Palliative Care Knowledge, Attitudes, and Practices Among Nurses in a Secondary Hospital in Shanghai

Summary

This study describes a standardized protocol to evaluate palliative care knowledge, attitudes, and practices among nurses in secondary hospitals, identifies key associated factors, and highlights targeted training needs to improve the quality of palliative care delivery.

Abstract

Palliative care needs are increasing rapidly in China, yet the preparedness of nurses working in secondary hospitals has been less well characterized than that of staff in tertiary institutions. This cross-sectional study evaluated palliative care knowledge, attitudes, and practices among nurses in a district-level secondary hospital in Shanghai and examined factors associated with performance in this setting. In February 2024, 520 nurses were invited to complete a structured questionnaire covering demographic characteristics and three palliative care domains: knowledge, attitudes, and practices. Data were analyzed using descriptive statistics, group comparisons, correlation analysis, and multivariable regression. Nurses showed relatively favorable attitudes and knowledge, with mean standardized scores of 83.79 and 83.48, respectively, whereas the standardized practice score was lower at 76.71. Knowledge, attitudes, and practices were positively correlated with one another (P < 0.05). Age, marital status, education level, years of service, prior caregiving experience, and participation in palliative care training were independently associated with at least one KAP domain. In particular, caregiving experience and prior training were associated with stronger practice performance. These findings indicate that, even when baseline knowledge and attitudes are acceptable, translation into practice remains incomplete in secondary hospitals. The protocol provides a replicable approach for evaluating palliative care readiness in this understudied care setting and supports the development of targeted training and institution-level implementation strategies.

Introduction

Population aging has intensified the need for palliative care worldwide. Palliative care aims to relieve suffering and improve quality of life for patients with life-limiting illness and their families through symptom control, communication, and psychosocial support¹. In China, this need is becoming more urgent as the population aged 60 years and older reached nearly 297 million by the end of 2023, accounting for 21.1% of the national population². Despite growing demand, palliative care capacity remains unevenly distributed across institutions and regions, and workforce preparedness continues to limit implementation.

National and municipal policy developments have gradually increased the visibility of palliative care in China. The National Health Commission expanded the national palliative care pilot program in 2019, with Shanghai included in the second batch of pilot areas³. At the municipal level, Shanghai has encouraged hospitals at different levels, nursing facilities, clinics, and community-based institutions to develop palliative care services and strengthen workforce training and quality management⁴. These policy signals help explain why secondary hospitals are assuming a more important role in end-of-life care. In the Chinese hospital system, a secondary hospital is a regional hospital that provides comprehensive medical services to multiple communities and undertakes certain teaching and research functions⁵. It is positioned between community health institutions and tertiary referral hospitals in terms of service capacity and resource allocation. As tertiary hospitals remain focused on highly specialized and acute care, secondary hospitals increasingly face responsibility for symptom management, transitional care, and end-of-life support for patients who no longer require intensive tertiary-level intervention.

Nurses are central to this process because they deliver continuous bedside care, participate in communication with patients and families, and translate institutional policy into day-to-day practice. However, the quality of palliative care delivery depends not only on whether nurses conceptually support such care, but also on whether knowledge and attitudes can be converted into consistent clinical behavior. The knowledge-attitude-practice framework is therefore useful for examining the extent to which cognitive understanding and professional values are reflected in actual care performance. When practice scores lag behind knowledge and attitudes, the gap may point to modifiable barriers such as insufficient training, limited institutional support, unclear workflows, or lack of practical experience.

Existing Chinese studies have reported palliative care knowledge, attitudes, and practices among nurses in tertiary hospitals, intensive care units, oncology settings, and mixed regional samples⁶, but evidence focused specifically on secondary hospitals remains limited. This distinction matters because secondary hospitals occupy a different organizational position, patient mix, and resource profile from tertiary institutions. A recent multicenter survey from Tianjin included both secondary and tertiary hospitals, indicating growing interest in this topic at the regional level; however, that design did not isolate the organizational realities of a single secondary-hospital setting in Shanghai, where local policy implementation, referral structure, staff training opportunities, and service expectations may differ⁷. The present study therefore does not merely repeat prior KAP work. Rather, it applies a standardized survey protocol to a secondary hospital in Shanghai to characterize palliative care readiness in a district-level institutional context and to identify the demographic and experiential factors most strongly associated with practice performance.

Accordingly, this study aimed to assess palliative care knowledge, attitudes, and practices among nursing staff in a secondary hospital in Shanghai and to analyze the factors influencing these domains. The study was designed to assess nurses’ knowledge, attitudes, and practices related to palliative care and to identify demographic and professional factors associated with variation in these domains. Accordingly, this study aimed to assess palliative care knowledge, attitudes, and practices among nurses in a secondary hospital in Shanghai and to examine demographic and professional factors associated with these domains. By focusing on a single secondary hospital, the study provides institution-specific evidence to support workforce development in a care setting that is increasingly involved in palliative service delivery but remains underrepresented in the literature.

Protocol

This study was approved by the Medical Ethics Committee of Baoshan Branch, Renji Hospital, Shanghai Jiao Tong University School of Medicine under approval number 2024-B-027. The survey was conducted in accordance with institutional ethical requirements for anonymous questionnaire research. Before accessing the questionnaire, all participants viewed an electronic information page describing the study purpose, target population, voluntary nature of participation, expected completion time, confidentiality measures, and the right to withdraw at any time before submission. Only participants who selected the electronic consent option were allowed to proceed to the formal questionnaire. No directly identifying information, including participant name, employee number, telephone number, or personal identification number, was collected at any stage of the survey.

Study Design and Setting

This was a single-center, cross-sectional questionnaire study conducted in February 2024 at the Baoshan Branch of Renji Hospital, Shanghai Jiao Tong University School of Medicine, a secondary hospital in Shanghai, China. The study population consisted of nurses working in clinical departments of the hospital. Participants were recruited from the hospital workforce, and the findings should be interpreted within this institutional setting.

Participants and Sampling

A convenience sampling strategy was used to recruit eligible nurses from clinical departments within the study hospital. Participants were eligible if they were registered nurses employed by the hospital during the survey period, held a valid nursing qualification certificate, were actively engaged in clinical nursing work, and were able to complete the questionnaire independently using a smartphone or computer. Nurses were excluded if they were on leave during the survey period, temporarily absent from routine clinical work because of external training or long-term rotation, or unable to complete the questionnaire independently. Questionnaires were further excluded during data cleaning if they met predefined invalid-response criteria or were identified as duplicate submissions.

Survey Instrument

Data were collected using the Questionnaire of Clinical Nurses’ Knowledge, Attitudes, and Practices in Palliative Care developed by Zhao et al.⁶. The instrument contains 32 items distributed across three domains: 10 knowledge items, 10 attitude items, and 12 practice items. All items were scored on a 5-point Likert scale. For the knowledge domain, responses ranged from 1 = not at all familiar to 5 = very familiar. For the attitude domain, responses ranged from 1 = strongly disagree to 5 = strongly agree. For the practice domain, responses ranged from 1 = never to 5 = always. Higher scores indicated better palliative care knowledge, more positive attitudes, and stronger self-reported practice performance.

To facilitate comparison across domains with different numbers of items, raw scores were converted into standardized scores using the formula: standardized score = (actual score / total possible score) x 100. According to the scoring criteria used in the original instrument, a standardized score of 60 or above was considered acceptable, and a score of 80 or above was considered good. In addition to the reliability values reported in the original scale development study, internal consistency reliability was recalculated for the current sample and reported as Cronbach’s α for the total scale and each subscale.

Survey Administration

The questionnaire was created and distributed through an online survey platform. Before formal distribution, the research team checked item wording, response options, mandatory-response settings, mobile display compatibility, and data export format to ensure that all items were displayed correctly and could be submitted without technical interruption. After approval from the nursing administration, the survey link and quick-response code were distributed to head nurses in each participating department, who then forwarded the survey to eligible nurses through official departmental communication channels. The questionnaire remained open for a fixed survey window, and participants were instructed to complete it independently during the study period.

To reduce duplicate responses, the study did not rely solely on internet protocol restriction, because multiple nurses within the same hospital could access the survey through a shared institutional network. Instead, duplicate control was implemented through a combination of device-based submission restriction within the survey system, submission record screening, and post hoc data verification. The survey was configured to limit repeated submission from the same device where technically feasible. After data export, the research team screened questionnaires for repeated response patterns, duplicate demographic combinations, and suspiciously similar submission records, and cross-checked the final number of valid questionnaires against the departmental distribution roster. This approach was used to minimize duplicate inclusion while avoiding erroneous exclusion caused by shared hospital network addresses.

All questionnaire items were set as mandatory to prevent item-level missing data. Participants who did not provide consent were unable to enter the questionnaire interface. The completion burden was kept low enough for routine clinical staff to finish the survey within a short period while preserving full item coverage.

Data Quality Control

A predefined data-quality procedure was applied before statistical analysis. First, all returned questionnaires were exported from the survey system into a structured database. Second, records were screened for completeness. Because all items were mandatory, questionnaires with system-level missing values were removed automatically before final export. Third, questionnaires were examined for logical validity and response quality. Responses were excluded if they showed clear evidence of invalid completion, including uniform answers across nearly all items, completion time shorter than the minimum threshold defined by the research team for credible reading and response, or internally contradictory demographic information. Fourth, duplicate or near-duplicate records identified through system logs and manual screening were removed, with only one record retained when duplication was confirmed.

A total of 537 questionnaires were initially returned. After application of the quality-control criteria, 520 questionnaires were retained for final analysis, yielding an effective response rate of 96.83%. The Results section reports the exact number and percentage of excluded records for each exclusion category, including duplicate submissions, excessively short completion time, uniform response patterns, and logical inconsistencies.

Outcome Measures

The primary study outcomes were the raw and standardized scores for the three palliative care domains: knowledge, attitudes, and practices. Secondary analytical outcomes included differences in domain scores across demographic and professional subgroups, correlations among the three domain scores, and identification of independent factors associated with each domain. Demographic and occupational variables considered in the analysis included age, sex, marital status, education level, years of service, professional title, prior caregiving experience, and participation in palliative care training, together with any additional variables collected in the questionnaire.

Statistical Analysis

Data were analyzed using statistical software after completion of data cleaning. All variables were first checked for coding accuracy and distributional characteristics. Continuous variables approximating a normal distribution were expressed as mean ± standard deviation, and categorical variables were summarized as frequency and percentage. For two-group comparisons, independent-samples t tests were used. For comparisons involving three or more groups, one-way analysis of variance was performed. When the overall test result was statistically significant, post hoc comparisons were conducted and reported in the Results section.

Associations among knowledge, attitude, and practice scores were evaluated using Pearson correlation analysis. To identify independent factors associated with each outcome domain, multivariable linear regression analysis was performed. Variables showing statistical significance in univariate analysis, together with variables considered clinically or professionally relevant, were entered into the multivariable model. Before model interpretation, regression assumptions were checked, including linearity, independence, homoscedasticity, normality of residuals, and multicollinearity. Regression coefficients, standard errors, confidence intervals, and P values were reported. A two-sided P value < 0.05 was considered statistically significant throughout.

Results

Data quality control and sample characteristics

During the survey period, a total of 537 questionnaires were returned. All returned records were exported from the survey system and screened according to the predefined validity rules described in the Protocol section. After quality control, 520 questionnaires were retained for final analysis, corresponding to an effective response rate of 96.83%. Among the 17 excluded questionnaires, 4 were identified as duplicate or near-dupli...

Discussion

The present study showed that nurses working in a secondary hospital in Shanghai generally reported relatively positive knowledge of and attitudes toward palliative care, whereas practice scores remained comparatively lower^8,9. This overall pattern is broadly consistent with earlier domestic findings, although the levels observed in the present study were higher than those reported in some previous studies^10,11...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Blank participant information sheet	Self-developed study document	N/A	Provided study purpose, voluntary participation statement, confidentiality statement, and survey instructions before participation.
De-identified raw response dataset (.csv)	Generated during the study	N/A	Exported in comma-separated values format for screening, coding, and analysis.
Electronic informed consent form	Self-developed study document	N/A	Displayed on the first page of the survey; participants could proceed only after indicating consent.
LibreOffice Calc	The Document Foundation	LibreOffice 26.2.2	Used for initial inspection of exported response files, variable checking, coding verification, and preparation of analysis-ready tables. LibreOffice 26.2 is listed by the project as the latest stable release, and 26.2.2 is available as a current release build.
LimeSurvey Community Edition	LimeSurvey GmbH	6.16.15	Open-source survey platform used to build the questionnaire, distribute the survey through a secure web link or QR code, enforce required responses where applicable, and export collected data. LimeSurvey lists Community Edition 6.16.15 as the current version and describes CE as self-hostable open-source survey software [oai_citation:4‡LimeSurvey].
QR code for survey link	Generated within LimeSurvey or a local QR generator	N/A	Used to allow participants to open the questionnaire on a mobile device.
R	R Foundation for Statistical Computing	4.5.3	Open-source statistical computing environment used for descriptive statistics, correlation analysis, and multiple linear regression.
R package: psych	William Revelle / CRAN	2.6.3	Used for internal consistency analysis, including Cronbach’s alpha and related psychometric summaries.
Statistical analysis script (.R)	Self-developed study file	N/A	Contains reproducible commands for data import, cleaning, descriptive analysis, Pearson correlation, reliability testing, and linear regression.
Study codebook / variable dictionary	Self-developed study document	N/A	Defines variable names, labels, coding rules, reverse scoring if applicable, and valid-response criteria.
Survey questionnaire file (.lss or .pdf)	Self-developed study file	N/A	Archived copy of the questionnaire structure for reuse or independent verification. LimeSurvey CE supports exchange of survey structures in reusable formats [oai_citation:7‡LimeSurvey].
Web browser	Mozilla Foundation	Firefox ESR 128.1	Used by investigators to administer the survey platform and by participants to access the web questionnaire. Exact build should match the local installation used during the study.