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Abstract
Objective To investigate the knowledge, attitude and practice (KAP) of early pulmonary rehabilitation (PR) of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) among Chinese medical staff and the relationship between them.
Design A multicentre cross-sectional survey was used in this study.
Setting The study was conducted at multiple hospitals in Guizhou Province, China.
Participants A total of 745 medical staff were recruited from several hospitals in Guizhou Province by convenient sampling method.
Primary and secondary outcome measures A 41-item questionnaire was used to collect the demographic characteristics of the respondents and the KAP of the medical staff on the early PR of AECOPD.
Results The average KAP scores were 64.49±17.24, 42.81±5.95 and 41.39±8.97. There were significant positive correlations between knowledge and attitude (r=0.491, p<0.001), knowledge and practice (r=0.129, p<0.001), and attitude and practice (r=0.246, p<0.001). Medical staff with prior PR training and AECOPD early PR experience had higher knowledge and practice scores. Attitudes were significantly influenced by gender, hospital level, professional title and respiratory staff status, while practice scores were significantly affected by prior experience, knowledge and patient contact frequency.
Conclusions The study found that medical staff’s knowledge and attitudes affect their practices, and experience and education influence their knowledge. It suggests that organisations should enhance education and training to improve medical staff’s knowledge and attitudes, thus enhancing clinical practice. However, the study’s focus on Guizhou Province and the high number of nurses in the sample may limit the generalisability of the results.
- China
- Cognition
- Cross-Sectional Studies
- Education, Medical
- Rehabilitation medicine
- Attitude
Data availability statement
All data relevant to the study are included in thearticle or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study is the first of its kind in China to investigate the knowledge, attitude and practice of medical staff on pulmonary rehabilitation of acute exacerbation of chronic obstructive pulmonary disease.
This study was only conducted in Guizhou Province, China, and the proportion of nurses was high, which affected the universality of the findings.
All of the data was self-reported by medical staff, which can create inherent bias.
As with all other cross-sectional studies, the data collection methods in this study capture a single moment, limiting the ability to make causal inferences.
Introduction
Chronic obstructive pulmonary disease (COPD) is a prevalent and progressive respiratory ailment characterised by persistent airflow obstruction and respiratory symptoms. Despite its heterogeneity, COPD is primarily caused by the inhalation of particulate matter,1 2 including cigarette smoke and air pollutants, in addition to genetic, developmental and social factors. Furthermore, COPD frequently presents with acute exacerbations, which necessitate additional treatment and pose a significant public health concern in contemporary society.2–4
Acute exacerbations are a frequent occurrence among individuals diagnosed with COPD,5 commonly referred to as acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and have the potential to be severe, leading to hospitalisations and significant healthcare expenditures.5 6 These exacerbations are a characteristic aspect of the disease and contribute significantly to both morbidity and mortality rates.1 7 AECOPD has detrimental effects on patients’ overall health and disease progression, rendering them more susceptible to subsequent exacerbations, hospitalisations and even death. Consequently, the primary objective of treatment for patients experiencing AECOPD is to mitigate the adverse consequences associated with these events and prevent their recurrence.8 9 These exacerbations can also result in further deterioration of quality of life, lung function and functional status, while simultaneously increasing the likelihood of subsequent hospitalisation and premature mortality. AECOPD, defined as an acute event marked by symptom exacerbation necessitating medication adjustment, may expedite disease progression and heighten the susceptibility to hospital admissions and mortality, in addition to diminishing overall quality of life.10 11
According to a statement from the American Thoracic Society and the European Respiratory Society, pulmonary rehabilitation (PR) is a comprehensive non-pharmacological treatment that holds the highest potential for enhancing symptoms of COPD; PR serves as a fundamental intervention in the management of patients with stable COPD, encompassing exercise training, education and behavioural modifications.12 13 While PR programmes are predominantly offered to stable patients or post-discharge, there is a scarcity of training programmes tailored to acute exacerbations during hospitalisation.10 There exists a substantial body of evidence that substantiates the advantages of PR subsequent to hospitalisation for AECOPD, encompassing enhanced exercise capacity and health-related quality of life, as well as diminished readmissions and mortality rates.14 Nevertheless, the rates of referral and acceptance for PR remain disappointingly low. Prior data have demonstrated that a mere 30% of eligible patients are referred for PR following hospitalisation, with less than 10% successfully completing the programme. The obstacles impeding referral and acceptance are intricate and multifaceted in nature.10
The objective of this study was to examine the knowledge, attitude and practice (KAP) of Chinese medical personnel regarding early PR with AECOPD, as well as to establish the correlation between their KAP in relation to early PR. This exploration of data on medical personnel’s KAP and their interrelationships can yield valuable insights for enhancing quality. Researchers have indicated that knowledge has a positive impact on a person’s attitude, which in turn affects practice or behaviour,15 based on which we assumed that the knowledge of medical personnel in PR is directly or indirectly related to practice through attitude.
Methods
Design and setting
This study employed a multicentre cross-sectional survey to investigate medical staff in various hospitals in Guizhou Province, China, from July to October 2023, using an online questionnaire. The study was guided by the behavioural theory referred to as ‘Knowledge-Attitude-Belief Practice (KABP)’.16 All medical personnel employed in the various hospitals from which data were gathered were deemed eligible for participation through convenience sampling. Convenient sampling may restrict the generalisability of the findings, as the sample might not represent China’s entire medical workforce. Self-reported data can also be biased by social expectations, with participants giving socially acceptable rather than genuine responses. To address this, we used a reverse scoring item to identify inconsistencies. Despite these limitations, the study offers valuable insights into the knowledge, attitudes and practices of healthcare workers in Guizhou Province about early PR for AECOPD. The sample size for this cross-sectional study was determined by considering 9 independent variables, 3 questionnaire dimensions and a maximum of 19 items in the scale, resulting in a minimum requirement of 180 participants. To ensure statistical robustness, we aimed for at least 300 participants. Anticipating a 30% response rate,17 we invited 1000 respondents and received 753 responses. After excluding 8 responses during data processing, 745 responses were included in the final analysis. Figure 1 illustrates the detailed algorithm for sample selection, registration and filtering. In order to be included in the study, these eligible individuals were required to meet two specific criteria: (a) they had to be currently employed in the hospitals for a minimum duration of 1 year and (b) they had to possess a Practice Certificate issued by the Ministry of Health of China. All participants willingly participated in the study, while medical personnel who did not meet the inclusion criteria were excluded from the study due to the unavailability of an informed consent form.18 The completion of the questionnaire signifies consent, resulting in a total sample size of 745 instances. To ensure the questionnaire data’s quality and validity, each item is designated as a compulsory question, and only the initial response’s valid data are chosen based on the IP address and answer time, thereby preventing multiple submissions from a single device. Individuals with a score rate exceeding 85% are classified as excellent and those falling within the 60%–85% range are considered good, while scores below 60% are categorised as poor.
Algorithm showing sample selection, enrolment, exclusion and final analysis. This figure illustrates the flow of participants from initial recruitment to final inclusion in the study. A total of 1000 participants were invited, 753 completed the questionnaire and 745 were included in the final analysis after exclusions.
The questionnaires
A structured self-report questionnaire was developed with the purpose of assessing the KAP of medical personnel in relation to early PR for AECOPD. Our decision to employ a self-designed questionnaire encompassing professional knowledge, precautions and operational techniques of PR is believed to provide valuable guidance to medical staff in facilitating patients’ engagement in early PR. The design of the questionnaire was executed in two distinct stages. In the initial phase, the research team conducted an extensive literature review to formulate a preliminary version of the questionnaire, which was later refined using the Delphi method. In the subsequent stage, the revised document will be subjected to expert scrutiny, ultimately leading to the creation of the final questionnaire. The questionnaire encompassed three distinct dimensions, namely knowledge (comprising 19 items), attitude (comprising 11 items) and practice (comprising 11 items). The knowledge dimension of this study primarily focused on the definition, main contents, curative effect, contraindications, implementation period and principles of PR. Participants were asked to rate their level of understanding on a 5-point Likert scale ranging from ‘Very little’ to ‘Very well’. The attitude dimension, on the other hand, assessed participants’ perceptions of the impact of PR, role perception and management of AECOPD in clinical practice. This dimension also used a 5-point Likert scale, ranging from ‘Strongly disagree’ to ‘Strongly agree’. The ‘practice’ dimension focuses on early PR actions and skills in AECOPD, such as (1) evaluating patient eligibility for early PR, (2) implementing PR methods like breathing exercises and physical training, (3) tracking patient progress in PR, and (4) providing PR benefits and technical education. Each aspect is rated on a 5-point Likert scale from ‘not willing’ to ‘willing’. To mitigate the risk of subjects completing the questionnaire in a careless manner and to minimise the occurrence of invalid responses, we employed a strategy of incorporating reverse questions within the first five items of the attitude dimension. The content validity of the questionnaire was evaluated by a panel of 16 local experts who fulfilled the following criteria: (1) possessing expertise in critical care, nursing management, nursing research, respiratory specialist nursing or respiratory department; (2) holding academic titles of associate chief senior nurse/doctor, associate professor or higher; and (3) affiliated with tertiary hospitals or medical colleges. Following two rounds of expert reviews and subsequent modifications, the Cronbach’s α coefficient and Kaiser-Meyer-Olkin value of the final PR scale were determined to be 0.953 and 0.969, respectively. Overall, the questionnaire exhibited acceptable levels of validity and reliability within the context of this study.
Data collection and ethical considerations
It is important to note that participation in the study was entirely voluntary. To gather data, web-based questionnaires were employed, with the design and creation of the questionnaire link being entrusted to Questionnaire Star (Changsha Ranxing Information Technology Co. Ltd). Data will be gathered via the facilitation of a WeChat group. Upon completion of the questionnaire, respondents are required to click the ‘Submit’ button to save their responses. Additionally, participants will not be provided with any financial compensation upon completing the questionnaire. The questionnaires were designed to be anonymous, and no personal information related to medical personnel will be collected, thereby ensuring that respondents’ identities remain unlinked and confidential.
Data analysis
In this study, IBM SPSS V.27.0 for Windows was used for statistical analysis. To ensure the robustness of the statistical analysis, we performed a normality test (Shapiro-Wilk) for all continuous variables. Descriptive information was presented as n (%) or mean±SD. The calculation of score percentages for both overall and individual dimensions involved dividing the average score by the theoretical maximum and multiplying by 100%. Certain continuous variables, such as age and number of years of hospitalisation experience, were categorised into distinct groups for analysis. In order to examine the disparities between the scale and demographic information, we employed an independent-sample t-test and a one-way analysis of variance (ANOVA). In the case of the t-test, if both samples meet the assumption of equal variance, the t-test of equal variance is used. Conversely, if the variances are unequal, a t-test for unequal variances is employed. The Tukey test was employed to conduct group comparisons. The examination of the association between KAP entailed the utilisation of Pearson correlation coefficients. To examine the factors influencing KAP, we employed multiple linear regression analysis, adjusting for potential confounders including age, years of experience and hospital classification to ensure the robustness of our results. Bilateral significance tests were conducted for all analyses, with the significance threshold established at 0.05.
Patient and public involvement
No patient is involved.
Results
Sociodemographic characteristics of participants
Out of 1000 invited participants, 753 medical staff completed the questionnaire, yielding 745 valid responses. This results in a 75.3% response rate and a 98.9% validity rate. The majority of participants were female (680, 91.3%) and predominantly occupied nursing roles (684, 91.8%). Among the respondents, 334 primarily worked in the tertiary hospitals, while the remaining 409 were affiliated with secondary hospitals, accounting for 54.9% of the sample. Furthermore, a significant proportion of participants held a bachelor’s degree or higher (566, 76%). Approximately 43.9% of the participants had undergone early PR training for AECOPD, while a similar proportion (42.7%) had practical experience in AECOPD early PR work. Further comprehensive details regarding the sociodemographic and professional characteristics can be found in table 1.
Sociodemographic characteristics
The level of KAP of medical staff towards AECOPD pulmonary rehabilitation
The average knowledge score was 64.49±17.24, corresponding to a scoring rate of approximately 68%. Likewise, the average attitude score was 42.81±5.95, indicating a scoring rate of around 77%. Furthermore, the average attitude score was 41.39±8.97, with a scoring rate of about 75%. Detailed analysis results for each dimension are provided in table 2.
The knowledge, attitude and practice score
Effects of demographic and job-related variables on healthcare workers’ KAP towards pulmonary rehabilitation for AECOPD
Knowledge
The findings from the one-way ANOVA presented in table 2 indicate significant variations in knowledge scores across various departments. Additionally, significant differences in knowledge scores were observed when comparing different frequencies of contact with patients. However, no significant relationship was found between age, education level, working time, professional title, hospital level, position and knowledge. Based on the results of the independent-sample t-test, significant variations in knowledge scores were identified among distinct categories, including gender, occupation, presence of work experience in early PR of AECOPD, participation in training related to early PR of AECOPD, familiarity with relevant knowledge, and employment as respiratory department staff. Based on the findings of Tukey’s test, it was observed that knowledge scores in various departments such as stomatology, gynaecology and ENT, among others, exhibited significant disparities when compared with the scores in emergency, internal medicine and ICU. Furthermore, variations in knowledge scores were also evident across different levels of patient interaction, specifically within the ranges of 0–9%, 10%–29% and ≥30%.
Attitude
Based on the findings from the independent-sample t-test and one-way ANOVA, significant statistical disparities were observed across various demographic variables, including gender, age, occupation, years of work, title, position, hospital level, experience in AECOPD PR work, familiarity with AECOPD PR knowledge, department affiliation and respiratory staff status. Based on the findings of Tukey’s test, a notable disparity in attitude scores was observed between individuals aged 20–29 and those aged ≥40. Furthermore, significant variations were identified in the scores of individuals with work experience of ≥10 years compared with those with work experience of 5–9 years and ≤5 years.
Practice
The results of the independent-sample t-test indicated significant relationships between occupation, participation in AECOPD PR training, relevant work experience, knowledge and being a respiratory staff member with practice. However, the one-way ANOVA revealed that only the department of the subjects and the frequency of patient contact were significantly associated with practice, while the other variables did not demonstrate statistical significance. Based on the findings of Tukey’s test, a statistically significant disparity was observed in the practice scores among patients with varying frequencies of contact, specifically those scoring between 10 to 29%, ≥30%, and 0–9%.
Correlation study of KAP of medical staff on PR in patients with AECOPD
The findings of the correlation analysis are presented in table 3, indicating a notable and positive correlation between knowledge and attitudes (r=0.491, p<0.001). As the knowledge score increased, there was a corresponding elevation in attitude scores. Additionally, a significant and evident correlation between knowledge and practice was observed, with a statistically significant relationship (r=0.129, p<0.001). Furthermore, a strong correlation between attitude and practice was clearly evident (r=0.246, p<0.001).
Correlation of knowledge, attitude and practice related to early pulmonary rehabilitation from acute exacerbation of chronic obstructive pulmonary disease of medical staff
Results of several linear regression equations
Statistically significant variables in univariate analyses were added to multivariate linear stepwise regression. An analysis was conducted employing multiple linear regression equations to explore the independent associations between KAP scores. The findings from the multiple linear regression model online supplemental table 1 revealed significant associations between knowledge and variables such as training received, AECOPD early PR work experience, familiarity with relevant knowledge, occupation as respiratory staff, and frequency of patient contact. After accounting for other variables, the analysis presented in online supplemental table 2 demonstrates that gender, hospital level, professional title and various positions within the respiratory staff are independent factors that significantly impact attitudes. Furthermore, the presence of prior AECOPD early PR work experience, knowledge pertaining to the subject matter, and frequency of contact with AECOPD patients were identified as independent factors influencing practice scores, as indicated in online supplemental table 3.
Supplemental material
Discussion
AECOPD has been found to have a substantial negative impact on quality of life and an elevated risk of mortality.19 Existing guidelines strongly advocate for the implementation of early PR following a severe exacerbation.12 Recent research has additionally demonstrated the advantages of early PR during hospitalisation for the management of AECOPD, highlighting its safety and reliability.5 20 The objective of this study was to evaluate the level of KAP among medical personnel regarding early PR for AECOPD. Our findings indicate that medical staff in the Guizhou region of China demonstrate promising KAP towards early PR for AECOPD. However, there is a need for improvement in the KAP of nurses in this area. Additionally, our study revealed a significant correlation between KAP scores for early PR in AECOPD. This finding aligns with previous research, indicating the necessity for further enhancement of PR education programmes within our nation.20 Additionally, it is evident that a majority of medical professionals, particularly nurses, possess a general comprehension of the field of PR, yet their knowledge lacks depth and comprehensiveness. However, Chinese scholars are actively endeavouring to address this phenomenon. Presently, studies pertaining to the PR management mode, spearheaded by respiratory specialist nurses, demonstrate the noteworthy long-term impact of multispecialist group collaboration in PR led by specialist nurses.21 22 This not only influences patient prognosis but also holds immense significance for the advancement of Chinese medical personnel in the realm of PR.
A thorough understanding and recognition of early PR among healthcare professionals are imperative for attaining favourable outcomes in patients with AECOPD, as it serves as the foundation for adopting suitable attitudes and practices.23 The present study revealed that the rate of knowledge pertaining to early PR was approximately 68%, with an average knowledge score of 64.49±17.24. These findings suggest that medical personnel possess inadequate knowledge regarding early PR, aligning with the research outcomes reported by Chinese scholars Su et al.24 Among the items assessed, PR programmes and prognostic and curative knowledge received the highest average scores, in that order. Conversely, the content of PR, the scale of assessment, and the related knowledge of the principles followed obtained the lowest average scores. These findings indicate that while medical staff possess a general understanding of early PR, their knowledge lacks comprehensiveness and depth. Currently, the most recent research demonstrates the efficacy and safety of early PR treatment for AECOPD.5 25–27 The field of medicine encompasses various components, including daily diagnosis, treatment and health service support, all of which heavily rely on the involvement of nurses.28 Consequently, the nursing workload is substantial and demanding. Particularly, due to factors such as limited nursing staff and the ratio of medical personnel, there is a scarcity of healthcare providers during rotation tasks, resulting in a primary focus on routine treatment and disease management.29 The inability to promptly and comprehensively update the most recent knowledge and skills necessitates the need for further standardisation of the rotation system for medical personnel, scientific innovation in nursing scheduling methods, and rational establishment of the medical care ratio.30 Furthermore, telemedicine presents potential benefits in mitigating disease symptoms,31 particularly when integrated with educational initiatives, self-management strategies (including swallowing training, the gradual reintegration into physical activity, food texture modification and psychological support), and physical exercise.
In the present study, the attitude dimension score rate among medical staff was approximately 77%, with an average score of 42.81±5.95. Not exactly consistent with previous studies, the study conducted by Guo et al revealed that a considerable percentage of nurses (86%) recognised the significance of PR in the care of individuals diagnosed with COPD.32 Johnston et al reported that 77% of healthcare professionals expressed a strong belief in the utmost importance of PR for COPD patients.33 The observed outcome may be attributed to variations in hospital level and specific departments. Findings from this investigation indicate a statistically significant elevation in the attitude score among medical personnel in tertiary hospitals compared with those in primary hospitals (p=0.044). Furthermore, medical staff working in the respiratory department exhibited significantly higher attitude scores in comparison to their counterparts in other departments (p<0.001). Previous research has demonstrated that the educational background of nursing staff with limited experience and junior positions in primary hospitals in China tends to be subpar.34 Currently, clinical nursing staff exhibit a low and heterogeneous level of scientific research proficiency. It is imperative for nursing managers to implement systematic training programmes that enhance nurses’ knowledge and practical skills in scientific research within the field of nursing.35 Evidently, substantial evidence supports the notion that knowledge significantly impacts attitudes.
In the present study, the practice dimension of medical staff yielded a score rate of approximately 75%, with an average score of 41.39±8.97. These findings suggest that the overall performance of medical staff in implementing PR is commendable. However, it should be noted that these results do not align entirely with the study conducted by Guo et al.32 Following extensive research, early PR for COPD has yielded significant outcomes, establishing its status as a secure and efficacious non-pharmacological intervention. Similarly, AECOPD early PR builds upon the advancements in COPD early PR and is likewise acknowledged as a reliable and effective non-pharmacological treatment. Only 25.9% of the population achieved a scoring rate of no less than 85%, while 48.9% of the population achieved a scoring rate between 60% and 85%. Notably, the three areas with the lowest scores were the mastery of accident cause analysis, the ability to organise patients in learning relevant content, and the proficiency in assessment techniques. However, it is worth noting that a subset of medical personnel exhibited suboptimal scores, potentially attributable to the limited sample pool used in this study. A significant majority of the samples were derived from level I and level II hospitals, suggesting a plausible explanation for the lack of standardised training among a considerable portion of healthcare providers.36 Consequently, the inability to deliver tailored and proficient treatment and care to patients undergoing PR may be a consequence of this deficiency.
The findings of this study indicate significant positive associations between KAP (p<0.01). This finding suggests that a higher level of PR knowledge among medical personnel is associated with the ability to cultivate a positive attitude and enhance behavioural compliance. It is evident that a causal relationship exists between knowledge, belief and action, aligning with the theoretical framework positing that knowledge influences attitude, which in turn drives behaviour. The medical staff in the respiratory department assumes a crucial role as the primary executors of PR training for patients with AECOPD. Extensive research has demonstrated that a deeper understanding of PR among medical staff correlates positively with their ability to enhance patients’ motivation and adherence to the programme.37 Ballesteros Reviriego et al38 demonstrated that early physical therapy enhances lung function and muscle strength without adverse effects, influencing both clinical practice and policy. The study found that better knowledge, attitudes and practices among healthcare workers, through targeted education, can boost their participation and confidence in implementing early PR for AECOPD. This may result from a better grasp of PR principles, enhanced patient assessment skills and more effective clinical decisions. Hospitals can offer regular workshops or online courses on early PR techniques. Policymakers might also integrate early PR training into ongoing education for healthcare professionals, particularly in resource-limited areas with limited access to specialised training. These initiatives can enhance knowledge and attitudes, leading to improved clinical practices and patient outcomes.
Through the utilisation of multiple linear regression analysis, our study revealed a significant correlation between knowledge and various factors, including training, prior experience in AECOPD PR, comprehension of relevant knowledge, occupation as respiratory workers, and frequency of patient interaction. The findings of this study suggest that medical personnel who have received training in PR and possess work experience in this field demonstrate superior levels of knowledge and practice. These results indicate that practical experience in clinical settings can enhance one’s understanding, abilities and confidence in the context of PR, aligning with previous research findings.39 The findings of the survey conducted by Mahendran et al on PR among nurses indicate that participation in training courses and gaining clinical experience have the potential to enhance nurses’ KAP.40 Engagement in PR training and relevant professional experience can enhance the knowledge and proficiency of healthcare personnel, thereby influencing the clinical advancement of PR.
The study has limitations: its cross-sectional design prevents establishing causality between knowledge, attitudes and practice, necessitating longitudinal studies or trials. Self-reported data may introduce social expectation bias, suggesting the need for observational measures in future research. Additionally, the sample, primarily nurses from Guizhou Province, may limit the findings’ generalisability to other regions or medical professionals. Future research should include a more diverse sample to enhance external validity and address potential confounding factors like experience, education and hospital class. While some factors were controlled in our analysis, unmeasured variables may influence outcomes. Collecting comprehensive data on these elements could clarify their impact on early PR-related knowledge, attitudes and practices in AECOPD.
Conclusions
This study examines the KAP of Chinese medical staff in Guizhou Province regarding early PR for AECOPD. While attitudes towards early PR are generally positive, there are gaps in knowledge and practical application. The study finds strong positive correlations between knowledge, attitudes and practices, indicating that better education and training could improve clinical outcomes. Medical staff with prior PR training and experience scored higher in knowledge and practice, highlighting the need for ongoing education and hands-on experience. However, the study’s focus on one region and a high number of nurses limits its generalisability. To enhance early PR for AECOPD, healthcare organisations should prioritise education, encourage positive attitudes and provide clinical exposure to improve patient care. Future research should involve more diverse samples and longitudinal studies to explore these relationships further.
Data availability statement
All data relevant to the study are included in thearticle or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants. The Medical Science Ethics Committee of the Affiliated Hospital of Guizhou Medical University approved this study (Ethics Approval No. 2023 Ethics Review No. 061-01). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We thank all the medical staff who participated in our study. We are grateful to the nursing departments and medical records departments of several hospitals in Guizhou for their support in data collection.
References
Footnotes
TW, ZW and LY contributed equally.
Contributors TrW, ZW and LY: supervision, project administration, methodology, formal analysis, data curation, resources, writing—original draft, writing—review and editing. FJ: investigation, validation, conceptualisation, formal analysis, data curation, writing—review and editing. YLi and PC: conceptualisation, methodology, investigation, writing—review and editing, resources. QL and YLiu: conceptualisation, methodology, investigation, writing—original draft, writing—review and editing, resources. TsW: methodology, investigation, data curation, conceptualisation, project administration, and editing. YC: formal analysis and review and editing. All authors read and approved the final manuscript. TrW is the guarantor responsible for the overall content.
Funding This research was supported by the Natural Science Foundation of Hunan Province in 2025 (No: 2025JJ80594), The Scientific Research Project of Hunan Nursing Association (No: HNKYP202413), Young Talent Project of Hunan Nursing Association (No: Q20241204020), The National Natural Science Foundation (NSFC) Regional Fund Cultivation Program project of Affiliated Hospital of Guizhou Medical University (No. Gyfynsfc[2023]-35), the 2023 research project of Chinese Nursing Association (No. ZHKYQ202316), The fourth batch of projects was approved by the Affiliated Hospital of Guizhou Medical University, Fudan University Evidence-Based Nursing Center (No. gyfyhlxz-2023-2) and Guiyang Science and Technology Plan Project (No. [2022]-4-2-2).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.