Abstract
Background
Intensive care unit (ICU) nurses exhibit gaps in their knowledge, attitudes, and behaviors regarding palliative care. In China, there is a lack of standardized training programs for palliative care among ICU nurses, and corresponding research on the needs and impact of such training is also limited.
Objective
Through the investigation and analysis of ICU nurses’ knowledge, attitudes, behaviors, and training needs regarding palliative care, this study explored the specific knowledge gaps and training needs of ICU nurses in palliative care.
Methods
A convenience sampling method was employed to survey ICU nurses at 23 tertiary (tier-A) hospitals in Anhui Province, adhering to the specified criteria, between December 2023 and April 2024. The study utilized a general demographic survey and a comprehensive questionnaire to assess ICU nurses’ knowledge, attitudes, behaviors, and training requirements in palliative care.
Results
Among the 693 ICU nurses surveyed, the scores for knowledge (73.67), attitude (77.1), behavior (75.84), and training needs (78.16) regarding palliative care were all below the middle level. Multivariate linear regression analysis indicated that gender, professional rank, prior attendance at death education or palliative care training, engagement with literature on death, experience caring for patients in advanced stages, and the number of terminally ill patients cared for in the past year significantly influence nurses’ knowledge, attitudes, behaviors, and training needs in palliative care (P < 0.05).
Conclusion
Training and education in palliative care should be enhanced for male and lower-level ICU nurses to address the specific knowledge gaps in this area. Chinese nursing managers should implement targeted and practical palliative care training programs to meet the specific training needs of ICU nurses.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12904-025-01767-6.
Keywords: Intensive care unit nurse, Palliative care, The KAP model, Training needs
Introduction
With the ongoing advancement of critical care medicine, the lives of numerous patients with acute and critical conditions have been saved. However, a significant number of patients in the terminal phase continue to receive life-sustaining measures in the ICU before ultimately facing death [1]. In the United States, nearly 29% of individuals spend their last 30 days in an ICU [2], and approximately one-third of adults over the age of 65 are admitted to an ICU at the end of their lives [3]. According to a survey, the mortality rate of ICU patients in a geriatric hospital in China was as high as 33.4% [4]. Studies have shown that ICU patients often undergo various invasive treatments before death, which not only increases their suffering and reduces the quality of death for terminally ill patients but also leads to a negative medical experience for their families [5]. However, implementing early palliative care in the ICU can not only improve the quality of death for patients but also alleviate anxiety and depression among their families [6]. Palliative care refers to the services provided to patients in the terminal stages of illness, offering care and humanistic concern in aspects such as physical, psychological, and spiritual well-being. It aims to control pain and discomfort, enhance the quality of life, and assist patients in passing away comfortably, peacefully, and with dignity [7]. Nurses, as pivotal members of the palliative care team, are instrumental in coordinating team dynamics, assessing patient conditions, implementing interventions, and addressing the multi-dimensional care needs of patients. Their contributions are crucial to the advancement of palliative care initiatives [8, 9]. However, palliative care in China is still in its infancy, with a coverage rate of only 1% [10]. As the main providers of palliative care, ICU nurses play a crucial role. Their knowledge, attitudes, and willingness to engage in palliative care practices can significantly contribute to the development and expansion of palliative care services. This research assesses the existing knowledge, beliefs, behaviors, and training requirements of ICU nurses regarding palliative care and identifies the factors that influence these aspects. The aim is to address the specific knowledge gaps in palliative care for ICU nurses in China, provide strategies for governments and medical institutions to further develop palliative care services, and offer better nursing care for end-of-life patients in the ICU in China.
Methods
Study design
This is a cross-sectional study utilizing convenience sampling. To minimize biases associated with convenience sampling, such as selection bias, underrepresentation, and non-response bias, we conducted a pilot study involving 103 ICU nurses from three hospitals in Hefei and Bengbu before the formal survey. Based on the pilot study results, we adjusted our sample selection strategy. To enhance the diversity of the sample, we recruited participants from the ICUs of 23 tertiary hospitals across 16 cities in Anhui Province, proportional to the number of tertiary hospitals in each city, and maximized the sample size as much as possible. To reduce non-response bias, electronic questionnaires were disseminated via the Questionnaire Star platform. After communicating with and receiving approval from the respective hospital administrators, ICU supervisors distributed the surveys through WeChat groups. All questions were designated as “mandatory” to ensure the integrity and validity of the responses. Additionally, it was stipulated that each IP address could only be used to complete the survey once. The 23 hospitals from which the research subjects were recruited are listed in Annex 1.
Population
An online survey was conducted among ICU nurses in 23 tertiary hospitals in Anhui Province from December 2023 to April 2024. The eligibility criteria for participation were as follows: ① Participants must be over 18 years of age; ② Hold a valid “Nurse Practice License” and be currently registered and active in their position; ③ Have at least 2 years of experience in ICU nursing or management; ④ Provide informed consent and voluntarily agree to participate in the study. The exclusion criteria included: ① Nurses who were not actively engaged in their duties during the study period; ② Nurses who were on external training programs, retired, or re-employed. The study adhered to the specified inclusion and exclusion criteria, distributing a total of 693 questionnaires and achieving a 100% effective response rate with 693 fully completed questionnaires returned. Ethical approval for the study was obtained from the Third People’s Hospital of Bengbu in February 2023 (L5).
Questionnaire
Demographic data of the ICU nurses
The questionnaire was self-developed by the researchers based on a review of the literature [11]. Included items on age, gender, marital status, highest degree obtained, religious affiliation, duration of professional experience, academic title, position, history of engagement in death education or palliative care-related training sessions or courses, history of reading literature on death, experience in caring for patients in advanced stages of illness, and the count of terminally ill patients attended to within the last year, among other details.
Survey on nurses’ knowledge, attitudes, behaviors, and training needs in palliative care
This study employed a questionnaire on nurses’ knowledge, attitudes, practices, and training needs in palliative care, developed by Liu Wei et al. [12]. The questionnaire comprises four dimensions with a total of 29 items. The knowledge section consists of four multiple-choice questions, with participants awarded one point for each correct answer, up to a maximum of four points for all correct answers. Incorrect answers and “do not know” responses receive zero points. The knowledge section ranges from a minimum of 0 to a maximum of 4 points, with higher scores indicating a more comprehensive understanding of palliative care among nurses. The remaining dimensions—Palliative Care Attitude (6 items), Palliative Behavior (9 items), and Training Needs (10 items)—utilize a 5-point Likert scale, with scores ranging from 1 (strongly disagree) to 5 (strongly agree). The potential total score for the entire scale ranges from 25 to 137 points, with the standardized score calculated using the formula (actual score / maximum possible score) × 100.
Statistical analysis
The analysis was conducted using SPSS version 26.0. Metric data that adhered to a normal distribution were expressed as mean ± standard deviation(
±s), while count data were presented as frequencies (%). To compare the differences in scores related to knowledge, attitudes, behaviors, and training needs in palliative care among nurses with varying demographic characteristics, independent t-tests and one-way analysis of variance (ANOVA) were employed. The relationships among the different dimensions of ICU nurses’ knowledge, attitudes, behaviors, and training needs in palliative care were examined using Pearson correlation analysis. To investigate the factors influencing each dimension of palliative care among ICU nurses, we conducted a multiple linear regression analysis. In this analysis, the scores of nurses’ knowledge, attitudes, behaviors, and training needs regarding palliative care were set as the dependent variables. The variables that were statistically significant in the univariate analysis were selected as independent variables, assigned values, and then included in the multiple linear regression model. P-values less than 0.05 were considered statistically significant.
Result
Characteristics of the 693 ICU nurses
The nurses have an average age of 31.84 years (± 5.73 standard deviation), ranging from 20 to 55 years old, with 146 (21.1%) males and 547 (78.9%) females. (Table 1)
Table 1.
Characteristics of the ICU nurses (N = 693)
| Variable | Classify | Frequency (N) | Percentage (%) |
|---|---|---|---|
| Sex | man | 146 | 21.1 |
| woman | 547 | 78.9 | |
| Age (year) | 20~30 | 316 | 45.6 |
| 31~40 | 326 | 47.0 | |
| 41 And above | 51 | 7.4 | |
| Marital status | married | 480 | 69.3 |
| unmarried | 205 | 29.6 | |
| other | 8 | 1.2 | |
| Highest education | junior college | 72 | 10.4 |
| undergraduate course | 611 | 88.2 | |
| Graduate student or above | 10 | 1.4 | |
| Religion | not have | 661 | 95.4 |
| have | 32 | 4.6 | |
| Working life | 2 years, < 10 years | 363 | 52.4 |
| 11 ~ 20 Years | 292 | 42.1 | |
| > 20 Years | 38 | 5.5 | |
| Professional ranks and titles | nurse | 86 | 12.4 |
| primary nurse | 293 | 42.3 | |
| nurse-in-charge | 290 | 41.8 | |
| Deputy chief nurse teacher and above | 24 | 3.5 | |
| Post | nurse | 657 | 94.8 |
| head nurse | 36 | 5.2 | |
| Have participated in death education or hospice care-related training or courses | yes | 252 | 36.4 |
| deny | 441 | 63.6 | |
| Have you read any articles or books on death | yes | 313 | 45.2 |
| deny | 380 | 54.8 | |
| Whether to care for the middle and advanced patients | yes | 655 | 94.5 |
| deny | 38 | 5.5 | |
| Number of terminal patients cared for in the last 1 year | < 5 People | 198 | 28.6 |
| 5 ~ 19 People | 246 | 35.5 | |
| > 20 People | 249 | 35.9 |
Score of knowledge, attitudes, behaviors, and training needs items among 693 ICU nurses
The total score of palliative care knowledge (8.84 ± 1.13), standard score 73.67; total attitude score (23.15 ± 3.95), standard score 77.1; total behavior score (34.13 ± 6.40), standard score 75.84; total training needs score (39.08 ± 6.98), the standard score is 78.16 (Table 2). The dimensions of knowledge, attitudes, and behaviors are ranked from highest to lowest as attitudes, behaviors, and knowledge, respectively.
Table 2.
Score of knowledge, attitudes, behaviors, and training needs items among 693 ICU Nurses(points, 
± s)
| Item | Score ( ±s) |
Standard score |
|---|---|---|
| Knowledge | ||
| 1. Regarding the description of fatigue, the following statement is correct | 2.57 ± 0.50 | |
| 2. Regarding the description of the dry mouth, the following statement is correct | 2.04 ± 0.48 | |
| 3. Nurses receiving hospice care should suddenly have an acute pain crisis as a team member | 1.70 ± 0.46 | |
| 4 Regarding the description of palliative sedation, the following statement is correct | 2.43 ± 0.50 | |
| Total points | 8.84 ± 1.13 | 73.67 |
| Attitudes | ||
| 5. I feel confident about controlling the pain (such as pain, fatigue, anorexia, insomnia, etc.) symptoms | 3.55 ± 0.84 | |
| 6. When patients receive palliative sedation, I actively participate in the palliative care team to communicate with patients and their families to ensure the comfort and dignity of patients | 3.87 ± 0.76 | |
| 7. I think the hospice care team should pay more attention to the patient’s family | 3.95 ± 0.75 | |
| 8. I think it is very important to introduce living wills to terminal patients and their families | 3.97 ± 0.77 | |
| 9. I think it is very important to take the care of the patients after their death | 4.01 ± 0.74 | |
| 10. I want to join the hospice care team | 3.78 ± 0.85 | |
| Total points | 23.13 ± 3.97 | 77.1 |
| Behaviors | ||
| 11. I think the painful symptoms (such as pain, fatigue, anorexia, insomnia, etc.) are very fully handled with the members of the palliative care team | 3.85 ± 0.79 | |
| 12. I think I have a very good communication with the families of patients near the end of their lives about “death, sadness, some important things to accomplish” | 3.77 ± 0.82 | |
| 13. I think I took very good care of the patient’s family after his death | 3.69 ± 0.84 | |
| 14. I will take the initiative to participate in the hospice care team, and I can soon enter my role in the team | 3.77 ± 0.79 | |
| 15. I pay attention to the pain symptoms of patients, and I can correctly apply pain assessment methods to conduct pain assessment of patients | 3.84 ± 0.74 | |
| 16. When a patient needs pain management, I can help him with adjuvant therapy (such as massage, acupuncture, listening to music, etc.) | 3.78 ± 0.80 | |
| 17. When providing palliative care for end-of-life patients with pain relief needs, I can clearly identify the adverse reactions of pain medication | 3.76 ± 0.76 | |
| 18. When patients receive palliative sedation, I can participate in the medical team to establish a good communication and trust relationship with patients and their families, and do a good job in communication and physical care of patients | 3.84 ± 0.76 | |
| 19. I focus on the nutritional needs of patients dying and provide appropriate nutrition and health guidance | 3.81 ± 0.78 | |
| Total points | 34.13 ± 6.39 | 75.84 |
| Training needs | ||
| 20. I really need the training to control the painful symptoms of the terminal patients | 3.86 ± 0.76 | |
| 21. I really need the training in pain assessment methods and pain coping methods | 3.89 ± 0.75 | |
| 22. I really need training in a comprehensive assessment of hospice care (including a comprehensive physical, psychological and social assessment of the patient) | 3.89 ± 0.74 | |
| 23. I desperately need the training in palliative sedation care | 3.91 ± 0.73 | |
| 24. I think it is very necessary to receive training on difficult topics (death, sadness, and finally some important things to accomplish) for patients or their families near the end of their lives | 3.89 ± 0.74 | |
| 25. I really need training in communication (including bad news) between terminal patients and their families | 3.93 ± 0.74 | |
| 26. I feel that there is a great need for training on preestablished medical care programs | 3.92 ± 0.74 | |
| 27. In order to carry out a variety of life and death education for patients and their families, I think it is very necessary to train life and death education knowledge and skills | 3.94 ± 0.74 | |
| 28. I really need the training to give grief coaching to the bereaved | 3.90 ± 0.75 | |
| 29. I really need hospice care training for intensive care unit patients | 3.96 ± 0.75 | |
| Total points | 39.08 ± 6.98 | 78.16 |
Note: ‘
± s’ represent: mean ± standard deviation
Comparison of palliative care knowledge, attitudes, behaviors, and training needs scores for 693 ICU nurses across various characteristics
Analysis of variance in palliative care knowledge, attitudes, behaviors, and training needs scores across nurses of varying characteristics is presented in Table 3. Univariate analysis revealed statistically significant differences in palliative care knowledge among ICU nurses across various characteristics such as gender, professional rank, prior attendance at death education or palliative care-related training, and experience caring for patients in advanced stages (P < 0.05).Statistically significant differences were observed in the attitudes towards palliative care among ICU nurses with varying age, marital status, duration of employment, professional rank, position, history of engagement in death education or palliative care-related training, exposure to literature on death, and the number of terminally ill patients attended to within the last year (P < 0.05).There were statistically significant differences in palliative care behaviors among ICU nurses based on whether they had participated in death education or palliative care-related training, read articles or books on death, and the number of terminally ill patients they had cared for within the last year (P < 0.05).Statistically significant differences were identified in the training needs dimension with respect to marital status, engagement in death education or palliative care-related training, reading materials on death, and experience caring for patients in advanced stages of illness (P < 0.05).
Table 3.
Comparison of palliative care knowledge, attitudes, behaviors, and training needs scores for 693 ICU nurses across various characteristics (Scores, 
±s)
| Item | Knowledge | Attitudes | Behaviors | Training Needs |
|---|---|---|---|---|
| Sex | ||||
| man | 8.59 ± 0.10 | 22.89 ± 0.34 | 34.41 ± 0.52 | 39.47 ± 0.55 |
| woman | 8.90 ± 0.05 | 23.20 ± 0.17 | 34.06 ± 0.27 | 38.98 ± 0.30 |
| t/F price | 9.023 | 0.697 | 0.354 | 0.582 |
| P price | 0.003 | 0.404 | 0.552 | 0.446 |
| Age | ||||
| 20 ~ 30 | 8.73 ± 0.07 | 22.61 ± 0.22 | 33.88 ± 0.35 | 38.92 ± 0.39 |
| 31 ~ 40 | 8.91 ± 0.06 | 23.42 ± 0.22 | 34.27 ± 0.35 | 39.13 ± 0.39 |
| 41 And above | 8.99 ± 0.15 | 24.57 ± 0.62 | 34.80 ± 0.99 | 39.76 ± 0.92 |
| t/F price | 2.537 | 7.020 | 0.595 | 0.335 |
| P price | 0.080 | 0.001 | 0.552 | 0.716 |
| Marital status | ||||
| married | 8.84 ± 0.05 | 23.45 ± 0.18 | 34.27 ± 0.30 | 39.09 ± 0.32 |
| unmarried | 8.82 ± 0.08 | 22.44 ± 0.25 | 33.66 ± 0.41 | 38.81 ± 0.47 |
| other | 9.38 ± 0.58 | 22.13 ± 2.45 | 38.00 ± 2.05 | 45.25 ± 2.03 |
| t/F price | 0.922 | 4.953 | 2.133 | 3.293 |
| P price | 0.398 | 0.007 | 0.119 | 0.038 |
| Highest education | ||||
| junior college | 8.60 ± 0.14 | 23.94 ± 0.43 | 35.10 ± 0.67 | 39.94 ± 0.74 |
| undergraduate course | 8.86 ± 0.05 | 23.06 ± 0.16 | 34.05 ± 0.26 | 38.97 ± 0.29 |
| Graduate student or above | 9.20 ± 0.37 | 22.00 ± 0.60 | 32.30 ± 1.84 | 39.60 ± 1.45 |
| t/F price | 2.264 | 2.027 | 1.289 | 0.654 |
| P price | 0.105 | 0.132 | 0.276 | 0.520 |
| Religion | ||||
| not have | 8.86 ± 0.04 | 23.14 ± 0.15 | 34.10 ± 0.25 | 39.07 ± 0.27 |
| have | 8.47 ± 0.19 | 23.03 ± 0.78 | 34.75 ± 1.08 | 39.31 ± 1.15 |
| t/F price | 3.575 | 0.023 | 0.315 | 0.037 |
| P price | 0.059 | 0.881 | 0.575 | 0.848 |
| Working life | ||||
| 2 years, < 10 years | 8.75 ± 0.06 | 22.61 ± 0.21 | 33.83 ± 0.34 | 38.95 ± 0.37 |
| 11 ~ 20 Years | 8.92 ± 0.06 | 23.52 ± 0.23 | 34.22 ± 0.37 | 39.09 ± 0.41 |
| > 20 Years | 8.97 ± 0.19 | 25.18 ± 0.70 | 36.32 ± 1.00 | 40.26 ± 1.08 |
| t/F price | 2.148 | 9.869 | 2.663 | 0.605 |
| P price | 0.118 | <0.001 | 0.070 | 0.547 |
| Professional ranks and titles | ||||
| nurse | 8.74 ± 0.12 | 22.36 ± 0.41 | 34.29 ± 0.60 | 38.95 ± 0.67 |
| primary nurse | 8.72 ± 0.07 | 22.92 ± 0.23 | 33.82 ± 0.38 | 38.75 ± 0.41 |
| nurse-in-charge | 8.97 ± 0.07 | 23.34 ± 0.23 | 34.12 ± 0.38 | 39.34 ± 0.42 |
| Deputy chief nurse teacher and above | 9.04 ± 0.21 | 26.00 ± 0.83 | 37.50 ± 1.27 | 40.46 ± 1.56 |
| t/F price | 2.862 | 5.940 | 2.499 | 0.669 |
| P price | 0.036 | 0.001 | 0.059 | 0.571 |
| Post | ||||
| nurse | 8.52 ± 0.04 | 23.04 ± 0.16 | 34.09 ± 0.25 | 39.00 ± 0.27 |
| head nurse | 9.19 ± 0.18 | 24.89 ± 0.61 | 34.97 ± 1.05 | 40.47 ± 1.02 |
| t/F price | 3.786 | 7.483 | 0.658 | 1.509 |
| P price | 0.052 | 0.006 | 0.417 | 0.220 |
| Have participated in death education or hospice care-related training or courses | ||||
| yes | 8.96 ± 0.07 | 23.78 ± 0.27 | 35.82 ± 0.40 | 40.68 ± 0.42 |
| deny | 8.77 ± 0.05 | 22.77 ± 0.18 | 33.17 ± 0.30 | 38.17 ± 0.33 |
| t/F price | 4.673 | 10.545 | 28.715 | 21.341 |
| P price | 0.031 | 0.001 | <0.001 | <0.001 |
| Have you read any articles or books on death | ||||
| yes | 8.90 ± 0.07 | 23.77 ± 0.24 | 35.73 ± 0.37 | 40.34 ± 0.40 |
| deny | 8.79 ± 0.06 | 22.61 ± 0.19 | 32.82 ± 0.31 | 38.04 ± 0.35 |
| t/F price | 1.525 | 14.773 | 37.435 | 19.003 |
| P price | 0.217 | <0.001 | <0.001 | <0.001 |
| Whether to care for the middle and advanced patients | ||||
| yes | 8.88 ± 0.04 | 23.17 ± 0.16 | 34.23 ± 0.25 | 39.21 ± 0.27 |
| deny | 8.13 ± 0.17 | 22.50 ± 0.67 | 32.47 ± 1.12 | 36.89 ± 1.21 |
| t/F price | 15.976 | 1.025 | 2.716 | 3.957 |
| P price | <0.001 | 0.312 | 0.100 | 0.047 |
| Number of terminal patients cared for in the last 1 year | ||||
| < 5 People | 8.71 ± 0.08 | 22.01 ± 0.267 | 32.93 ± 0.44 | 38.41 ± 0.47 |
| 5 ~ 19 People | 8.84 ± 0.07 | 23.25 ± 0.25 | 34.10 ± 0.40 | 39.45 ± 0.43 |
| > 20 People | 8.94 ± 0.07 | 23.92 ± 0.26 | 35.12 ± 0.42 | 39.24 ± 0.47 |
| t/F price | 2.300 | 13.443 | 6.548 | 1.318 |
| P price | 0.101 | <0.001 | 0.002 | 0.268 |
Note: ‘
± s’ represent: mean ± standard deviation
Correlation analysis of scores and total score of nurse palliative care scale
Correlation analysis of the individual dimension scores and the total score for the palliative care Knowledge, Attitudes, Behaviors, and Training Needs Questionnaire among nurses: Refer to Table 4. The findings indicate a positive correlation between the dimensions of palliative care training needs, behaviors, attitudes, knowledge, and the overall score, with correlation coefficients of 0.941, 0.939, 0.907, and 0.186, respectively (P < 0.01).
Table 4.
Correlation analysis of scores and total score of nurse palliative care scale
| Variable | Training needs | Behaviors | Attitudes | Knowledge | Knowledge and credit line total score |
|---|---|---|---|---|---|
| Training needs | 1 | ||||
| Behaviors | 0.807** | 1 | |||
| Attitudes | 0.783** | 0.825** | 1 | ||
| Knowledge | 0.139** | 0.063 | 0.137** | 1 | |
| Knowledge and credit line total score | 0.941** | 0.939** | 0.907** | 0.186** | 1 |
Note: * indicates P < 0.05, and * * indicates P < 0.01
Multivariate linear regression analysis of the influencing factors on ICU nurses’ hospice care knowledge, attitudes, behaviors, and training needs
In this study, the scores for knowledge, attitudes, behaviors, and training needs related to hospice care were established as the dependent variables, while variables that were statistically significant in the univariate analysis were selected as independent variables for the multivariate linear regression analysis. The values assigned to each independent variable are presented in Table 5. The findings reveal that gender, professional rank, prior attendance at death education or palliative care-related training, and the care of patients in advanced stages significantly influence palliative care knowledge (P < 0.05). Participation in death education or palliative care-related training, engagement with literature on death, and the number of terminally ill patients cared for within the last year significantly influence nurses’ attitudes and behaviors towards palliative care (P < 0.05) .Whether nurses have engaged in death education or palliative care-related training, as well as their history of reading literature on death, significantly influence their training needs in palliative care (P < 0.05) (Table 6).
Table 5.
Assignment mode of independent variables
| Argument | How to assign value |
|---|---|
| Sex | Male = 1, female = 2 |
| Age | 20–30 years = 1; 31 ~ 40 years = 2; 41 years and above = 3 |
| Marital status | Married = 1; Unmarried = 2; other = 3 |
| Working life | 2 years, < 10 years = 1; 11 ~ 19 years = 2;> 20 years = 3 |
| Professional ranks and titles | Nurse = 1; nurse = 2; nurse in charge = 3; deputy chief nurse and above = 4 |
| Post | Nurse = 1; Head nurse = 2 |
| Have participated in death education or hospice care-related training or courses | Yes = 1; No = 2 |
| Have you read any articles or books on death | Yes = 1; No = 2 |
| Whether to care for the middle and advanced patients | Yes = 1; No = 2 |
| Number of terminal patients cared for in the last 1 year | < 5 = 1; 5 ~ 19 = 2;> 20 = 3 |
Table 6.
Multiple linear regression analysis of influencing factors of ICU nurses
| Variable | Partial regression coefficient | Standard error | Normalized regression coefficient, β | t price | P price |
|---|---|---|---|---|---|
| Knowledge | |||||
| Constant | 2.551 | 0.315 | -- | 8.109 | <0.001 |
| Sex | 0.300 | 0.104 | 0.108 | 2.870 | 0.004 |
| Professional ranks and titles | 0.118 | 0.058 | 0.077 | 2.048 | 0.041 |
| Have participated in death education or hospice care-related training or courses | -0.167 | 0.088 | -0/71 | -2.002 | 0.045 |
| Whether to care for the middle and advanced patients | -0.715 | 0.186 | -0.144 | -3.840 | <0.001 |
| Attitudes | |||||
| Constant | 22.828 | 1.304 | -- | 17.508 | <0.001 |
| Age | -0.166 | 0.483 | -0.026 | -0.343 | 0.731 |
| Marriage | -0.814 | 0.446 | -0.098 | -2.004 | 0.059 |
| Working life | 0.884 | 0.487 | 0.133 | 1.817 | 0.070 |
| Professional ranks and titles | -0.100 | 0.314 | -0.019 | -0.318 | 0.751 |
| Post | 0.905 | 0.714 | 0.051 | 1.267 | 0.206 |
| Have participated in death education or hospice care-related training or courses | -0.696 | 0.323 | -0.084 | -2.155 | 0.032 |
| Have you read any articles or books on death | -0.746 | 0.311 | -0.094 | -2.401 | 0.017 |
| Number of terminal patients cared for in the last 1 year | 0.840 | 0.184 | 0.169 | 4.560 | <0.001 |
| Behavior | |||||
| Constant | 38.704 | 1.199 | -- | 32.272 | <0.001 |
| Have participated in death education or hospice care-related training or courses | -1.827 | 0.513 | -0.138 | -3.561 | <0.001 |
| Have you read any articles or books on death | -2.162 | 0.499 | -0.169 | -4.336 | <0.001 |
| Number of terminal patients cared for in the last 1 year | 0.851 | 0.294 | 0.107 | 2.894 | 0.004 |
| Training needs | |||||
| Constant | 46.344 | 1.719 | -- | 26.960 | <0.001 |
| Marital status | -0.095 | 0.536 | -0.007 | -0.178 | 0.859 |
| Have participated in death education or hospice care-related training or courses | -1.909 | 0.578 | -0.132 | -3.306 | 0.002 |
| Have you read any articles or books on death | -1.612 | 0.556 | -0.115 | -2.901 | 0.004 |
| Whether to care for the middle and advanced patients | -1.439 | 1.155 | -0.47 | -1.246 | 0.213 |
Note: Knowledge: R2 = 0.047, Adjusted for R2 = 0.042, F = 8.512, P < 0.001; Attitude: R2 = 0.088, Adjusted for R2 = 0.077, F = 8.199, P < 0.001; Behavior: R2 = 0.080, Adjusted for R2 = 0.076, F = 20.042, P < 0.001; Training requirement: R2 = 0.045, Adjusted for R2 = 0.039, F = 8.107, P<0.001
Discussion
The current status of ICU nurses’ knowledge, attitudes, practices, and training needs regarding palliative care
The results of this study reveal that ICU nurses’ knowledge of palliative care is inadequate, with a standard score of 73.67. This is lower than the score of 76.47 reported in a study conducted by Zhang Xiaodan et al. [11] on 204 nurses at Peking Union Medical College Hospital. The analysis points to two primary reasons: ① The development of palliative care within domestic in Chinese ICUs has been relatively recent, resulting in a lack of structured education and training [13]. ② In China, ICU nurses, who primarily focus on critically ill patients, are burdened with heavy workloads, leaving them with insufficient time and energy to acquire knowledge in palliative care [14, 15]. The score for the attitude dimension of palliative care among ICU nurses was 77.1, which is lower than the 88.04 obtained using the same scale [11]. Compared with hospice nurses and other healthcare professionals in other countries, the attitudes of Chinese ICU nurses towards palliative care are less positive [16, 17]. This may be related to the fact that the core competencies of Chinese ICU nurses in palliative care are at a moderate level, and they generally perceive death as an inevitable stage in the life process, one that is natural, undeniable, and unavoidable [18, 19]. The score for palliative care behaviors among ICU nurses (75.84) was lower than the results of previous surveys of clinical and community healthcare workers [20, 21]. Meanwhile, we also found that in the attitude dimension of palliative care, ICU nurses scored highly in their attitudes towards caring for family members (4.01 ± 0.74), but scored lower in their actual caring behaviors towards family members (3.69 ± 0.84). The reasons for this discrepancy are threefold: ① The open layout of ICU beds and the noisy treatment environment are not conducive to the implementation of palliative care. ② The focus of ICU medical staff is on saving patients’ lives, with less attention paid to the quality of death for terminal patients [22], which leads to the situation where ICU nurses’ high attitudes towards caring for the families of end-of-life patients cannot easily be translated into actual behaviors. ③ In this study, ICU nurses scored below average in both knowledge and attitude towards palliative care, where inadequate knowledge and insufficient confidence are the principal factors impeding the delivery of palliative care. The aggregate score for ICU nurses’ training needs in palliative care was 78.16 points, making it the highest scoring dimension among the four aspects of the KAP (Knowledge, Attitudes, Practices) survey. The primary areas of training interest for ICU nurses in palliative care include death education knowledge and skills specific to the ICU, as well as communication techniques with patient families. This highlights a deficiency in ICU nurses’ access to palliative care knowledge and skills, underscoring the need for medical institutions and hospital managers to offer targeted education and training.
Pearson correlation analysis indicates a positive correlation between ICU nurses’ knowledge, behaviors, attitudes, and training needs in palliative care with the overall score, and among the four dimensions themselves, which aligns with the KAP model [23]. Consequently, the KAP model should serve as the theoretical foundation for developing palliative care training programs for ICU nurses. Enhancing their knowledge base in palliative care is essential, and bolstering their attitudes and beliefs will provide the impetus necessary to effect behavioral changes in the delivery of palliative care by ICU nurses.
Factors influencing ICU nurses’ knowledge, attitudes, behaviors, and training needs regarding palliative care
This study demonstrates that female ICU nurses outperform their male counterparts in terms of palliative care knowledge. This may be attributed to the fact that female nurses are generally more patient and empathetic. They tend to approach palliative care in a more emotionally sensitive manner in clinical practice and excel in listening and empathizing. Additionally, female nurses show a greater interest in palliative care knowledge. These findings are consistent with previous survey studies on palliative care knowledge among ICU nurses in tertiary hospitals and nursing staff in general hospitals [24, 25]. The knowledge level of palliative care also increases with the advancement in professional titles. ICU nurses with higher titles tend to be older, earn more, possess extensive clinical experience, have more opportunities for continuing education and training, and have gained more knowledge in end-of-life care compared to their peers. This could explain why higher professional titles correlate with greater knowledge in palliative care. This research additionally discovered that ICU nurses with experience in death education or palliative care-related training, as well as those who have provided care for patients in advanced stages of illness, achieve higher knowledge scores in palliative care, aligning with prior studies [26]. This is likely because caring for patients in advanced stages of illness provides valuable learning experiences, and the proactive efforts of nurses to acquire knowledge in palliative care play a crucial role in shaping their knowledge base.
The findings of this study reveal that ICU nurses with experience in death education or palliative care courses, exposure to literature on death, and a higher number of terminal care cases within the last year tend to exhibit more positive attitudes and behaviors in palliative care, consistent with the research by Wen Tu et al. [27]. Furthermore, a positive correlation exists between palliative care knowledge and both attitudes and behaviors, suggesting that increased knowledge in this area is associated with more favorable attitudes and behaviors. ICU nurses with experience in death education or palliative care-related training, as well as those who have read literature on death, possess a robust knowledge base in palliative care. Nurses who have cared for a significant number of terminal patients often seek advice from peers and refer to resources to address challenges encountered in their care, thereby gaining substantial practical experience in palliative care. Consequently, they exhibit a more proactive attitude and are more likely to effectively deliver end-of-life care.
This study also revealed that ICU nurses with experience in death education or palliative care courses, as well as those who have read literature on death, exhibit a higher demand for palliative care training. This contrasts with the findings from Xu Yifan et al.‘s survey of medical staff in Shanghai [28]. ICU nurses who have been exposed to death education and who possess related knowledge are more likely to experience a shift in their attitudes towards death. Research indicates that a positive stance on death can facilitate a scientific comprehension of mortality, encouraging a professional and scientific approach to acquiring knowledge and skills in death education [29]. Consequently, this leads to a more proactive stance on palliative care and an increased demand for related training. Prior research indicates that specialized training in palliative care significantly boosts nurses’ confidence and decreases perceived threats and obstacles in delivering such care, while also increasing their perceived benefits and self-efficacy [10, 30]. Consequently, it is crucial to foster Chinese ICU nurses’ interest in death education, palliative care courses, and related literature. Enhancing their knowledge and skills in palliative care will improve the palliative care environment for Chinese ICU patients and their families.
Strength and limitation points
To the best of our knowledge, this is the first study in China to focus on the knowledge, attitudes, behaviors, and training needs of ICU nurses in palliative care across a wide geographical area, resulting in a comprehensive report. However, the study has certain limitations. First, to accurately assess the current training methods for ICU nurses in palliative care, there is a need for enhanced monitoring and follow-up of clinical nursing practices. Second, despite our efforts to mitigate some of the biases associated with convenience sampling through methods such as conducting a pilot study, diversifying sample sources, and increasing the sample size, the fact that participants were recruited from various cities across Anhui Province may still introduce certain regional variations. Additionally, because this is a cross-sectional study, it cannot establish the causal relationships between variables.
Conclusions
According to this study, ICU nurses demonstrate knowledge, attitudes, and behaviors in palliative care that are below the medium level. In china, the training requirements for nurses’ knowledge and skills are set at a standard where a score above 80 is considered average or qualified. Therefore, this highlights the necessity for a greater emphasis on education and training in end-of-life care for ICU nurses. The training requirements for ICU nurses in palliative care are primarily centered around acquiring knowledge and skills in death education specific to the ICU setting, as well as communication techniques for interacting with patients’ families. ICU nurses with exposure to death education or palliative care courses and literature on death exhibit a heightened demand for palliative care training. The findings of this study offer a guiding direction for the development of specialized training programs for ICU nurses in China, aimed at elevating their understanding of palliative care and encouraging the standardization of palliative care practices within the ICU.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Author contributions
Weiwei Cai: Study design, implementation, data analysis, and manuscript preparation and revision; Fei Wang: Study design and implementation; Changchun Song: Data collection.
Funding
This research was funded by [Key Research Project of Humanities and Social Sciences of Bengbu Medical University] (Grant Number: 2022byzd131sk). The funding body played no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.
Data availability
Data is provided within the manuscript or supplementary information files.
Declarations
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval was obtained from the Third People’s Hospital of Bengbu in February 2023 (L5).
Consent for publication
Participants provided informed consent for the publication of any associated data, images, or videos. Specific consent forms were obtained from the participants for the use of their data in the publication.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Data is provided within the manuscript or supplementary information files.