
Knowledge	32.29 ± 4.50	71.75 ± 9.99	15(7.28)	164(79.61)	27(13.11)
Attitudea	34.64 ± 4.81	86.59 ± 12.02	106(51.46)	99(48.06)	1(0.49)
Practices	30.41 ± 7.47	76.02 ± 18.67	62(30.10)	107(51.94)	37(17.96)
Total Score	97.33 ± 13.43	77.86 ± 10.74	61(29.61)	133(64.56)	12(5.83)

^a The sum of the shares for this item is not 100%

ICU: intensive care unit

Fig. 1.

Proportion of nurses with different knowledge-attitude-practices levels regarding ICU-AW

Table 4.

Knowledge, attitude, and practice dimension score of nurses towards ICU-AW (n = 206)

Dimensions	Items	Score()
Knowledge(K)		32.29 ± 4.50
	Early mobilization of ICU patients is the most effective intervention to prevent or mitigate ICU-AW.	2.89 ± 0.32
	The clinical manifestations of ICU-AW mainly include difficulty weaning from the ventilator, paresis or quadriplegia, reduced reflexes, and muscle atrophy.	2.82 ± 0.41
	ICU-AW is one of the common complications in critically ill patients.	2.77 ± 0.46
	The diagnosis of ICU-AW primarily relies on the Medical Research Council score (MRC-score) for assessment.	2.63 ± 0.55
	Muscle weakness and functional impairment remain common in ICU survivors even two years after discharge.	2.57 ± 0.65
	ICU-AW Concept	2.25 ± 0.68
	ICU-AW Clinical Manifestations	2.15 ± 0.71
	ICU-AW Risk Factors	2.15 ± 0.73
	ICU-AW Preventive Measures	2.13 ± 0.73
	ICU-AW Evaluation Criteria	2.04 ± 0.74
	ICU-AW Diagnostic Criteria	2.02 ± 0.75
	ICU-AW can prolong hospital stays and increase medical costs, but it does not significantly affect patients’ functional independence or survival rates.	1.82 ± 0.88
	Standardized insulin therapy may reduce the incidence and duration of neuromuscular complications, but it does not significantly improve the incidence of ICU-AW.	1.53 ± 0.63
	Critically ill patients on mechanical ventilation for more than 1–2 days have an ICU-AW incidence of 33%–82%.	1.27 ± 0.48
	Mechanical ventilation may be an important risk factor for the development of ICU-AW.	1.26 ± 0.49
Attitude(A)		34.64 ± 4.81
	Should receive formal training in ICU-AW care	4.53 ± 0.57
	ICU nurses should dynamically observe patients’ ICU-AW status	4.51 ± 0.59
	In clinical practice, patients or their families should be educated about ICU-AW-related knowledge.	4.46 ± 0.63
	Healthcare providers should prioritize the prevention of ICU-AW just as they do for other symptoms (e.g., delirium).	4.44 ± 0.64
	Early functional exercise is crucial for the prevention and recovery of ICU-AW.	4.44 ± 0.64
	The ICU-AW status of critically ill patients should be included in clinical handover content.	4.26 ± 0.83
	Self-ICU-AW related knowledge needs to meet clinical needs	4.05 ± 0.99
	Nurses should take responsibility for assessing ICU-AW care	3.95 ± 1.08
Practices(P)		30.41 ± 7.47
	Early functional exercise for patients with team assistance	3.93 ± 1.01
	Closely monitoring the patient’s early mobility process	3.92 ± 1.06
	Promptly report the patient’s muscle strength status to the physicians in the department.	3.92 ± 0.95
	Proactively assist critically ill patients in performing effective early functional exercises.	3.90 ± 0.97
	Assess whether critically ill patients have indications for early mobilization during clinical work.	3.82 ± 1.10
	Timely evaluate the effectiveness of nursing interventions for early patient mobilization.	3.79 ± 1.07
	Develop an early mobilization plan for critically ill patients in clinical practice.	3.68 ± 1.18
	Assess ICU-AW in patients during clinical work.	3.47 ± 1.28

Note: ICU-AW: intensive care unit-acquired weakness

Factors related to ICU nurses’ knowledge and practice around ICU-AW

Multiple linear regression analysis was performed in this study, with the overall KAP level of ICU nurses toward ICU-AW as the dependent variable, and all factors included as independent variables, namely: age, gender, educational background, employment type, hospital level, professional title, marital status, years of experience, years of ICU nursing experience, and ICU type. The assignment method is shown in Table 5. It should be noted that no explicit causal hypothesis was pre-specified in this study, and it is classified as an exploratory analysis.

Table 5.

Assignment method of independent variables

Related factors	Assignment method
Hospital Level	Tertiary Hospital = 1;Secondary Hospital = 2
Age(y)	≤ 26 = 1;27 ~ 32 = 2; ≥33 = 3
Gender	male = 1; female = 2
Educational Background	bachelor’s degree and above = 1, college diploma = 2, technical secondary school diploma = 3
Employment Type	Regular = 1, Agency = 2, Contract = 3
Professional Title	Senior = 1;Intermediate = 2; Junior = 3
Marital Status	Married = 1;Unmarried/Divorced = 2
Years of Experience(y)	≤ 5 = 1;6 ~ 10 = 2; ≥11 = 3
Years of ICU nursing experience(y)	≤ 3 = 1;4 ~ 8 = 2; >8 = 3
ICU Category	General ICU = 1;Medical-surgical ICU = 2

The results showed that hospital level and marital status independently related to the knowledge and practice of ICU nurses around ICU-AW (both P < 0.05). The multiple linear regression equation was as follows: Y = 91.736 − 6.373 × hospital level − 4.119 × marital status (Table 6). Hospital level (β = -6.373) (95%CI: -9.422~-3.323): Due to the value assignment (1 = tertiary hospital, 2 = secondary hospital), this negative coefficient indicates that the total score of KAP of nurses in secondary hospitals is approximately 6.373 points lower on average than that of nurses in tertiary hospitals. Marital status (β = -4.119) (95%CI: -7.099~-1.140): Due to the value assignment (1 = married, 2 = Unmarried/Divorced), this negative coefficient indicates that the total KAP score of unmarried nurses is approximately 4.119 points lower on average than that of married nurses. These coefficients quantify the degree to which different variables were associated with the KAP level.

Table 6.

Results of the multiple linear regression analysis of factors related to ICU nurses’ knowledge and practice around ICU-AW

Variables	Unstandardized β	S.E.	Standardized β	t	P	95% CI
						upper limit	lower limit
(Constant)	91.736	3.066	—	29.922	<0.001	85.691	97.780
Hospital levela	-6.373	1.547	-0.275	-4.120	<0.001	-9.422	-3.323
Marital statusb	-4.119	1.511	-0.182	-2.726	0.007	-7.099	-1.140

R² = 0.101, adjusted R² = 0.092, F = 11.349, P < 0.001

^a Tertiary hospital was the control

^b Married was the control

Considering the potential clustering effect of hospital levels on ICU-AW KAP scores, linear mixed model analysis was performed on hospital levels in this study. The results showed that AIC = 1547.411 and BIC = 1554.047. Both the fixed-effect test and the covariance parameter intercept test yielded a P-value of 1.000 (> 0.05), indicating that hospital categories had no statistically significant impact on ICU-AW KAP scores and that the clustering effect of hospital levels on ICU-AW KAP scores was not significant. In addition, the results of the generalized linear mixed model (GLMM) showed that AIC = 1487.865 and BIC = 1491.106. With a sample size of 206 cases in this study, the model demonstrated a good fit. Furthermore, hospital level and marital status were identified as factors associated with ICU-AW KAP. (P < 0.05) (see Tables 7 and 8; Figs. 2 and 3), which was consistent with the results of multiple linear regression analysis.

Table 7.

Fixed effects^a

Source	F	df1	df2	P
Corrected Model	2.452	15	190	0.003
X1 (Hospital Level)	5.014	1	190	0.026
X2 (Age)	0.788	2	190	0.456
X3 (Gender)	0.474	1	190	0.492
X4 (Professional Title)	0.454	2	190	0.636
X5 (Marital status)	4.391	1	190	0.037
X6 (Years of experience)	0.163	2	190	0.850
X7 (Years of ICU Nursing Experience)	0.911	2	190	0.404
X8 (ICU Category)	1.493	1	190	0.223
X9 (Education)	1.307	1	190	0.254
X10 (Employment Type)	0.364	2	190	0.695

Probability distribution: Normal

Link function: Identity

^a Target: Y (KAP Standard Score)

Table 8.

Fixed coefficients^a

Model Term	Coefficient	S.E.	t	P	95% CI
					lower limit	upper limit
Intercept	76.228	4.5119	16.895	<0.001	67.329	85.128
X1 (Hospital Level)Tertiary Hospital VS Secondary Hospital	4.444	1.9845	2.239	0.026	0.529	8.358
X2 (Age ≤ 26)	3.745	4.6447	0.806	0.421	-5.417	12.907
X2 (Age>26–32)	-0.478	3.2113	-0.149	0.882	-6.812	5.857
X3 (Gender)male VS female	1.440	2.0915	0.688	0.492	-2.686	5.565
X4 (Professional Title)(Senior)	4.376	4.6803	0.935	0.351	-4.856	13.608
X4 (Professional Title)(Intermediate)	1.475	2.2979	0.642	0.522	-3.057	6.008
X5 (Marital status)Married VS Unmarried/Divorced	4.981	2.377	2.095	0.037	0.292	9.670
X6 (Years of Experience ≤ 5)	-2.419	4.4091	-0.549	0.584	-11.116	6.278
X6 (Years of Experience>5–10)	-0.649	3.1025	-0.209	0.835	-6.769	5.471
X7 (Experience in ICU ≤ 3)	-1.703	3.0345	-0.561	0.575	-7.689	4.282
X7 (Experience in ICU>3–8)	-3.490	2.6243	-1.330	0.185	-8.667	1.686
X8 (ICU Category)General ICU Medical-surgical ICU	-2.035	1.6655	-1.222	0.223	-5.321	1.250
X9 (Education Background)(bachelor’s degree and above)	-2.625	2.2961	-1.143	0.254	-7.154	1.904
X10 (Employment Type)(Regular)	-2.518	3.0683	-0.821	0.413	-8.570	3.534
X10 (Employment Type)(Agency)	-0.269	2.0276	-0.133	0.894	-4.269	3.730

Fig. 2.

Fixed effects

Fig. 3.

Fixed coefficients

In addition, cluster analysis was performed on the data, and the results showed that all indices of Cluster 2 were the optimal, followed by Cluster 1, while those of Cluster 3 were the least satisfactory (see Table 9). The table of the number of cases in each cluster presents the class membership of the three clusters (see Table 10). There were 75 participants in Cluster 1 (moderate level), 62 in Cluster 2 (good level), and 69 in Cluster 3 (poor level). The results of one-way analysis of variance (ANOVA) are shown in Table 11.

Table 9.

Final cluster centers

	Cluster
	1	2	3
X1 (Hospital Level)	1.23	1.23	1.48
X2 (Age)	2.69	1.16	2.09
X3 (Gender)	2.00	2.00	2.00
X4 (Professional Title)	1.97	2.98	2.81
X5 (Marital status)	1.05	1.89	1.16
X6 (Years of experience)	2.73	1.00	2.12
X7 (Years of ICU Nursing Experience)	2.96	1.06	1.81
X8 (ICU Category)	1.36	1.50	1.36
X9 (Education)	1.04	1.39	1.10
X10 (Employment Type)	2.07	2.02	2.16

Table 10.

Number of cases in each cluster

Cluster	1	75.000
	2	62.000
	3	69.000
Valid		206.000
Missing		0.000

Table 11.

One-way Analysis of Variance

	Cluster		Error		F	P value
	Mean Square	df	Mean Square	df
X3 (Gender)	0.389	2	0.136	203	2.861	0.060
X1 (Hospital Level)	1.457	2	0.203	203	7.178	0.001
X2 (Age)	40.007	2	0.157	203	255.292	<0.001
X4 (Professional Title)	20.660	2	0.155	203	133.221	<0.001
X6 (Years of experience)	51.628	2	0.137	203	377.823	<0.001
X5 (Marital status)	13.485	2	0.095	203	142.264	<0.001
X9 (Education)	2.254	2	0.118	203	19.165	<0.001
X8 (ICU Category)	0.418	2	0.240	203	1.742	0.178
X7 (Years of ICU Nursing Experience)	62.911	2	0.124	203	507.335	<0.001
X10 (Employment Type)	0.350	2	0.300	203	1.167	0.313

Discussion

Analysis of ICU nurses’ knowledge, attitudes, and practices around ICU-AW

ICU nurses’ knowledge, attitudes, and practices around ICU-AW were generally moderate. ICU-AW is one of the most common neuromuscular complications seen in the ICU [22]. Early identification and intervention can prevent ICU-AW and improve patient prognosis [10, 23–25]. Currently, there are relatively few studies in China that examine the KAP of ICU nurses regarding ICU-AW in third- and fourth-tier cities or regional contexts. Meanwhile, as a medical hub in northwestern Hubei, hospitals in the Shiyan area provide services to—and extend their reach to—multiple neighboring counties and cities. The knowledge and practical competence of ICU nurses in this region were directly related to the quality of care for critically ill patients across the area. Conducting research in Shiyan can thus serve as a reference for similar surrounding regions, while also addressing the gap in regionalized studies on this topic. Based on the theory of knowing, believing, and acting, effective knowledge about ICU-AW is the key to professional assessment and prevention [5].

The knowledge dimension was categorized as moderate. The moderate level of knowledge scores may be attributed to insufficient coverage of relevant content in the existing training system and limited time for active learning due to heavy clinical workloads. This moderate knowledge level could be potentially related to the accurate implementation of intervention measures and the effectiveness of patient education, thereby providing a targeted direction for optimizing subsequent training programs. The percentage of nurses with good knowledge (7.28%) was lower than the percentage of nurses with poor knowledge (13.11%), indicating that the knowledge dimension requires improvement. Further analysis of the questionnaire entries revealed that the highest scores were obtained in the areas related to the clinical manifestations of ICU-AW and the importance of early prevention, indicating that ICU nurses are aware of the importance of early intervention for ICU-AW. The low scores were observed in the areas of risk factors and interventions, which may be related to the delayed initiation of research on ICU-AW in China and the lack of ICU nurses’ learning around ICU-AW-related nursing concepts and guidelines, which have been studied more in foreign countries [26–28]. Therefore, it is necessary for nurses to draw on the latest research results from abroad to inform their clinical work [29]. Moreover, it will be important to standardize nursing and training systems and strengthen the training around risk factor identification and intervention for ICU-AW.

ICU nurses’ attitudes toward ICU-AW outperformed their knowledge levels, reflecting a positive stance toward the condition. Specifically, higher scores were observed in items related to nurse training and patient condition monitoring—findings that underscore nurses’ willingness to enhance their professional competencies through specialized training to prevent ICU-AW. In contrast, relatively low scores were recorded for workload-related items, a trend likely closely linked to heavy nursing caseloads and inadequate human resources [30, 31].Notably, this positive attitude does not stem from in-depth understanding rooted in systematic knowledge. Instead, it is more plausibly a form of cognitive awareness shaped by the repeated emphasis on ICU-AW prevention in routine hospital training. This disconnect between attitude and knowledge highlights a key shortcoming of current training: it prioritizes concept dissemination over the development of a comprehensive knowledge framework. Building on these findings, two key interventions are recommended. First, efforts should be made to improve ICU nurses’ working environments, strengthen medical team structures, and implement talent echelon management to fully boost their work motivation and sense of responsibility. Second, nursing administrators need to continuously update and expand the theoretical framework for ICU-AW, broaden the reach of existing educational and training programs, and reinforce specialized ICU-AW training modules. These measures will help nursing teams develop a more profound understanding of ICU-AW, thereby comprehensively enhancing their knowledge reserves, attitudes, and behavioral responses related to the condition.

The practice dimension was at a moderate level. The percentage of nurses with a poor practice dimension was the highest among the three dimensions (17.96%). This may be related to the current lack of specific ICU-AW risk assessment tools and the insufficient awareness of risk prevention and control among nurses [14]. Therefore, we recommend the development of accurate identification tools, and once developed, their application should be actively promoted. The highest scores were observed for early exercise and communication and collaboration in critically ill patients, indicating that ICU nurses are willing to work together with the unit team to prevent ICU-AW. The lowest two scores also proved the above point. Therefore, we suggest that unit managers should strengthen multidisciplinary teams, and healthcare professionals at all levels should encourage close collaborations with each other to create conditions that are conducive to the prevention of ICU-AW. Knowledge is defined as the objective mastery of professional theories and practical skills relevant to ICU-AW; awareness refers to the perceived clinical significance of ICU-AW, serving as a mediating variable that bridges knowledge and attitude; attitude represents a subjective psychological inclination that was directly associated with nursing practices.

Based on this conceptual delineation, the observed phenomenon—moderate knowledge levels coexisting with positive attitudes—indicates that although ICU nurses have not yet established a systematic knowledge framework of ICU-AW, they fully recognize the critical role of ICU-AW management in improving patient prognosis. This positive attitude is primarily driven by their professional sense of responsibility, highlighting the necessity of optimizing clinical training programs to strengthen the KAP transformation pathway.

Related factors to the knowledge, attitudes, and practices of ICU nurses around ICU-AW

A greater number of years of work experience and ICU work experience, a more senior title, and greater specialization of ICU nurses were associated with a higher level of knowledge around ICU-AW [14, 32].

Nurses with extensive overall professional tenure, and those with long-term experience in the ICU, tend to achieve higher knowledge scores related to ICU-AW. This likely stems from their greater intellectual curiosity: they proactively access relevant literature and learning resources during their spare time, and integrate daily clinical practice to analyze, synthesize challenges, and develop targeted solutions. ICU nurses holding senior professional titles outperform their junior counterparts in ICU-AW knowledge scores. This advantage may be attributed to their superior problem-analysis and problem-solving capabilities: they excel at anticipating clinical deterioration in critically ill patients, implementing preemptive interventions, and mitigating adverse patient outcomes. Advancement in professional titles, in turn, contributes to the enhancement of ICU nurses’ individual professional competence and comprehensive clinical capabilities [15, 32].

As the backbone of the department, senior and specialized nurses should fully fulfil their leading role [33]. Training should be focused on less senior nurses, and less senior nurses should also seize the opportunity to gain knowledge and experience around ICU-AW.

Hospital level and marital status were independent related to ICU nurses’ knowledge, attitudes, and practices around ICU-AW, with tertiary hospital nurses and married nurses having higher levels of knowledge and better attitudes and practices [34–36]. In other words, the total KAP score of nurses in secondary hospitals is approximately 6.373 points lower on average than that of nurses in tertiary hospitals, and the total KAP score of unmarried nurses is approximately 4.119 points lower on average than that of married nurses. It may be that differences in resource allocation and training opportunities across hospitals of varying levels have been related to the research outcomes. In other word, tertiary hospitals have relatively well-developed medical teams, more abundant medical resources, and a more complete system of related training and assessment. Additionally, marital status is likely to exert an indirect effect through factors such as social support networks and mental health status. Married nurses may have better family support systems, which would be more favorable to the development of healthy practices. Married nurses may have more comprehensive family and social support networks, making them more likely to show positive tendencies in relevant practical behaviors. Tertiary hospitals, by virtue of their more robust medical team configuration, abundant medical resources, and well-developed training and assessment systems, can provide dual references for optimizing clinical practice and enhancing industry quality. At the team-building level, an experience-sharing platform can be established to promote learning, communication, and mutual support among nurses with different marital statuses, facilitating the collaborative improvement of overall professional capabilities. At the industry development level, relying on the policy framework of the national “Medical Consortium (yilianti)” initiative, we can promote tertiary hospitals to exert the radiating effect of their resources and technologies. Through targeted assistance, technical guidance, and other approaches, standardized training systems and practical experiences can be extended to primary hospitals, thereby advancing the balanced development of professional literacy and service quality across the entire industry. A low R² value (0.101) indicates the potential existence of unmeasured latent variables, such as organizational context, ICU culture, implementation environment, measurement error and other relevant factors. Additionally, the cross-sectional design indeed cannot reflect dynamic changes, and future studies will explore more factors through longitudinal research or qualitative interviews.

This study systematically investigated the current status of ICU-AW KAP among ICU nurses in hospitals of different levels in Shiyan. It found that there were significant differences in KAP levels between nurses in tertiary hospitals and those in secondary hospitals, with the factors associated with ICU-AW showing obvious contextual heterogeneity. This result stands in sharp contrast to the findings of Zhao et al., further confirming that the difference in the level of medical institutions is significantly correlated with the divergence of nurses’ ICU-AW KAP. Zhao et al.’s study focused on nurses in tertiary hospitals and proposed that factors such as age, working years, and professional titles are the core determinants of KAP levels. This conclusion is basically consistent with the data analysis results of tertiary hospitals in our study. However, by including samples from multiple secondary hospitals, this study further revealed that hospital level shows a more prominent association with the KAP of nurses in secondary hospitals, whereas the association of working years and professional titles is significantly weakened. This discrepancy is closely related to the “high workload and low resource” working environment faced by nurses in secondary hospitals. Constrained by the inadequate training system, nurses in secondary hospitals acquire knowledge more through regular in-hospital training rather than relying on the autonomous learning ability derived from their working years and professional title backgrounds. This finding revises the scope of application of the conclusions drawn by Zhao et al. and breaks through the traditional “professional title determinism”. In addition, this study also found that nurses in secondary hospitals scored significantly lower in the practice dimension of ICU-AW. The core barriers are not “knowledge deficiency”, but “lack of standardized assessment tools” and “non-standard clinical operation procedures”. This is completely different from the barrier characteristics of “lack of motivation to update knowledge” among nurses in tertiary hospitals reported in Zhao et al.’s study. This differentiated conclusion stems from the sample design of this study that extends to secondary hospitals, and such pain points in grassroots nursing practice have never been revealed in previous studies that only focused on tertiary hospitals.

Guided by the KAP theoretical framework, the knowledge dimension functions as a foundational pillar—its moderate score may constrain the positive transformation of attitudes and hinder the standardization of practical behaviors. The attitude dimension plays a mediating role: the positive attitudes demonstrated in the study’s findings can effectively facilitate the translation of knowledge into practice. Furthermore, deficiencies identified in practical implementation can inversely reveal existing knowledge gaps or attitude biases, thereby offering targeted directions for subsequent intervention strategies.

Limitations

While the 100% response rate of this study appears to enhance the apparent representativeness of the sample, it is susceptible to the risk of reverse non-response bias. Specifically, the on-site group questionnaire administration might induce perfunctory responses from some nurses due to social pressure. Concurrently, the sample may exhibit inherent homogeneity, which could constrain the generalizability of the study findings.

The convenience sampling approach employed in this study is inherently prone to selection bias. The included participants were predominantly nurses from ICU departments with high levels of collaboration with the research team, thus failing to adequately represent the characteristics of nursing cohorts across hospitals of different tiers and with disparate levels of professional experience. Furthermore, given the non-probabilistic nature of this sampling method, sampling error cannot be quantified, warranting prudence when extrapolating the study conclusions to broader populations.

The self-report methodology is subject to social desirability bias, whereby nurses may be inclined to report normative, guideline-concordant practices rather than their actual clinical behaviors. Additionally, notable discrepancies may exist between self-reported behaviors and objectively observed clinical performance. Future research will integrate objective assessment modalities, including direct clinical observation and retrospective medical record review, to implement triangulation for more robust validation of study outcomes.

It is also important to note that the model in this study has a low coefficient of determination (R²), indicating that the currently included variables have limited explanatory power, and there may be other important related factors not incorporated.

Conclusions

In summary, ICU nurses’ knowledge and practices around ICU-AW: were categorized as moderate, while their attitudes were categorized as good. Among nurses, those with short overall work experience, short work experience in the ICU, a junior professional title, unmarried status, and those working in secondary hospitals had relatively lower KAP scores regarding ICU-AW. Among these factors, hospital level and marital status were related to nurses’ overall KAP level towards ICU-AW. As an exploratory cross-sectional study without prespecified directional hypotheses, the potential associations identified provide testable hypotheses for future large-sample prospective cohort studies or randomized controlled trials, which are needed to verify the causal relationships and clinical significance of these factors.

Clinical Implications

ICU managers should formulate a refined nursing management strategy based on these related factors, as well as providing effective nursing training, such as modular training, scenario simulation teaching, and online-offline blended training and so on.

Research Implications

In future research, we plan to adopt the following measures: employ a longitudinal study design to explore potential causal pathways, and use more rigorous sampling strategies, e.g., stratified random sampling, to enhance sample representativeness, thereby improving the validity and generalizability of the research conclusions.

Abbreviations

ICU

Intensive Care Unit

KAP

Knowledge attitude and practice

ICU-AW

Intensive care unit (ICU)-acquired weakness

Author contributions

Zhenzhen Rao is responsible for data collection, data organization, statistical analysis, and paper writing and submission; Yaling Li is responsible for project design, implementation, and quality control; Baoyi Yang is responsible for the design of the project, data collection, and organization; Xiaofei Zhang and Dongmei Zhao are responsible for data organization and paper revision; Puqing Wang oversaw the study design, guided data analysis strategies, and critically revised the manuscript..

Funding

This work was supported by the Hubei Provincial Science and Technology Program – Key Special Project (grant No. 2023BCB140); the Philosophy and Social Science Program of Hubei Provincial Department of Education (grant number 21D074); the Science and Technology Bureau Guiding Scientific Research Project of Shiyan City of Hubei Province (grant number 22Y34); and the Innovative Research Program for Graduates of Hubei University of Medicine (grant number YC2022021).

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the guidelines of the Declaration of Helsinki and was approved by the Medical Ethics Committee of Shiyan Taihe Hospital (2023KS15). Informed consent was obtained from all participants, all of whom were nursing staff and had the right to withdraw from the study at any time. The confidentiality of participants’ names and other personal information was maintained, and no harm was caused to any participant.

Consent for publication

Consent for publication is Not Applicable. No identifiable individual clinical data or images of participants were included in this cross-sectional survey.

Competing interests

The authors declare no competing interests.