Knowledge, Attitudes and Practices Levels of Clinical Nurses towards Humanistic Caring: the First Nationwide Multi-Centre Cross-Sectional Survey in China

doi:10.21203/rs.3.rs-4647158/v1

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Research Article

Knowledge, Attitudes and Practices Levels of Clinical Nurses towards Humanistic Caring: the First Nationwide Multi-Centre Cross-Sectional Survey in China

https://doi.org/10.21203/rs.3.rs-4647158/v1

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Background

The development of humanistic care in China is being faster. However, patients' satisfaction with nurses' humanistic care is still at a moderate level. There is a lack of a nationwide multi-centre, large-sample cross-sectional survey of nurses' knowledge, attitudes and practices of humanistic care in China. It is not conducive to the identification of gaps in the development of humanistic care.

Method

A multi-centre, large-sample cross-sectional survey was conducted in July-August 2022 in 25 provinces (cities and districts) in China. Convenience sampling was used to recruit nurses who met inclusion and exclusion criteria in tertiary hospitals in these areas. The survey instruments used were a self-designed general information questionnaire and The Knowledge, Attitudes and Practices (KAP) of Clinical Nursing Staff on Humanistic Care Questionnaire designed by Chinese scholar Li Yuqin. The original scale had a content validity index of 0.980(P < 0.001), a Cronbach's α of 0.982(P < 0.001), and a retest reliability of 0.983(P < 0.001). The Cronbach's α for the scale in this study was 0.991(P < 0.001). The questionnaire was collected using Question Star, a widely used questionnaire web-based collection platform in China. In August 2022, we collected a total of 14,305 valid questionnaires, with an effective recovery rate of 99.72%. The software SPSS 26.0 was used to conduct descriptive and inferential statistical analyses. The software SPSS 26.0 was used to conduct descriptive and inferential statistical analyses.

Result

The average scores of the knowledge, attitudes and practices indexes of humanistic care of the participating nurses in this study were 80.24%, 83.62% and 87.95%, respectively. There are still deficiencies in the knowledge index, especially regarding the current development of humanistic care, the essence of humanistic care, and the basic requirements for implementing humanistic care. The attitudinal aspect was about the fact that humanistic care can reduce the number of patient hospitalisation days, the starting point of nurses' care and whether nurses' humanistic care should be included in the nursing quality assessment index. In terms of influencing factors, nurses' gender, satisfaction with their work, the importance of self-care, love of nursing, family support for their work, and harmonious relationship with colleagues would have a positive impact on their knowledge, attitudes, and practices of humanistic care. Whether or not they had participated in humanistic care training, satisfaction with their salary, and their title of being an associate nurse positively influenced their knowledge and attitudes toward humanistic care competence. Whether or not they had worked on a humanistic care pilot ward and whether they had a teaching role would also have an impact on the knowledge score. In addition, nurses whose departments were operating theatres and ICUs had poorer caring behaviours.

Conclusion

Chinese clinical nurses have a medium level of knowledge and attitude towards humanistic caring and good behavioural performance. Nurses' humanistic care training needs to be strengthened, and the content can focus on the development status, nature, role, and basic requirements of humanistic care. Hospitals should encourage nurses to actively participate in humanistic care training, and at the same time permeate humanistic care in management to enhance the caring atmosphere in the organisational environment.

Chinese

Nurses

Humanistic caring

Humanistic nursing

National survey

Influencing factors

Nurses play an important role in human health care in the current COVID-19 post-epidemic era. In China, however, the doctor-patient relationship is in a special period of intensified conflict of interest and unstable development. The same applies to the nurse-patient relationship. The incidence of violence against nurses from patients is still not optimistic [1]. Improving nurses' humanistic caring skills is one of the most important ways to improve the nurse-patient relationship [2]. Nurses' implementation of humanistic care for patients is a fundamental duty that nurses should fulfil [3].In China, humanistic care has attracted widespread attention from managers and researchers in the nursing profession.Since 2010, the Chinese Ministry of Health has emphasised the importance of humanistic care in hospital care through various directives and demonstration projects [4]. Chinese nursing scholars have also conducted cross-sectional surveys and qualitative studies on the importance of humanistic care in the treatment of patients with different kinds of diseases[5-6]. Then, a series of caring nursing training courses and expert consensus were constructed to improve the humanistic caring ability of Chinese nurses.[7-10]. Nevertheless, the satisfaction level of Chinese hospitalised patients with humanistic care is still at a medium level, and some patients still have a poor experience of humanistic care satisfaction [11]. Analysis of the reasons may be related to the nurses' lack of humanistic caring knowledge, poor sense of conviction, and insufficient caring behaviours [12].

Currently, there is a lack of multi-centre, large-sample cross-sectional surveys on the humanistic care competencies of clinical nurses in China. Therefore, it is not possible to understand and analyse the status of the nurses' humanistic caring competence. This study conducted a multi-centre status survey on nurses' humanistic caring knowledge, attitudes and practices in tertiary hospitals nationwide in China. The purpose was to conduct a baseline survey on the humanistic caring competence of nurses in Chinese tertiary hospitals, to understand the current general level and to analyse the relevant influencing factors. The study will provide data support to promote the development of humanistic nursing practice in China and provide a reference for nursing administrators' decision-making.

The concept of humanistic care was first introduced in the 1950s by Madeleine Leininger, an American nursing academic, and later developed by Dr Jean Watson [13–14]. Watson suggested that humanistic care is the essence and core of nursing, which is based on a set of universal humanistic and altruistic values, and aims to help patients achieve physical, psychological and socio-cultural health [15]. The ten elements of humanistic care include: the development of the humanistic-altruistic system of values; instilling confidence and hope; developing sensitivity to self and others; the development of helping-trusting human-caring relationships; encouraging and accepting clients' expression of positive and negative emotions; systematically applying problem-solving approaches to decision-making; facilitating interpersonal teaching and learning; the provision for a supportive, protective, and/or corrective mental, social, spiritual environment; assisting in the fulfilment of human needs; and allowing for the existence of noticing, phenomenalism and the power of the mind. The ten elements are now commonly used and recognised in clinical practice [16].

Humanistic care plays an irreplaceable role in both clinical nursing, nursing management and nursing education. In clinical nursing, Waston suggests that nurses with a high level of caring competence can increase patients' adherence to treatment and satisfaction with the work of nurses [3]. During the COVID-19 epidemic, humanistic nursing care is necessary for patients treated in shelter hospitals and can effectively help patients prevent mental distress [17]. At the same time, combining humanistic care in the nursing of stroke patients can significantly reduce the incidence of mental disorders, which directly affects their rehabilitation effects [18]. Moreover, physiological care and rehabilitation care are in high demand in humanistic care for stroke patients and their families [19]. In the ICU ward, if nurses use the humanistic care time checklist to communicate with patients, it can effectively improve patients' satisfaction with care [20]. The full implementation of humanistic care in ophthalmic wards can also help to improve nurses' communication skills and motivation, and improve the quality of care and patient satisfaction [21]. Meanwhile, in the maintenance of the nurse-patient relationship, if the humanistic care teaching mode is used in the training of nurses, it can significantly improve their sense of professional identity and problem-solving ability in the face of nurse-patient conflicts, and promote the harmonious development of nurse-patient relationship [8]. Therefore, humanistic care nursing can play a contributing role in both the cure of certain patients' diseases and the improvement of patients' hospitalisation quality, which is conducive to the healthy and harmonious development of the nurse-patient relationship. In nursing management, Waston has suggested that caring attitudes are transmitted through professional culture. When caring is absent nurses feel undervalued or objectified, which leads to dissatisfaction among subordinate staff as well as lower job satisfaction [22]. Scholar Joko Gunawan has integrated Waston's theory of caring with nursing management in 2022. He has suggested that humanistic care is an essential element of nursing management and that caring nursing management has improved the quality of life of both nurses and managers [23]. Through a large sample cross-sectional survey in China, Chinese scholar Lulu Liao concluded that the ability of nursing managers and clinical nurses to implement humanistic care is a key factor influencing clinical nursing behaviour [24].On the other hand, integrating humanistic care with nursing education can promote the development of caring nursing. Humanistic care ability is one of the core abilities that nursing staff must possess, there is a need for targeted training and teaching to improve the competency of nursing students. WANG has explored the process of forming nursing students' humanistic caring competence using the structural equation method, hoping to inspire future nursing teaching [6]. Waterman et al. used a case study approach to study the learning process of caring in 20 students and found that the humanistic caring competence of all students who participated in the training improved over time [25]. The development of caring learning programmes in schools also facilitates the development of humanistic caring skills in nursing students[26].

In China, although the development of humanistic care nursing is relatively recent, it has gained more momentum. Since 2010, the Chinese government has been promoting the development of care in hospital treatment and care through the enactment of policies [4].In 2021 The Humanistic Care Committee of the China Life Care Association published the “Expert Consensus on the Code of Practice for Humanistic Care Practice in Hospital Nursing” [9]. In 2022, the China Life Care Association released the “001-2022 Management Norms for Humanistic Care in Ward Nursing” [27]. All of the above have greatly contributed to the development of humanistic nursing in China. But despite this, the results of a multi-centre, large-sample study by Chinese scholars in 2023 still show that Patient satisfaction with humanistic nursing in secondary and tertiary hospitals in China is at a moderate level [11]. Currently, there is no multi-centre, large-sample cross-sectional survey of nurses' humanistic caring competence in China. Therefore, it is not possible to analyse the reasons for low patient care satisfaction from the perspective of the current state of nurses' caring competence.

Knowledge, Attitudes, and Practices Theory is one of the commonly used theories for investigating the current state of behavioural implementation and exploring the factors that influence it. The study is guided by the theory of knowledge, attitudes, and practices (KAP theory). The theory suggests that the acquisition of knowledge, the establishment of attitudes and the emergence of practice are three consecutive processes. Correct knowledge of a phenomenon contributes to the establishment of positive beliefs and attitudes, which are the basis for correct behaviour; attitudes are the driving force for correct behaviour [28]. Understanding the level of knowledge and attitudes of Chinese nursing staff towards humanistic care can provide a perspective and basis for thinking about the improvement of competence.

This study is the first national multi-centre cross-sectional survey conducted by the Humanistic Care Committee of the China Life Care Association with the theme of nurses' humanistic care competence. The aim of our study is to identify the deficiencies of nurses in humanistic care nursing by understanding their knowledge, attitudes and practices level of humanistic care. And the results also can provide data support and reference for subsequent nationwide improvement of humanistic care nursing competence and support the development of relevant interventions for future nursing administrators.

3.1 Design and participants

In July-August 2022, a convenience sampling method was used to select the tertiary hospital in 25 provinces (cities and districts) where the Humanistic Nursing Professional Committee of the China Life Care Association is located as the survey site. Inclusion criteria for survey respondents: (1) obtaining a nurse's licence; (2) working in nursing for one month or more, and currently engaged in clinical nursing or nursing management. Exclusion Criteria: (1) Nurses in further training, standardised training; (2) Nurses on leave (3) Nurses who have recently suffered major life events. Based on the consensus of calculating the overall mean in a sample survey: n = calculate the sample size, where α = 0.05, u 0.05/2 = 1.96, 2 is the overall variance, the report shows σ = 33.55, and let the tolerable error = 1, then n = 1.962×33.552/12 ≈ 4325, and the minimum number of questionnaires to be collected is 4325(Li 2019). A total of 14,345 questionnaires were eventually sent out for this study.

3.2 Data collection instrument

We used the General Information Questionnaire and the Knowledge, Attitudes and Practices(KAP) of Clinical Nursing Staff on Humanistic Care Questionnaire in our study.

General information included the region, gender, age, marital status, education, department, title, years of experience, type of hospital, and 10 questions for the study participants. Q1: Whether to hold a management position? Q2: Whether to undertake teaching tasks? Q3: Whether to hold good terms with colleagues? Q4: Is your family supportive of your work? Q5: Do you love nursing? Q6: Are you satisfied with your salary? Q7: Are you satisfied with your job? Q8: Have you ever worked in a humanistic care pilot ward? Q9: Do you pay attention to self-care? Q10: Have you attended any humanistic care training?

The Knowledge, Attitudes and Practices (KAP) of Clinical Nursing Staff on Humanistic Care Questionnaire was developed by Chinese scholar Li Yuqin in 2019 to assess clinical nurses' knowledge, attitudes and practices of humanistic care [29]. The questionnaire consisted of 3 indexes of knowledge (18 items), attitudes (22 items), and practices (23 items) with a total of 63 items. Each item was answered on a Likert 5-point scale. The knowledge index of 1–5 represents "don't know at all" to "know very much"; the attitudes index of 1–5 represents "strongly disagree" to "strongly agree"; the practices index of 1–5 represents "never" to "always". The questionnaire can score a minimum of 63 points and a maximum of 315 points. Higher scores represent more knowledge, positive attitudes and better behaviours of clinical nurses in humanistic care. The original scale had a content validity index of 0.980(P < 0.001), a Cronbach's α of 0.982(P < 0.001), and a retest reliability of 0.983(P < 0.001). The Cronbach's αfor the scale in this study was 0.991(P < 0.001).

3.3 Data collection

We distributed and collected the questionnaire using a professional online questionnaire survey, evaluation and voting platform called Questionnaire Star in China. In August 2022, actually returned 14,305 valid questionnaires, with a valid return rate of 99.72%.

3.4 Ethical considerations

The study was approved by the Ethics Committee of Tongji Medical College of Huazhong University of Science and Technology (No. S161) and appropriate permission was obtained from the Director of Nursing of the participating hospitals. The questionnaire collection process is carried out on the premise that survey respondents participate in the survey voluntarily.

3.5 Data analysis

The study used SPSS 26.0 software for data analysis. Demographic data were described using frequencies and percentages. By performing Shapiro-Wilk test on the data, the results showed that the data did not conform to normal distribution. Therefore, mean ± SD, median (P₂₅, P₇₅) and average score rate (the average score/full score×100%) were used in describing the scores of the indicators and items. Demographic data were analysed by non-parametric tests (Mann-Whitney U-test and Kruskal-Wallis H-test), and P < 0.05 was considered statistically significant. The multiple linear stepwise regression analysis of each index score was also performed to derive meaningful factors affecting the index of knowledge, attitudes and practice of humanistic care among nursing staff.

4.1 Characteristics of the participants

A total of 14,305 questionnaires were collected, of which 13,658(95.48%) were female and 647(4.52%) were male. The age range was from 22-59 years, mean±SD=32.37±6.62. 85.53% of the nurses had a maximum education of bachelor's degree and above, 38.95% had the title of supervisor nurse and above, and more than one-third of the nurses had not received training about humanistic care. The other sociodemographic characteristics are shown in Table 1.

Table 1 Demographic details (N=14305)

Variables	N(%)	Knowledge Mean±SD	Attitudes Mean±SD	Practices Mean±SD
Region
Northeast China	859(6.00)	69.34±15.16	89.10±17.91	99.67±16.88
North China	1571(10.98)	72.32±14.52	92.27±17.12	103.51±14.31
East China	1704(11.91)	71.64±13.64	91.62±16.08	101.14±14.02
South China	2346(16.40)	71.26±14.04	90.53±16.65	99.37±14.74
Central China	5991(41.88)	73.05±13.75	92.71±16.37	101.28±14.32
Northwestern China	769(5.38)	72.01±13.80	92.32±16.39	101.62±14.11
Southwest China	1065(7.44)	72.93±13.50	93.31±16.19	101.64±14.14
Gender
Female	13658(95.48)	72.39±13.92	92.20±16.52	101.39±14.39
Male	647(4.52)	68.64±14.67	87.42±17.29	95.89±16.70
Age
22-24	1164(8.14)	71.74±13.89	90.45±16.55	98.89±15.32
25-29	4037(28.22)	71.79±14.04	91.30±16.65	100.25±14.87
30-34	4658(32.56)	71.57±14.06	91.56±16.70	100.79±14.61
35-39	2543(17.78)	72.66±14.07	92.50±16.64	102.01±14.43
≥40	1903(13.30)	74.44±13.34	94.71±15.79	104.13±12.67
Marriage
Unmarried	4285(29.95)	71.08±13.94	90.16±16.75	99.09±15.10
Married	9760(68.23)	72.69±13.94	92.76±16.43	101.98±14.21
Divorced	236(1.65)	74.19±14.44	93.83±16.75	103.74±13.42
Widowed	24(0.17)	66.25±17.43	83.92±22.06	99.83±16.14
Level of education
Junior College or below	2070(14.47)	72.02±14.36	91.33±17.07	101.10±14.68
Bachelor's degree	11977(83.73)	72.20±13.94	92.03±16.52	101.15±14.54
Master's degree or above	258(1.80)	74.78±12.53	95.10 ±15.27	100.98±13.07
Department
Internal medicine	4075(28.49)	72.50±13.99	91.96±16.64	101.00±14.37
Surgery	3278(22.92)	72.93±14.11	93.04±16.43	102.33±14.15
Obstetrics-Gynaecology	1145(8.00)	73.81±13.93	93.76±16.63	103.15±14.18
Paediatrics	821(5.74)	71.86±13.63	91.86±16.63	101.08±14.09
Geriatrics	236(1.65)	74.54±13.18	93.92±16.41	103.42±12.81
Ophthalmology and Otorhinolaryngology	253(1.77)	72.94±14.00	92.82±16.38	102.60±14.15
Outpatient and emergency	875(6.12)	70.42±13.86	90.17±16.56	99.87±14.34
Operating room	883(6.17)	70.24±14.56	89.85±17.03	99.04 ±16.39
ICU	1261(8.82)	70.09±13.38	90.02±16.14	98.52±14.90
Oncology	579(4.05)	72.96±14.03	92.37±16.50	100.90±14.79
Other	899(6.28)	72.08±13.67	91.71±16.58	101.11±14.77
Professional title
Nurse	2074(14.50)	71.59±14.03	90.46±16.97	99.51±15.69
Senior nurse	6658(46.54)	71.55±14.20	91.12±16.77	100.69±14.70
Supervisor nurse	5099(35.64)	72.81±13.72	93.11±16.24	101.98±14.02
Deputy director nurse or above	474(3.31)	78.04±11.61	98.53±13.34	105.74±10.34
Years of work
0-4	3087(21.58)	71.86±13.63	91.00±16.28	99.38±14.97
5-9	4291(30.00)	71.63±13.98	91.35±16.69	100.65±14.69
10-14	3843(26.86)	71.72±14.44	91.76±17.03	101.07 ±14.85
≥15	3084(21.56)	74.02±13.59	94.13±15.98	103.70 ±13.08
Type of hospital
General Hospital	12169(85.07)	72.36±14.03	92.11±16.65	101.35±14.51
Specialized hospital	2136(14.93)	71.42±13.66	91.26±16.18	99.95±14.60
Q1: Whether to hold a management position?
No	13609(4.87)	71.93±14.02	91.63±16.65	100.94±14.65
Yes	696(95.13)	77.91±11.84	98.82±13.63	105.21 ±11.47
Q2: Whether to undertake teaching tasks
Yes	6517(45.56)	73.79±13.84	93.99±16.21	102.69±13.86
No	7788(54.44)	70.91±13.96	90.30±16.71	99.85±14.96
Q3: Whether to hold good terms with colleagues?
Yes	13586(94.97)	72.67±13.82	92.57±16.32	101.68±14.16
General	701(4.90)	63.77±14.05	80.85±17.46	91.00±17.47
No	18(0.13)	61.94±21.61	82.67±21.23	88.83±20.31
Q4: Is your family supportive of your work?
Yes	13258(92.68)	72.88±13.71	92.85±16.20	101.89±14.02
General	1005(7.03)	64.09±14.37	81.11±17.26	91.92±17.24
No	42(0.29)	59.14±19.36	78.05±20.29	87.40±19.72
Q5: Do you love nursing?
Yes	11126(77.78)	74.22±13.24	94.58±15.49	103.32±13.33
General	2963(20.71)	13.24±13.94	15.49±16.71	13.33±15.73
No	216(1.51)	60.60±17.00	76.02±20.58	89.05±17.80
Q6: Are you satisfied with your salary?
Yes	8007(55.97)	75.68±12.90	96.39±14.94	104.37±12.82
General	5010(35.02)	68.50±13.62	87.35±16.42	97.53±15.13
No	1288(9.00)	65.17±15.36	82.63±18.06	95.18±16.85
Q7: Are you satisfied with your job?
Yes	9923(69.37)	74.96±13.04	95.51±15.18	104.00±12.96
General	3986(27.86)	66.45±66.45	84.48±84.48	94.86±94.86
No	396(2.77)	61.69±16.89	79.11±19.14	92.71±17.90
Q8: Have you ever worked in a humanistic care pilot ward?
Yes	4001(27.97)	76.80±12.81	96.55±15.33	104.38±13.37
No	10304(72.03)	70.44±14.01	90.21±16.71	99.89±14.77
Q9: Do you pay attention to self-care?
Yes	11277(78.83)	74.12±13.36	94.31±15.72	102.99±13.54
General	2816(19.69)	65.32±13.59	83.44±16.60	94.28±15.79
No	212(1.48)	62.90±18.03	81.89±20.07	94.20±18.35
Q10: Have you attended any humanistic care training?
Yes	8272(57.83)	75.32±12.90	95.01±15.56	103.27±13.56
No	6033(42.17)	67.97±14.28	87.83±17.05	98.23±15.30

4.2 Questionnaire scores

The average scores of knowledge, attitudes and practices indexes are 80.24%, 83.62% and 87.95% respectively. In the knowledge index, the current development of humanistic care, the essence of humanistic care, and the basic requirements for implementing humanistic care scored the lowest, with average scores of 65.20%, 77.80%, and 78.60%, respectively. In the attitudes, humanistic care can reduce the number of days of hospitalisation, the starting point of nurses' care, and whether nurses' humanistic care should be included in the indicators of nursing quality assessment received the lowest scores. For the practices, participating nurses had higher overall scores on the implementation of caring behaviours. The relatively low scores were related to the formation of the humanistic care team, the visits and accompanying of patients' relatives, and the participation in humanistic care training. The scores for each dimension are shown in Table 2.

Table2: Score status

Variables	Mean±SD	M(P₂₅, P₇₅)	Average score rate
Knowledge index	72.22±13.98	72.00(61.00, 86.00)	80.24%
Three highest-scoring items
K11	4.15±0.86	4.00(3.00, 5.00)	83.00%
K12	4.15±0.85	4.00(4.00, 5.00)	83.00%
K9	4.13±0.86	4.00(3.00, 5.00)	82.60%
Three lowest-scoring items
K1	3.26±0.99	3.00(3.00, 4.00)	65.20%
K2	3.89±0.91	4.00(3.00, 5.00)	77.80%
K3	3.93±0.92	4.00(3.00, 5.00)	78.60%
Attitudes index	91.98±16.58	88.00(83.00, 110.00)	83.62%
Three highest-scoring items
A8	4.26±0.80	4.00(4.00, 5.00)	85.20%
A12	4.24±0.81	4.00(4.00, 5.00)	84.80%
A4	4.22±0.81	4.00(4.00, 5.00)	84.40%
Three lowest-scoring items
A9	4.06±0.87	4.00(3.00, 5.00)	81.20%
A15	4.07±0.88	4.00(3.00, 5.00)	80.40%
A13	4.11±0.85	4.00(3.00, 5.00)	82.20%
Practices index	101.14±14.54	105.00(92.00,115.00)	87.95%
Three highest-scoring items
P6	4.52±0.68	5.00(4.00, 5.00)	90.40%
P17	4.51±0.68	5.00(4.00, 5.00)	90.20%
P1	4.50±0.69	5.00(4.00, 5.00)	90.00%
Three lowest-scoring items
P23	4.05±1.08	4.00(3.00, 5.00)	81.00%
P14	4.26±0.83	4.00(4.00, 5.00)	85.20%
P21	4.27±0.84	4.00(4.00, 5.00)	85.40%

K1 Do you know the domestic and international development of humanistic care?

K2 Do you know that the essence of humanistic care nursing is embodied in respecting the value of human life?

K3 Do you know that respect and care are the basic requirements for the implementation of humanistic care nursing?

K9 Do you know that establishing trust is the prerequisite for good communication in humanistic care nursing?

K11 Do you know that the protection of privacy is the expression of respect for patients in humanistic care nursing?

K12 Do you know that a good relationship of mutual trust can be better perceived by patients?

A4 Do you think that the implementation of humanistic care nursing can improve the patient experience and increase patient and carer satisfaction?

A8 Do you think that terminally ill patients also need humanistic care?

A9 Do you believe that humanistic care can reduce the number of days of hospitalisation?

A12 Do you think humanistic care should be carried out throughout the whole process of nursing?

A15 Do you think the implementation of humanistic care in the department should be included in the nursing quality assessment index?

A13 Do you think that conforming to patients' interests is the starting point of nurses' caring actions?

P1 Are you neatly dressed at work, have a dignified appearance, and behave appropriately and generously?

P6 Do you treat the patient and take your medication on time?

P17 Do you treat your patients the same?

P14 Do you understand and support the visits and companionship of the patient's relatives and/or friends, and facilitate them?

P21 Have you actively participated in training to improve your caring skills?

P23 Does your department have a human care team of clinicians, nursing staff, dietitians, psychologists, rehabilitation therapists, and volunteers?

4.3 Correlation analysis

The results of the single-factor analysis for each dimension are shown in Table 3. The scores of each index were used as dependent variables. The variables that the results of the single-factor analyses showed to be meaningful were set as independent variables, and the scores of the knowledge and the attitudes indexes were also used as independent variables. Stepwise linear regression analysis (α_entry=0.05, α_removal=0.10) was used to derive the correlates affecting the scores of clinical nursing faculty on each dimension. The results of stepwise linear regression for knowledge, attitudes and practices dimensions are shown in Table 4.

Table 3: Single-factor analysis of general demographic information for each index.

Variables	Knowledge Index		Attitudes Index		Practice Index
Variables	Z or H^**	P	Z or H^**	P	Z or H^**	P
Region	62.96	＜0.001	57.06	＜0.001	104.51	＜0.001
Gender	-5.989	＜0.001	-7.051	＜0.001	-7.841	＜0.001
Age	61.904	＜0.001	66.816	＜0.001	107.318	＜0.001
Marriage	46.678	＜0.001	82.239	＜0.001	118.119	＜0.001
Level of education	7.729	0.021	8.337	0.015	1.642	0.440
Department	110.239	＜0.001	83.449	＜0.001	120.835	＜0.001
Professional title	98.770	＜0.001	113.834	＜0.001	52.141	＜0.001
Years of work	61.571	＜0.001	63.861	＜0.001	121.433	＜0.001
Type of hospital	-3.649	＜0.001	-2.467	0.014	-5.020	＜0.001
Q1: Whether to hold a management position?	-10.527	＜0.001	-10.444	＜0.001	-5.682	＜0.001
Q2: Whether to undertake teaching tasks?	-12.702	＜0.001	-13.224	＜0.001	-10.898	＜0.001
Q3: Whether to hold good terms with colleagues?	253.542	＜0.001	296.335	＜0.001	278.576	＜0.001
Q4: Is your family supportive of your work?	364.024	＜0.001	445.365	＜0.001	358.198	＜0.001
Q5: Do you love nursing?	1014.586	＜0.001	1186.384	＜0.001	1024.602	＜0.001
Q6: Are you satisfied with your salary?	1187.032	＜0.001	1337.333	＜0.001	877.669	＜0.001
Q7: Are you satisfied with your job?	1258.623	＜0.001	1451.499	＜0.001	1180.805	＜0.001
Q8: Have you ever worked in a humanistic care pilot ward?	-26.054	＜0.001	-21.470	＜0.001	-18.338	＜0.001
Q9: Do you pay attention to self-care?	984.558	＜0.001	1017.576	＜0.001	800.205	＜0.001
Q10: Have you attended any humanistic care training?	-31.842	＜0.001	-25.637	＜0.001	-20.486	＜0.001

^** For 2 independent samples the Mann-Whitney U test for non-parametric tests was used, with the indicator being the Z-value. For multiple independent samples the Kruskal-Wallis H

Table 4: Multiple linear stepwise regression analysis of the three level indexes

Model	Unstandardized Coefficients			t	P	Collinearity Statistics
Model	B	SE B		t	P	Tolerance	VIF
Knowledge index			R²=0.186, R²=0.185, F=136.348, P＜0.001
Constant	51.220	0.815	/	62.880	＜0.001	/	/
Q7-Yes	2.453	0.342	0.081	7.179	＜0.001	0.449	2.227
O10-Yes	4.461	0.235	0.158	18.993	＜0.001	0.828	1.208
Q9-Yes	4.254	0.285	0.124	14.903	＜0.001	0.819	1.221
Q6-Yes	3.833	0.452	0.136	8.478	＜0.001	0.221	4.524
Q8-Yes	2.585	0.255	0.083	10.138	＜0.001	0.850	1.176
Q5-Yes	2.397	0.339	0.071	7.070	＜0.001	0.560	1.785
Gender-Female	3.054	0.516	0.045	5.923	＜0.001	0.970	1.030
Q1-Yes	1.690	0.548	0.026	3.084	0.002	0.801	1.248
Region-North China	3.281	0.453	0.073	7.242	＜0.001	0.555	1.801
Region-Central China	2.036	0.355	0.072	5.736	＜0.001	0.363	2.754
Dept-Geriatrics	3.955	0.842	0.036	4.697	＜0.001	0.968	1.033
Q4-Yes	1.393	0.460	0.026	3.032	0.002	0.777	1.287
Region-East China	1.964	0.440	0.046	4.467	＜0.001	0.549	1.822
Region-Southwest China	1.893	0.500	0.036	3.785	＜0.001	0.646	1.548
Q3-Yes	1.398	0.526	0.022	2.659	0.008	0.844	1.185
Professional Title -Deputy director nurse or above	1.763	0.653	0.023	2.700	0.007	0.815	1.226
Q6-General	1.085	0.405	0.037	2.681	.007	0.299	3.345
Dept-Obstetrics-Gynaecology	1.536	0.413	0.030	3.716	＜0.001	0.885	1.130
Dept-Internal medicine	0.988	0.264	0.032	3.742	＜0.001	0.785	1.274
Dept-Surgery	0.653	0.282	0.020	2.316	0.021	0.794	1.259
Marriage- Divorced	1.829	0.830	0.017	2.203	0.028	0.996	1.004
Q2-Yes	0.454	0.221	0.016	2.050	0.040	0.916	1.092
Region-South China	0.818	0.410	0.022	1.994	0.046	0.482	2.073
Attitudes index			R²=0.687,R²=0.687, F=2091.680, P＜0.001
Constant	20.380	0.617	/	33.013	＜0.001	/	/
K-Score	0.931	0.006	0.785	152.725	＜0.001	0.830	1.205
Q7-Yes	1.105	0.251	0.031	4.395	＜0.001	0.449	2.230
Q9-General	-1.347	0.214	-0.032	-6.292	＜0.001	.831	1.204
Q5-Yes	1.081	0.249	0.027	4.344	＜0.001	0.563	1.775
Q6-Yes	1.931	0.330	0.058	5.851	＜0.001	0.224	4.456
Professional Title-Supervisor nurse	1.403	0.244	0.041	5.754	＜0.001	0.441	2.265
Q4-General	-0.930	0.341	-0.014	-2.726	0.006	0.792	1.262
Gender-Female	1.005	0.377	0.013	2.664	0.008	0.980	1.021
Q6-General	0.917	0.296	0.026	3.095	0.002	0.302	3.315
Professional Title-Senior nurse	0.850	0.235	0.026	3.626	＜0.001	0.440	2.273
Q10-Yes	-0.496	0.165	-0.015	-3.008	0.003	0.909	1.100
Professional Title -Deputy director nurse or above	1.306	0.477	0.014	2.740	0.006	0.828	1.208
Q3-General	-0.846	0.390	-0.011	-2.171	0.030	.852	1.174
Region-Southwest China	0.601	0.296	0.010	2.030	0.042	.995	1.005
Dept-Surgery	0.365	0.185	0.009	1.968	0.049	.993	1.007
Practices index			R²=0.517, R²=0.517, F=850.817, P＜0.001
Constant	40.020	0.785	/	50.994	＜0.001	/	/
A-score	0.492	0.009	0.561	54.186	＜0.001	0.315	3.177
Q5-Yes	1.298	0.260	0.037	4.994	＜0.001	0.612	1.635
K-Score	0.127	0.011	0.122	11.934	＜0.001	0.322	3.108
Region-North China	2.567	0.276	0.055	9.313	＜0.001	0.961	1.040
Years of work	0.109	0.013	0.054	8.347	＜0.001	0.806	1.240
Q7-General	-1.262	0.231	-0.039	-5.462	＜0.001	0.665	1.504
Gender-Female	2.056	0.422	0.029	4.875	＜0.001	0.929	1.076
Q9- General	-1.137	0.232	-0.031	-4.895	＜0.001	0.837	1.195
Q3-Yes	1.738	0.419	0.026	4.143	＜0.001	0.850	1.177
Professional Title-Senior nurse	0.723	0.181	0.025	4.004	＜0.001	0.879	1.138
Q1-Yes	-1.529	0.415	-0.023	-3.680	＜0.001	0.894	1.119
Dept-Operating room	-0.999	0.365	-0.017	-2.736	0.006	0.925	1.081
Region-East China	0.802	0.265	0.018	3.025	0.002	0.967	1.034
Dept-ICU	-0.629	0.313	-0.012	-2.006	0.045	0.904	1.106
Q4-Yes	0.832	0.366	0.015	2.272	0.023	0.785	1.274
Region-Northwestern China	0.758	0.380	0.012	1.996	0.046	0.974	1.027
Dept-Surgery	0.503	0.212	0.015	2.377	0.017	0.903	1.107
Dept-Obstetrics-Gynaecology	0.730	0.321	0.014	2.274	0.023	0.941	1.063

Abbreviation: Dept, department.

Q1: Whether to hold a management position?

Q2: Whether to undertake teaching tasks?

Q3: Whether to hold good terms with colleagues?

Q4: Is your family supportive of your work?

Q5: Do you love nursing?

Q6: Are you satisfied with your salary?

Q7: Are you satisfied with your job?

Q8: Have you ever worked in a humanistic care pilot ward?

Q9: Do you pay attention to self-care?

Q10: Have you attended any humanistic care training?

4.4 Correlation of the three first-level indexes

There was a significant positive correlation (P<0.05) between the knowledge, attitudes and practices of the participating nurses towards humanistic care, as shown in Table 5.

Table 5: Correlation analysis of the three indexes

Variables	r_s	P
Knowledge-Attitudes	0.827	＜0.001
Knowledge-Practices	0.636	＜0.001
Attitudes-Practices	0.706	＜0.001

This study is the first multi-centre, large-sample cross-sectional survey of clinical nurses' level of knowledge, attitudes and practices in humanistic care conducted nationwide in China by the Humanistic Care Committee of the China Life Care Association. The results showed that the scores on the three indexes of knowledge, attitudes and practices were correlated, matching the theoretical framework, the KAP Theory.

About the scores of the three indexes, the practices index was the best level of scoring. According to the questionnaire developer's classification of the questionnaire scores, only this index scored at an excellent level, greater than 85%. While the knowledge index scored the worst. This indicates that the nurses who participated in the survey had a relatively inadequate grasp of the theoretical knowledge and that there is still room for further improvement in humanistic caring. The reason for this is presumed to be related to factors such as the late start of humanistic care education, the incomplete training system, and the low participation rate in humanistic care training (57.83%) in China. Clinical professional theoretical knowledge and practical ability have been valued and developed as the embodiment of nurses' hard power in nursing. However, humanistic care is one of the embodiments of nursing soft power. Its training is still relatively insufficient [30]. On the other hand, it is need to understand that humanistic caring behaviours and the release of theoretical knowledge can be achieved and mastered through short-term training and assessment, but the right humanistic caring attitudes need to be infected with the caring atmosphere of the organisational environment and the cultivation of a caring culture. This is a long-term and continuous process.Therefore, the humanistic caring education system should be soundly based on the process of issuing humanistic caring behaviours of nurses. Managers should not only encourage nurses to participate in humanistic caring training and provide caring care to patients, but also reflect caring in their management, education and relationship with nurses. This will lead to the realisation of the fundamental promotion of nurses' competence in humanistic care.

In terms of knowledge, some of the nurses did not understand the current status of the development of humanistic care, the essence of humanistic care nursing, and the basic requirements. It proves that the training and education system of humanistic care needs to be further improved, and the content of the education should focus on the status of the development of humanistic care, its essence and basic requirements. In the attitudes, some nurses felt that humanistic caring care did not contribute to a reduction in the number of days patients stayed in the hospital and did not think that the implementation of humanistic caring care should be assessed. The rehabilitation of patients involves a number of aspects, including the patient's condition, treatment modality, psychological state, medical skills of doctors and nursing skills of nurses. Research has proved that caring care has a positive effect on the recovery of patients, the improvement of hospitalisation quality [31] and the alleviation of pain [18]. And the assessment of nurses' humanistic care should be different from nursing techniques. Assessment of humanistic care should be as routine and hidden as possible. Through covert appraisal, managers can find out the shortcomings of nurses' humanistic care in nursing, and remind and improve them. Both of the scores can be improved through the implementation of extensive humanistic care education and training and changes in the way managers implement the specifics of humanistic care assessment. In addition, Waston suggests that care and love can produce care and love [32]. It has also been shown that nursing students' perceived care and love from their peers is conducive to their humanistic caring skills [3]. The same is true for nurses. As a result, the improvement of nurses' attitudes towards humanistic care can be achieved by enhancing the caring atmosphere in the department. The formation of caring atmosphere in the department helps nurses to feel caring and discover the role of caring, thus achieving recognition of caring. In terms of behaviour, the formation of a humanistic care team within the nurses' department scored the lowest. This may be related to the insufficient awareness of the importance of humanistic care in health organisations such as hospitals and the strain on healthcare human resources.

By analysing the influencing factors, the gender of the nurses, their job satisfaction, the importance of self-care, their love of nursing, their family's support of their work, and the rapport of their colleagues had a positive impact on their knowledge, attitudes, and practices in humanistic caring nursing. We can consider good co-worker relationships, family support at work, and an individual's focus on self-care as important components of an individual's perceived care. It is hypothesised that for individuals, perceived care and emitted care are in dynamic equilibrium. The more care an individual feels, the more caring he or she may be able to do. However, a more comprehensive and systematic study of the care received by individuals needs to be followed up and analysed in conjunction with their humanistic care competence scores. And the specific relationship between the two can be explored.

Whether or not they have participated in humanistic care training, satisfaction with their salary, and the level of their job title will positively influence their knowledge and attitudinal aspects of humanistic care. Therefore, training can be used to improve nurses' theoretical knowledge of humanistic care. Whether or not they worked on a humanistic care pilot ward and whether they had a teaching role also had an impact on knowledge scores. In addition, nurses whose departments were operating theatres and ICUs had poorer caring behaviours. It is hypothesised that this may be related to the fact that nurses working in operating rooms and ICUs have fewer opportunities to interact and communicate with patients and their families. But precisely because patients in the operating rooms and ICU are in a separate space, they are unable to have contact with their families and feel less care and support. For this reason, humanistic caring nursing care by nurses is more meaningful and important for patients in these two units than for patients in general wards. It is suggested that managers should pay attention to the particularities of different unit environments and patients to understand the differences in their nurses' humanistic caring competence. Focused attention and training should be given to nurses in operating rooms and ICUs where caring competence may be poor.

However, there are some limitations to this study. Firstly, although this study involves 25 provinces and municipalities in China, the questionnaires were distributed by means of online collection on the Internet. This may have some impact on the reliability of the study results. Secondly, the analysis of the influencing factors in this study was only conducted by single factor analysis and multiple linear regression analysis, and the relationship between the variables can be further explored using path analysis in the future.

The educational group of humanistic care for nurses should be expanded. The content of education should be more focused on the essence, basic requirements and current development of humanistic care. In addition, managers should focus on the process of realising humanistic care for nurses. While encouraging nurses to participate in humanistic caring training, they should infiltrate caring into the process of management and create a good caring atmosphere within the department. Eventually, the overall improvement of the caring ability of the nurses' group from the inside out will be realised. At the institutional level, there is a need to form a humanistic care team so that multidisciplinary cooperation can be achieved to jointly promote a humanistic care climate in the institution.

For the first time, the Humanistic Care Committee of the China Life Care Association conducted a cross-sectional survey on the humanistic caring ability of nurses nationwide. The survey found that the mastery of theoretical knowledge of humanistic caring was not high; some nurses had incorrect attitudes towards caring-related content; and the overall performance level of caring behaviour was good. Their humanistic caring ability should be improved by strengthening the training of humanistic caring. And humanistic care should be reflected everywhere in the working atmosphere of the department and the management style of the leaders, so as to enhance the kernel of personal care and improve the ability of humanistic care. At the same time, the institutional mechanism of the hospital should pay attention to the humanistic care for patients and employees. Form a humanistic care team to promote the formation of the overall humanistic care atmosphere in the hospital.

KAP theory Knowledge, Attitudes and Practices theory

COVID-19 Corona Virus Disease 2019

ICU Intensive Care Unit

Acknowledgments

We acknowledge the nurse managers of all the hospitals in this survey, we also thank to the China Life Care Association for the help and support.

Authors’ contributions

Project Conception: CHW, LYL, WHY, XDL; Project organization: CHW, LYL, XDL, WHY, HDY; Project execution: CHW, YRY, LYJ, DDM, LZ, CYY, ZGH; Statistical analysis design: CHW, TR; Statistical analysis—execution: CHW, XDL, TR; Statistical analysis—review and critique: CHW, XDL, WHY; Preparation of the first draft of manuscript: CHW; Review and critique of manuscript:CHW, XDL, LYL, WHY, HDY, YRY, LYJ, DDM, LZ, CYY, ZGH, TR.

Funding

This work was supported by the Chinese Nursing Association [grant numbers ZHKY202006], 2020 Research Projects.

Availability of data and materials

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

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Tongji Medical College of Huazhong University of Science and Technology (No. S161) and appropriate permission was obtained from the Director of Nursing of the participating hospitals. All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki) and informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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No competing interests reported.

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Knowledge, Attitudes and Practices Levels of Clinical Nurses towards Humanistic Caring: the First Nationwide Multi-Centre Cross-Sectional Survey in China

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Abstract

Background

Method

Result

Conclusion

1 Introduction

2 Background

3 Methods

3.1 Design and participants

3.2 Data collection instrument

3.3 Data collection

3.4 Ethical considerations

3.5 Data analysis

4 Results

4.1 Characteristics of the participants

4.2 Questionnaire scores

4.3 Correlation analysis

4.4 Correlation of the three first-level indexes

5 Discussion

6 Implications of research

7 Conclusions

Abbreviations

Declarations

References

Additional Declarations

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