Study design and Sample size
This cross-sectional descriptive study used stratified sampling and quota sampling. The institutions with hospice care were classified according to institution type: nursing homes, medical institutions, integrated medical and nursing institutions, and community health service centers. Questionnaires for hospice care practitioners were administered by quota sampling in each type of institution. The required sample size was determined by utilizing the formula used for cross-sectional surveys. The prevalence rates of the practitioners, including doctors, nurses, and nursing workers, who implement hospice care service by applying their knowledge, attitude, and practice are unknown. Therefore, we assumed that the proportion was 50% (p=.5) to recruit a larger sample size. By using a 5% margin of error and a Deff of 2, and adding a non-response rate of 10%, the minimum sample size required was determined to be 720.
Participants and Period
Thirty-two hospice care institutions in Guangxi, China were recruited for the study: 10 nursing homes, 7 medical institutions, 8 integrated medical and nursing institutions, and 7 community health service centers. Inclusion criteria for hospice care institutions were the following: the duration of hospice care was ≥ 1 year; and the number of beds was ≥ 5. The inclusion criteria for the practitioners were age ≥ 18 years, and experience providing hospice care for more than 1 year. “Nurses” refers to registered nurses, and “nursing workers” denote those who provide direct patient care and assist nurses in daily nursing in hospitals or nursing homes. All participants were informed that they could discontinue or withdraw from the study at any time for any reason. From November 2021 to February 2022, 1,902 practitioners were invited to participate.
Measurements
Based on literature review and consultation with experts, The questionnaire consists of two parts, the first part is the social-demographic and potential influencing factors questionnaire, including sex, age, ethnicity, education, nationality, profession, professional qualifications, working years, monthly income, professional title, marital status, religious beliefs, physical status, sources of knowledge of hospice care, frequency of hospice care training, job satisfaction, whether the hospice care system and supervision need to be improved, and ways to learn about hospice care.
The second part is the scale of the knowledge, attitude, and practices of hospice care practitioners (KAP scale). The KAP scale was compiled by researchers and guided by the knowledge, belief, and practice model. It was prepared via literature analysis, fieldwork, and Delphi expert consultation. The pilot survey was then conducted among 290 hospice nursing workers in Guangxi to test its reliability and validity, the total Cronbach’s α coefficient of the scale was 0.90, and the coefficients for knowledge, attitude, and practice were 0.70, 0.75, and 0.84, respectively, the content validity was 0.893. The KAP scale is consisted of 30 items in three dimensions—knowledge (10 items), attitude (9 items), and practice (11 items). The knowledge dimension comprised the concept, physiology, psychology, service content, and social support of hospice care, each item had three response options, “right,” “wrong,” and “do not know.” Answering “right” gained 1 point, and answering “wrong” or “do not know” gained 0 points. A higher scores indicated a greater level of hospice care knowledge. The Attitude dimension includes the cognitive attitude of hospice care, acceptance of hospice care, support for hospice care, the choice of hospice care, personal death and death, attitude to death and dying, the attitude of patients and family members, self-assessment of hospice care knowledge, the attitude of death education and hospice care education. each item was scored using a 5-point Likert scale that ranged from 1 (“strongly agree”) to 5 (“strongly disagree”), a higher score indicated a more positive hospice care attitude. The practice dimension consisted of grief counseling, psychological nursing, actively doing everything possible to alleviate the pain and discomfort of the dying, and actively paying attention to the disease trajectory of the dying, each item was scored using a 5-point Likert scale that ranged from 1 (“almost nothing”) to 5 (“being able to do it and doing it often”), a higher score indicated better hospice care practice.The details of the compilation process have been published in Chinses (23).
Data collection
The online survey conducted via a questionnaire website platform was sent to the heads of each organization providing hospice care services(from Nanning City, Guilin City, Baise City, Wuzhou City, Beihai City, Chongzuo City, Guigang City, Liuzhou City, and Qinzhou City in Guangxi, China), who were then asked to send the questionnaire to the eligible participants. The survey contained an invitation letter containing information regarding the study’s purpose and procedures, and the time required to response the questionnaire (10–20 min). Consent via electronic signature was assumed if the participants connected to the website link and completed the questionnaire.
Data analysis
Data were analyzed using SPSS version 26.0 (IBM Corporation, Armonk, NY, USA). Frequencies and percentages were used to summarize categorical variables (participants’ general information), and mean and standard deviation (SD) were used to express continuous variables (knowledge, attitude, and practices). Potential factors that influenced knowledge, attitude, and practices were identified by univariate analyses (e.g., independent samples t-tests, ANOVAs, and chi-square [χ2] tests) to ascertain the differences between groups. The three dimensions(knowledge, attitude, and practice) scores were the dependent variables in the multivariate linear regression analysis, we then performed a multiple linear analysis using all potential factors that were identified by the univariate analyses. All analyses were based on two-sided p-values, and statistical significance was set at p< .05.
Ethics approval
The study procedures involving human participants were reviewed and approved by the Institutional Review Board of The Second Affiliated Hospital of Guangxi Medical University (No.2022-KY0773). All methods were performed in accordance with the relevant guidelines and regulations. All the data collected from participants were anonymous, confidentiality was ensured to protect the privacy of the participants. Informed consent was obtained from all participants.