To our knowledge, this is the first study to investigate attitudes and the related factors of HPC among NAs in NH settings in China. Although an increasing number of older adults need high-quality HPC in NHs and NAs are the main providers, we found that limitations still exist in their attitudes and knowledge regarding HPC. The findings will not only clarify NAs’ attitudes towards HPC, but also suggest targeted training and enabling facilitators for the extension of HPC to NHs, in which HPC should be provided but rarely involved. Policymakers can formulate policies based on the results of this study to ensure high-quality HPC for end-of-life elderly patients as a whole.
Our study revealed that NAs of NH had moderate attitudes towards HPC. The overall scoring rate was 72.44%, which is a little lower than the previous study in Shanghai (volunteers of HPC, 74.54%) [21] and in Taiwan (long-term care staff of advanced dementia, 73.7%) [22], while higher than that in Canada (long-term care workers of EOL palliative care, 70.6%) [23]. These differences are likely attributable to international cultural differences in life and death and related training, lack of related study on NAs and differences in scales as well.
This study found that NAs fully recognised the benefits of HPC in NH settings. They agreed that HPC could positively affect EOL residents, reduce pain and enhance dignity. Nevertheless, most NAs felt passive when faced with the worsening conditions of advanced residents and unable to face dying process and distress. These findings were also supported by previous research [24, 25], where NAs often feel cowardly and helpless when providing EOL care for residents. Considering NAs as a key role in providing routine services in NHs, where death often occurs on a daily basis, it is reasonable for them to develop negative attitudes when caring for EOL residents, such as avoidance, fear, self-doubt, and communication problems [26, 27]. In addition, these negative views could affect the motivation of NAs to continue their careers in nursing, and have profound consequences for the provision and extension of HPC [28].
In terms of NAs’ knowledge of HPC, less than half of NAs had been exposed to related knowledge. The average response accuracy of HPC knowledge was 61.1%, which is significantly lower than a Chinese study involving volunteers (82.1%) [21], a Taiwan study involving long-term care staff (62.3%) [22], and an Australian study involving staff of dementia care (62.5%) [29]. The results highlight a significant gap in NAs’ knowledge and limited promotion of HPC in NHs. It is suggested that NAs’ knowledge was out of portion to their importance in the HPC team, resulting in the incompetence of providing HPC in NHs and negatively impacting residents’ EOL quality [30]. This could be explained by the situation of NAs in mainland China, the overall age is relatively high, and their educational level is relatively low [8]. The knowledge levels of NAs and their compliance with hospice guidelines are known to be low, which is in line with this study, where the mean age of participants was 50.8 years, with an educational level of high school and below, causing difficulties in the ability to receive training and update professional knowledge.
There was a significant positive correlation between knowledge and attitudes, and knowledge was proved to be the strongest factor associated with attitudes, which was also reported elsewhere [22, 31]. The results indicate that better mastery of HPC knowledge can help improve NHs’ attitudes regarding HPC. This optimistic view may be explained by self-confidence construction through acquiring knowledge. Previous research demonstrated that NAs often lack confidence and feel uncomfortable in providing HPC when feeling a lack sufficient knowledge, which negatively influences their work performance, levels of work stress, ability to provide health guidance to residents, and sensitivity to residents’ and families’ care needs, as well as their HPC attitudes [31, 32].
In this study, HPC attitudes were also associated with NAs’ marital status. NAs who were divorced or widowed reported better attitudes towards HPC than unmarried and married NAs. This finding differed from the view that married medical staff have more positive attitudes in another study conducted in China [33]. This may be caused by two different populations and the setting of the variable. The previous study investigated attitudes towards HPC among medical staff in tertiary hospitals. In the setting of variables, marital status variables were divided into married, unmarried and others, and no separate variable for divorce or widowhood was set. NAs with broken family relationships are significant triggers for empathy. Such experience enables them to share the pain of the death of a loved one, thus having a deep understanding of the HPC, and is assumed to demystify the dying process and thereby reduce negative emotions. This finding was similar to some research [34], but different from other studies [25, 35, 36].
NAs from suburban NHs showed more positive attitudes towards HPC than those working in urban areas. This result was rarely mentioned in other studies. This may be related to the strong sense of community and mutual assistance in suburban communities, which help develop harmonious communication and intimate emotional bonds through daily contact and caregiving. Our study reveals that there may be an opportunity to have attitudes improved through better communication, highlighting the importance of excellent bedside communication skills with EOL residents.
Similar to previous findings, this study showed training experience of HPC had a positive impact on attitudes. It indicates that a lack of professional training in HPC will inevitably affect NAs’ attitudes. Furthermore, we found that over 95.5% of NAs reported urgent training needs on HPC, similar to a previous study of NH settings [3, 22]. NAs with higher training needs were found to have better attitudes regarding HPC than those with poorer needs, more likely to believe in the benefits of HPC for EOL residents and thus more eager to acquire relevant knowledge to provide quality HPC. Therefore, it is urgent to promote professional and targeted training tailored to their characteristics and acceptability, based on their knowledge deficiency, moderate attitudes, and training needs, which can rationally and perceptually improve NAs’ HPC attitudes, and help equip NAs with rich knowledge, full self-confidence, abundant first-hand experience, and excellent bedside communication skills of HPC for EOL residents.
Limitations
There were several limitations in our study. First, this is a cross-sectional study, showing only correlations but no causal relationship between attitudes towards HPC and the factors mentioned above, so further longitudinal research is needed to evaluate these associations. Second, based on the self-reported questionnaire, information bias may have occurred. Additionally, due to the limited length of the questionnaire, only a few influencing factors were conducted in this study. It is worthwhile to include factors like years of work experience, income, and physical conditions so as to find more effective ways to tailor targeted training programs.