Participants’ characteristics
A convenience sample of 250 respondents completed the questionnaire (Table 1). Most of them were female (66.4%) and working in public hospital settings (70.7%). Their mean age was 41.8 years (SD 10.3), ranging from 21 to 69. The respondents mainly included physicians (38.8%), nurses (48.8%), and social workers (11.2%), with an average clinical experience of 17.9 years (SD 10.3, in the range 1– 42).
Table 1. Respondents’ characteristics
|
ALL
(N = 250)
|
Trained
(n = 130)
|
Not trained
(n = 120)
|
pY
|
Gender
Male
Female
|
83 (33.2%)
167 (66.8%)
|
38 (29.2%)
92 (70.8%)
|
45 (37.5%)
75 (62.5%)
|
0.165
|
Age (years)#
|
41.8 ± 10.3
|
43.9 ± 9.19
|
39.5 ± 11.0
|
0.001
|
Disciplines
Medical doctors
Nurses
Allied health
|
97 (38.8%)
120 (48.0%)
33 (13.2%)
|
50 (38.5%)
60 (46.2%)
20 (15.4%)
|
47 (39.2%)
60 (50.0%)
13 (10.8%)
|
0.554
|
Clinical experience (years)#
|
17.9 ± 10.3
|
19.7 ± 9.5
|
15.9 ± 10.8
|
0.004
|
Educational level
Bachelor
Master
Doctoral
|
129 (51.6%)
111 (44.4%)
10 (4.0%)
|
61 (46.9%)
64 (49.2%)
5 (3.8%)
|
68 (56.7%)
47 (39.2%)
5 (4.2%)
|
0.274
|
Workplace
Public hospitals
Private hospitals
Community centres
Care homes
Hospices
Private clinics
Universities
Others
|
177 (70.8%)
9 (3.6%)
9 (3.6%)
7 (2.8%)
13 (5.2%)
14 (5.6%)
6 (2.4%)
15 (6.0%)
|
92 (70.8%)
3 (2.3%)
4 (3.1%)
4 (3.1%)
11 (8.5%)
6 (4.6%)
1 (0.8%)
9 (6.9%)
|
85 (70.8%)
6 (5.0%)
5 (4.2%)
3 (2.5%)
2 (1.7%)
8 (6.7%)
5 (4.2%)
6 (5.0%)
|
0.142
|
Specialty
Medical wards
Long-term
Community care
Surgical wards
Palliative Care
AED
ICU/CCU
Oncology
O&T
Psychiatry
Others
|
79 (31.6%)
16 (6.4%)
20 (8.0%)
14 (5.6%)
27 (10.8%)
8 (3.2%)
6 (2.4%)
12 (4.8%)
5 (2.0%)
19 (7.6%)
44 (17.6%)
|
51 (39.2%)
9 (6.9%)
12 (9.2%)
4 (3.1%)
23 (17.7%)
2 (1.5%)
2 (1.5%)
6 (4.6%)
3 (2.3%)
5 (3.8%)
13 (10.0%)
|
28 (23.3%)
7 (5.8%)
8 (6.7%)
10 (8.3%)
4 (3.3%)
6 (5.0%)
4 (3.3%)
6 (5.0%)
2 (1.7%)
14 (11.7%)
31 (25.8%)
|
£ 0.001
|
Footnote: YChi Square test, unless specified; #M ± SD, independent t test
Training experience
Approximately half of the respondents (n = 129, 51.6%) had received formal training related to ACP in didactic format only (such as lectures, talks, or seminars) (n = 63, 48.5%); a combination of didactic and web-based (n = 12, 9.2%); a combination of didactic and workshop (n = 29, 22.3%); blended learning with didactic, web-based, and workshop (n = 13, 10.0%); and any format with local or overseas placement (n = 13, 10.0%). Training was associated with older age (p ≤ 0.001), increased years of clinical experience (p = 0.004), and working in internal medicine and palliative care specialties (p ≤ 0.001).
Associations between training and readiness for ACP
Table 2 compares the perceived clinical relevance of, and willingness and confidence in, for ACP between respondents who had and had not received relevant training. Respondents who had received training were more likely to find ACP related to their clinical work than the counterparts (p ≤ 0.001) and they reported significantly higher levels of willingness (p ≤ 0.001) and confidence (p ≤ 0.001) with conducting ACP when compared with those who did not receive such training. Univariate linear regression showed that these three variables were associated with specialty and previous ACP training, but not age and clinical experience. Multiple linear regression indicated that respondents received relevant training perceived higher relevancy of ACP in relation to their clinical work (b = 0.23, p < 0.001), higher level of willingness to conduct ACP with their clients (b = 0.30, p < 0.001) and higher level of confidence in facilitating the ACP conversation (b = 0.35, p < 0.001). Specialty is associated with higher level of clinical relevancy (b = 0.22, p < 0.001) and higher level of confidence (b = 0.15, p < 0.05), but not for willingness. A significantly higher proportion of respondents who had received ACP training had the experience of conducting ACP with their patients and/or their family members (p < 0.001). Table 3 shows that respondents who received blended training generally reported the highest levels of relevance, willingness, and confidence when compared with other modes of learning. Those received training only in didactic format reported the lowest ratings and a significant difference was noted in confidence compared with their counterparts (p = 0.012).
Table 2. Comparison of readiness for ACP between respondents who had or had not received training (N = 250)
|
Not trained
(n = 120)
|
Trained
(n = 130)
|
p
|
Relevancy
|
6.1 ± 3.3
|
7.7 ± 2.5
|
£ 0.001a
|
Willingness
|
6.5 ± 2.8
|
8.2 ± 2.1
|
£ 0.001a
|
Confidence
|
5.3 ± 2.4
|
7.2 ± 2.2
|
£ 0.001b
|
Had experience in conducting ACP with patients and/ or their family
|
26.7%
|
75.4%
|
£ 0.001c
|
Footnote: a Independent t test, unless specified; b Mann-Whitney U test; c Chi-square test
Table 3. Comparison of readiness for ACP among respondents who had received different modes of training (n = 130)
|
Relevancy
|
Willingness
|
Confidence
|
Types of training
|
|
|
|
· Didactic format only (n= 63)
|
7.1 ± 2.7
|
7.7 ± 2.4
|
6.6 ± 2.3
|
· Didactic format and web-based learning (n = 12)
|
8.3 ± 2.2
|
8.3 ± 1.3
|
7.6 ± 1.5
|
· Didactic format and workshop (n=29)
|
8.0 ± 1.7
|
8.7 ± 1.7
|
8.0 ± 1.3
|
· Blended learning (n = 13)
|
9.1 ± 1.4
|
9.2 ± 1.3
|
8.1 ± 1.7
|
· Any type with local / overseas placement (n = 13)
|
7.9 ± 2.9
|
8.5 ± 2.6
|
7.4 ± 2.9
|
p
|
0.068
|
0.076
|
0.012
|
Footnote: ANOVA
Comparisons of attitudes toward ACP between trained and non-trained
As shown in Table 4, significant differences were noted between those with and without relevant training in the levels of agreement with 19 out of the 25 statements concerning ACP. Training was associated with perception of more facilitators and lower barriers for ACP. For example, a higher proportion of respondents who had relevant training indicated that they were comfortable with discussing end-of-life care issues with patients and their family members (ps ≤ 0.001) than their counterparts. They were more likely to disagree that “patients and their family members find end-of-life care discussion difficult or a taboo” (ps ranged from ≤ 0.001– 0.006), but they were less likely to be “hesitant to follow ACP documents for fear of legal liability” (p ≤ 0.001) and considered time a barrier to conducting ACP (p = 0.010), compared with those without training.
By contrast, more respondents who did not have relevant training were uncertain whether “the existing ACP policy and guidelines are clear” (p ≤ 0.001), whether their “seniors/supervisors or co-workers support them to conduct ACP” (ps ≤ 0.001), whether “patients find end-of-life care discussion taboo” (p ≤ 0.001) and the difficulty “for patients and their family members to reach consensus on end-of-life care” (p ≤ 0.001).
Table 3. Comparison of level of agreement regarding ACP
|
Group
|
Level of agreement (%)
|
p
|
Strongly disagree/ Disagree
|
Unsure
|
Strongly agree/ Agree
|
Process
|
|
|
|
|
|
ACP should be integrated into routine care services for patients with chronic illness.
|
Trained
|
5.4%
|
11.6%
|
82.9%
|
.831
|
Not trained
|
6.7%
|
13.3%
|
80.0%
|
ACP conversation can be initiated by any health professional.
|
Trained
|
13.2%
|
13.2%
|
73.6%
|
.063
|
Not trained
|
17.5%
|
22.5%
|
60.0%
|
Better not to initiate ACP unless asked by patients or their family members.
|
Trained
|
84.5%
|
7.8%
|
7.8%
|
.013*
|
Not trained
|
69.2%
|
18.3%
|
12.5%
|
ACP should be started early to allow time for contemplation.
|
Trained
|
1.6%
|
11.6%
|
86.8%
|
.656
|
Not trained
|
3.3%
|
11.7%
|
85.0%
|
|
ACP should not be started before the patients’ condition worsens because their preferences may change according to the context.
|
Trained
|
61.2%
|
14.7%
|
24.0%
|
.050*
|
Not trained
|
45.8%
|
21.7%
|
32.5%
|
|
ACP is not necessary because use of life-sustaining treatments is a medical decision based on patients’ best interests.
|
Trained
|
88.4%
|
7.0%
|
4.7%
|
.072
|
Not trained
|
77.5%
|
14.2%
|
8.3%
|
|
Documentation of ACP discussion is useful for care management.
|
Trained
|
7.0%
|
9.3%
|
83.7%
|
.052
|
Not trained
|
5.0%
|
20.0%
|
75. 0%
|
|
Outcomes
|
|
|
|
|
|
ACP is helpful to clarify patients’ goals and preferences for end-of-life care.
|
Trained
|
1.6%
|
1.6%
|
96.9%
|
.193
|
Not trained
|
1.7%
|
5.8%
|
92.5%
|
ACP destroys patients or their family members’ sense of hope.
|
Trained
|
92.2%
|
1.6%
|
6.2%
|
£.001***
|
Not trained
|
75.0%
|
15.8%
|
9.2%
|
|
Under no circumstances should life-sustaining treatments be withheld or withdrawn from patients.
|
Trained
|
68.2%
|
15.5%
|
16.3%
|
.014*
|
Not trained
|
50.8%
|
28.3%
|
20.8%
|
|
It is hard for patients and/or their family members to reach consensus on end-of-life care.
|
Trained
|
43.4%
|
31.8%
|
24.8%
|
£.001***
|
Not trained
|
21.7%
|
37.5%
|
40.8%
|
|
ACP can help to prevent disputes between health care team and family members on medical decisions.
|
Trained
|
2.3%
|
7.8%
|
89.9%
|
.036*
|
Not trained
|
3.3%
|
18.3%
|
78.3%
|
|
ACP can help to alleviate burden on family decision makers.
|
Trained
|
3.1%
|
5.4%
|
91.5%
|
£.001***
|
Not trained
|
4.2%
|
21.7%
|
74.2%
|
|
Facilitators
|
|
|
|
|
|
I am comfortable with discussing end-of-life care issues with patients.
|
Trained
|
6.2%
|
10.9%
|
82.9%
|
£.001***
|
Not trained
|
14.2%
|
32.5%
|
53.3%
|
I am comfortable with discussing end-of-life care issues with patients’ family members.
|
Trained
|
6.2%
|
11.6%
|
82.2%
|
£.001***
|
Not trained
|
13.3%
|
30.8%
|
55.8%
|
My seniors/supervisors support me to conduct ACP.
|
Trained
|
10.1%
|
24.8%
|
65.1%
|
£.001***
|
Not trained
|
18.3%
|
55.8%
|
25.8%
|
|
My co-workers support me to conduct ACP.
|
Trained
|
8.5%
|
31.0%
|
60.5%
|
£.001***
|
Not trained
|
18.3%
|
52.5%
|
29.2%
|
|
The existing ACP policy and guidelines is clear.
|
Trained
|
23.3%
|
28.7%
|
48.1%
|
£.001***
|
Not trained
|
34.2%
|
50.8%
|
15.0%
|
|
Barriers
|
|
|
|
|
|
It is difficult to determine if the patient has the mental capacity to make medical decisions.
|
Trained
|
54.3%
|
21.7%
|
24.0%
|
.020*
|
Not trained
|
36.7%
|
28.3%
|
35.0%
|
Patients usually find end-of-life care discussion a taboo.
|
Trained
|
46.5%
|
27.9%
|
25.6%
|
£.001***
|
Not trained
|
23.3%
|
42.5%
|
34.2%
|
Patients usually find end-of-life care discussion difficult, e.g. difficult to understand the treatments or predict the future.
|
Trained
|
42.6%
|
18.6%
|
38.8%
|
.006**
|
Not trained
|
24.2%
|
30.0%
|
45.8%
|
Patients’ family members usually find end-of-life care discussion a taboo.
|
Trained
|
34.9%
|
27.1%
|
38.0%
|
£.001***
|
Not trained
|
12.5%
|
29.2%
|
58.3%
|
Patients’ family members usually find end-of-life care discussion difficult, e.g. difficult to understand the treatments or predict the future.
|
Trained
|
38.0%
|
14.7%
|
47.3%
|
£.001***
|
Not trained
|
15.0%
|
31.7%
|
53.3%
|
I am hesitant to follow the preferences stated in the ACP form for fear of legal liability, especially if the patients have not signed an advance directive.
|
Trained
|
60.5%
|
18.6%
|
20.9%
|
£.001***
|
Not trained
|
32.5%
|
31.7%
|
35.8%
|
I do not have time to conduct ACP.
|
Trained
|
43.4%
|
19.4%
|
37.2%
|
.010*
|
Not trained
|
26.7%
|
32.5%
|
40.8%
|
Footnote: Chi-square test