| BackgroundHospice care is an urgent need for China’s aging population and the increasing burden of cancer.In recent years,China has enacted a number of policies to promote the development of hospice care.At present,the quality of hospice care for patients at the end-of-life in China is not high.The Department of oncology is an important department to carry out hospice care,and the nurses in the department of oncology are the main force to provide hospice care.However,there is a shortage of studies on the situation,influencing factors and mechanisms of the hospice care behavior of oncology nurses in China,and it is urgent to conduct relevant research.Objectives1.To translate and revise the scale used to evaluate the self-efficacy of hospice care.2.To develop the Hospice Care Outcome Expectancy Scale and the Hospice Care Environment Scale based on social cognitive theory.3.To understand the current status and influencing factors of hospice care behaviors of oncology nurses and explore its influencing mechanism.4.In-depth interviews on oncology nurses’ perceptions,experiences and the influencing factors of hospice care behaviors.Methods1.Translation and revision the scale to evaluate the self-efficacy of hospice careFollowing the principles and methods of scale translation and revision,the selected English scale End-of-Life Professional Caregiver Survey(EPCS)for assessing hospice care self-efficacy was translated,pre-experimented,and formally data collected,and the scale was evaluated for reliability and validity by adopting exploratory factor analysis,validation factor analysis,and internal consistency tests.2.Development of Hospice Care Outcome Expectancy Scale and Hospice Care Environment ScaleBased on social cognitive theory and literature review,12 oncology nurses were selected by purposive sampling method to conduct semi-structured interviews to form the initial item pool.Then combined with the group discussion,the final item pool was formed.Through two rounds of Delphi expert consultation involving 16 experts,the dimensions and items of the scale were revised to form the initial scale.A preliminary survey was conducted on 25 oncology nurses to optimize the language of the items.At last,a cross-sectional survey was conducted among 530 oncology nurses in a large tertiary oncology hospital in Hubei province.A total of 500 valid questionnaires were randomly divided into two groups in the ratio of 1:1.Sample 1(n1=250)was used for item screening and sample 2(n2=250)was used for quality evaluation.Item analysis,reliability analysis,validity analysis,and acceptability analysis of the formed scale are used.3.Study on current situation,influencing factors and influencing mechanism of hospice care behavior of nurses in oncology departmentUsing convenience sampling method,a total of 933 oncology nurses who met the inclusion and exclusion criteria were selected as the study population in six tertiarylevel grade A hospitals in Hubei province.Data were collected using the web-based questionnaire platform Questionnaire Star including the above-mentioned translated and developed scales and other scales.Descriptive analysis,univariate analysis,multiple linear regression analysis,random forest regression analysis,back-porpagation neural network model and mediation analysis were applied to analyze the collected data.4.Qualitative research on hospice care behavior experience and influencing factors of nurses in oncology departmentBy using the descriptive qualitative research method,oncology nurses were purposive sampled for semi-structured interview.Interviews were stopped when data saturation was achieved.Finally,18 oncology nurses were included,and transcribed interview data were analyzed using the Colaizzi’s seven-step analysis.Results1.Translation and revision the scale to evaluate the self-efficacy of hospice careThe Chinese version of the EPCS scale contains 21 items,and five experts agreed that the Chinese version of the EPCS scale is suitable for use in China because it conforms to the cultural background and linguistic customs of China.The exploratory factor analysis produced three factors,which could solve 70.60% of the total variance,and each item has a high factor loading(>0.4)in the corresponding dimension.Confirmatory factor analysis showed that the factor loadings values ranged from 0.60 to 0.89,the model fit indexes met the requirements,and the Chinese version of the EPCS scale had good structural validity.The Cronbach’s a coefficients of the total scale and the three dimensions were 0.964,0.956,0.887 and 0.864,respectively.2.Development of Hospice Care Outcome Expectancy Scale and Hospice Care Environment Scale(1)Construction of the initial version of the two scales: The item pool of Hospice Care Outcome Expectancy Scale with 8 items in 3 dimensions and the item pool of Hospice Care Environment Scale entries with 10 items in 2 dimensions were first constructed.After two rounds of Delphi expert consultation,the initial scales with 3dimensions and 9 items,as well as 2 dimensions and 13 items were formed respectively.The expert authority coefficients in the two rounds of expert consultation were 0.853 and 0.869,respectively.In the first round of expert consultation,the coefficient of variation of the two scale items ranged from 0.063 to 0.198 and 0.000 to 0.119,respectively,and the full score ratio ranged from 75.0% to 93.8% and 75.0% to 100.0%,respectively.In the second round of expert consultation,the coefficients of variation of the two scale items ranged from 0.000 to 0.198 and 0.000 to 0.088,respectively,and the full score ratios ranged from 75.0% to 100.0% and 87.5% to 100.0%,respectively.(2)Construction of the formal version of the two scales: Through item analysis,2items were deleted from the Hospice Care Outcome Expectancy Scale and 0 items were deleted from the Hospice Care Environment Scale,and the formal scale was formed by exploratory factors.The formal version of the two scales were formed by exploratory factor scores,the Hospice Care Outcome Expectancy Scale consisted of 1 dimension and 7 items,while the Hospice Care Environment Scale included two dimensions:social environment(4 items)and organizational environment(9 items).(3)Evaluation of the two scales: The Cronbach’s alpha coefficients for the total scale of the Hospice Care Outcome Expectancy Scale and the Hospice Care Environment Scale were 0.939 and 0.970,respectively,and the Cronbach’s alpha for the 2 dimensions of the Hospice Care Environment Scale were 0.952 and 0.969,respectively.The item-level content validity index of the two scales ranged from 0.875 to 1.000 and 1.000,respectively.The scale-level content validity index of the two scales were 0.982 and 1.000,respectively.Confirmatory factor analysis showed that the factor models of the two scales had good fit,the standardized path coefficients of the entries were basically above 0.5,and the factor structure models were stable and appropriate.The average completion time of the two scales was about 3 minutes,so it had good feasibility.3.Study on current situation,influencing factors and influencing mechanism of hospice care behavior of nurses in oncology departmentA total of 852 valid questionnaires were collected in this study,with effective return rate of 91.3%.The specific results are as follows.(1)The hospice care behavior score of oncology nurses was 50.47±10.56 with a mean item score of 3.61±0.75,which is in the middle to upper level.The top three items were item 5 "Assessing patients for pain",item 7 "Meeting the physical and psychological needs of end-of-life patients" and item 11 "Establishing good relationships between medical staff and family members",with frequency between "often" and "always".Item 2 "Proactively recommend medical institutions for end-oflife care to end-of-life patients and their families" and item 1 "Proactively talk to patients and families about death-related topics for patients who are critically ill and cannot be reversed" scored the lowest,with a frequency between "hardly ever" and "occasionally".(2)The results of univariate analysis showed that 1)Socio-demographic and jobrelated information: there were statistically significant differences in hospice care behavior among different titles,different positions,different working years,satisfaction with work intensity,the number of end-stage patients cared for in the past year,the hospice care education received as a student,the number of hospice care training received,whether hospice care wards were set up in the work unit,whether they were willing to engage in hospice care,the frequency of sharing hospice care experience with colleagues,and whether to obtain the hospice care specialist nurse certificate issued by the Chinese Nursing Association(P<0.05);2)cognitive factors: hospice care knowledge,hospice care attitude,hospice care self-efficacy,hospice care outcome expectation were significantly and positively correlated with hospice care behaviors(r= 0.196-0.508);3)environmental factors: hospice care environment was significantly and positively correlated with hospice care behavior(r=0.456).(3)The results of the multivariate analysis showed that in the multiple linear regression analysis,the predictors of nurses’ hospice care behavior were hospice care self-efficacy,frequency of sharing hospice care experience with colleagues,hospice care environment,hospice care attitude,and position in descending order of contribution,with the above variables explaining a total of 41.3% of the variance in hospice care behavior.In the random forest regression analysis,hospice care selfefficacy,frequency of sharing hospice care experience with colleagues,hospice care environment,hospice care attitude,willingness to engage in hospice care services,and the number of hospice care training received were ranked in descending order of the influence.In the back-porpagation neural network model analysis,hospice care attitude,hospice care self-efficacy,hospice care environment,willingness to engage in hospice care and the number of hospice care training received were ranked in descending order of the influence.Multiple linear regression,random forest regression,and backporpagation neural network models had similar fit results,and all three models were applicable to the analysis of factors influencing hospice care behavior.(4)The results of the parallel mediation analysis showed that hospice care selfefficacy,hospice care attitude and hospice care environment were the direct factors affecting the hospice care behavior of oncology nurses.Hospice care self-efficacy and hospice care attitude played a parallel mediation role between hospice care environment and hospice care behavior,with a mediation effect value of 0.197,accounting for 53.97%of the total effect.4.Qualitative research on hospice care behavior experience and influencing factors of nurses in oncology departmentFive themes were extracted from the study: patients’ end-of-life care,family members’ support and care,self-limitations and psychological distress,cultural and moral factors and external environmental constraints,and self-coping and gain.The patient’s end-of-life care included four sub-themes: physical care,psychological care,social support,and spiritual care;the family member’s support and care included two sub-themes: promoting caregiver role function,and psychological support for family members;the self-limitations and psychological distress included three sub-themes:lack of knowledge and competence,attitude toward hospice care,and psychological distress;the cultural and ethical factors and constraints of the external environment constraints include 4 sub-themes: cultural and moral factors,public awareness,lack of policy guarantee and financial support,hospital and departmental philosophy and objective conditions;and the self-coping and gains included 2 sub-themes: dealing with negative emotions,and personal growth and gains.Conclusions and Suggestions1.The translated and revised Chinese version of EPCS scale has good validity and reliability,which provides an effective assessment tool for evaluating the self-efficacy of hospice care of Chinese nurses.2.The Hospice Care Outcome Expectancy Scale and the Hospice Care Environment Scale have good reliability,validity and acceptability,can be used to evaluate nurses’ hospice care outcome expectancy and hospice care environment,and can provide scientific and reliable assessment tools for future studies on hospice care.3.The hospice care behavior frequency of oncology nurses was generally moderate to high.The frequency of performing these behaviors is very low: proactively recommending referral agencies to terminally ill patients and proactively talking about the topic of death.It is necessary to strengthen the construction of tiered hospice care,strengthen the death education of the whole people and the communication training of nursing staff,so as to promote the provision of various services in hospice care.4.The higher the frequency of sharing hospice care experiences with colleagues the more frequent the hospice care behaviors of oncology nurses,suggesting that we should take measures to promote more sharing of hospice care experiences among nurses to facilitate the implementation of hospice care.Although position appeared only in multiple linear regressions and had the lowest effect on hospice care behavior,it also provided scientific guidance for the direction of intervention.The two factors that were not significant in the multiple linear regression,willingness to engage in hospice care services and the number of hospice care training received,both appeared in the random forest regression model and the back-porpagation neural network model,which are not as significant but provide a direction for future research to consider.5.The predictive power of cognitive and environmental factors on hospice care behavior significantly exceeded that of demographic factors,suggesting that we should focus on these influences that can be improved through interventions to promote hospice care services for nurses.Hospice care self-efficacy,hospice care attitudes,and hospice care environment showed strong predictive power for hospice care behavior in all three models,suggesting that we should focus on these factors and take measures to improve nurses’ self-efficacy and attitudes for hospice care and the environment for hospice care.6.The relationship between hospice care environment and hospice care behavior was influenced by the parallel mediation of hospice care self-efficacy and hospice care attitude,which verified the applicability and validity of social cognitive theory to the hospice care behavior of Chinese oncology nurses and reinforced the key role of cognitive factors in the mechanism of hospice care behavior.This suggests that we can improve the hospice care service environment to improve nurses’ attitude and selfefficacy,so as to promote nurses to carry out hospice care.7.Oncology nurses had a good awareness and understanding of hospice care,have positive and negative feelings,and are basically able to cope with themselves.Factors affecting hospice care behavior include lack of knowledge and competence,psychological distress,cultural and ethical factors,public awareness,lack of policy guarantee and financial support,and hospital and departmental philosophy and objective conditions,etc.The results suggest that measures to strengthen nurses’ positive feelings,enhance nurses’ ability to carry out hospice care services through training,assist nurses to better cope with various problems,increase public awareness of hospice care,increase funding for hospice care,and support hospice care by hospital and departmental medical staff and provide good objective conditions will help nurses to carry out hospice care. |
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