Support Care Cancer DOI 10.1007/s00520-014-2172-9
ORIGINAL ARTICLE
Knowledge, attitudes, and practice behaviors (KAPb) of nurses and the effectiveness of a training program in psychosocial cancer care Rathi Mahendran & Joanne Chua & Chao Xu Peh & Haikel A. Lim & Emily N. K. Ang & Siew Eng Lim & Ee Heok Kua
Received: 28 October 2013 / Accepted: 17 February 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Psychosocial distress in oncology patients may significantly interfere with their health outcomes and quality of life. Nurses work closely with their patients and are in the best position to screen for distress and provide timely intervention. It is thus important for nurses working in oncology settings to be equipped and prepared to address distressing psychosocial issues. The present study aims to investigate the impact of a training program in psychosocial care on nurses’ knowledge, attitudes, and clinical practice behaviors. Methods A total of 180 nurses working in medical oncology and radiation oncology departments at the National University Cancer Institute Singapore underwent a training program in psychosocial care as part of their continuing nursing education curriculum. One hundred fifty four of these nurses completed a self-designed questionnaire on nurses’ knowledge, attitudes, R. Mahendran (*) : J. Chua : E. H. Kua Department of Psychological Medicine, National University Hospital, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, Singapore 119228 e-mail: [email protected] R. Mahendran : C. X. Peh : H. A. Lim : E. H. Kua Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, Singapore 119228 E. N. K. Ang : S. E. Lim National University Cancer Institute, Singapore, National University Health System, NUHS Tower Block, Level 7, 1E Kent Ridge Road, Singapore, Singapore 119228 E. N. K. Ang Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, MD11, Level 2, 10 Medical Drive, Singapore, Singapore 117597
and practice behaviors (KAPb) at all four time points: baseline, post-training, and at 6 and 12 weeks post-training, respectively. Results The self-designed KAPb questionnaire proved adequate for this study. Positive gains on applied knowledge and practice behaviors were sustained over a 12-week period. There were no changes in theoretical knowledge. A decreasing trend in attitudes was noted, although this was specific to the participants’ attitudes toward the importance of emotional concerns as compared to physical concerns in cancer treatment. Enrolled nurses seemed to have higher starting levels of theoretical knowledge than their registered counterparts were. There were no other differences on demographic variables in relation to the efficacy of the training program. Conclusions The training program was successful in improving the applied knowledge and practice behaviors of nurses in providing psychosocial care for cancer patients. However, further refinement to the program, with particular attention to nurses’ existing training and years of clinical nursing experience, would enhance staff empowerment and care improvement. Keywords Oncology nursing . Psychosocial care . Training program . Asia
Introduction Psychosocial support for cancer patients is recognized as a crucial aspect integral to quality cancer care [1, 2]; patients’ psychosocial health needs must be identified and care plans appropriately developed, yet psychosocial support and care is firstly often delayed, or not offered, for various reasons. Psychological issues are sometimes undetected or dismissed as normal reactions to the serious illness [3]. Secondly,
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misdiagnoses sometimes arise because of the presence of delirium or poorly controlled pain and emotional distress [4, 5]. A third issue is the diagnostic complexity that occurs when many of the psychological symptoms, such as fatigue, loss of energy and appetite, and interrupted sleep in major depressive disorders, for example, overlap with those of the medical condition [6]. Nurses in oncology settings have greater opportunities for patient interactions as they are often the first to meet patients, orientate them to the clinic setting, and undertake various screenings. Their knowledge of, and ability to, recognize and identify presenting symptoms becomes an important step in the delivery of timely and holistic care. Equally important are nurses’ attitudes towards psychological issues of their patients and their skill sets in providing basic emotional support. However, in Singapore, nurses are often not empowered or formally trained in managing the emotional distress of their patients. While it may be similar elsewhere, Singapore’s context of having non-specialist nurses caring for oncology patients results in a heterogeneous cohort striated by both seniority and experience. Further, nurses in Singapore did not previously routinely screen oncology patients for distress and psychological issues until a recent Healthcare Quality Improvement and Innovation (HQI2F) Project was started in 2012, making screening an integral part of cancer care [7]. As it was important to have staff trained to recognize and identify distress and other psychiatric conditions, a training program was planned and developed in consultation with nursing leadership prior to the introduction of screening patients for distress. This study, thus, sought to investigate the effectiveness of a training program in improving nurses’ knowledge, attitudes, and practice behaviors towards psychosocial care in cancer patients. Training programs for nurses in psychosocial care Despite the importance placed on cancer patients’ psychosocial health, a review of the extant literature did not surface contemporaneous training programs specific to the psychosocial care of cancer patients that were designed for nurses. This, however, may not be due to a lack of training programs: it is more likely that such programs are integrated into formal general and specialty training in educational institutions as well as professional continuing education courses instead of initially being conceptualized as research per se. Regardless, the closest to the proposed training program are two studies conducted and reviewed as detailed in the following discussion. The first is a three-day mental health training program in the UK that sought to improve nurses’ confidence in dealing with mental health calls, knowledge of mental health issues, and attitudes to mental health [8]. The training course was centered on improving skill sets, for example, in patient-
centered interviewing, risk assessment, and problem formulation. Nurses who underwent the training reported significantly increased confidence in dealing with mental health calls and felt more positive towards their role in treating depressed patients. The training, however, did not examine the actual practice behaviors that those nurses engaged in as part of their routine care; in addition, the study also reported no significant impact on improving nurses’ knowledge about mental health. The other study, done in Sweden, examined the effects of a 12-h nurse training course in improving six oncology nurses’ confidence, knowledge, and skill sets in assessing psychosocial problems in cancer patients [9]. Despite the limitations of a very small sample, the authors found that participants reported that the training course not only improved their knowledge and skills regarding the assessment and management of distress but also improved their confidence in handling such psychosocial issues. A recently published review of training programs targeted at nurses found that the more effective programs were those of longer duration, incorporating didactic components of theoretical knowledge and practical application as well as facilitator feedback in small group format [10]. The present training program This two-hour standardized training program was aimed at (a) reviewing and enhancing existing psychosocial care skills that nurses had already gained as part of their nursing training, (b) enabling nurses to recognize distress and psychological disorders frequently associated with cancer, and (c) empowering them to provide support for patients and refer them for further assessment and treatment as needed. Given the heterogeneous sample of nurses working in oncology settings at NCIS, this program was targeted at the general nurses with the intent to subsequently develop more training programs. Components of this exploratory training were drawn from various sources such as the basic training curriculum in psychosocial oncology developed by the International PsychoOncology Society [11] and the general model of psychosocial interventions in cancer survivorship [12]. The training consisted of two segments: 1. A didactic session, which provided information on screening tools such as the distress thermometer [13], symptoms of distress, anxiety, and depression, and clinical scenarios of patient presentations. Nurses were also taught relaxation techniques such as progressive muscle relaxation [14, 15], and controlled breathing [16, 17]. This was done in groups of approximately 20 to 25 nurses. 2. Smaller groups of between six and ten nurses who were provided clinical scenarios for experiential learning through role playing. These groups were facilitated by
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psychiatrists and psychologists. Training sessions were standardized with prepared material and delivered by the same team of psychologists and psychiatrists. In this study, we hypothesized that (a) the training program would improve and sustain oncology nurses’ knowledge, attitudes, and practice behaviors and (b) individual differences (e.g., specialty training) would be predictive of any changes in knowledge, attitudes, and practice behavior.
Methods Participants All nurses working in medical and radiation oncology inpatient and ambulatory settings at the National University Cancer Institute, Singapore (NCIS), were provided this training as part of their continuing nursing education program and were invited to participate in this study. All 180 nurses (97 % female; 41 % ethnically Chinese) who underwent training volunteered to participate in this study. Registered nurses accounted for three quarters of the participants (76 %), 86 % of whom were staff or charge nurses, 13 % were head nurses, and one was an advance practice nurse. The remaining 24 % were enrolled nurses (or assistant nurses and senior assistant nurses in Singapore). Slightly more than half (54 %) were general medical nurses with no specialty training; of the remaining oncology nurses, 53 % had worked in oncology for less than 4 years. Most participants worked in inpatient settings (65 %), and nearly all were from medical oncology as there were only four nurses in the radiation oncology department, three of whom participated in the study. Table 1 displays the demographic information of this population. Instrument and procedures A review of the literature revealed no suitable instruments to investigate the efficacy of the program on the three measures: knowledge (K), attitudes (A), and practice behaviors (Pb). Thus, a self-report questionnaire specific to the needs of the study, the Knowledge, Attitudes, and Practice Behaviors Scale (KAPb), was developed for the purposes of this study to assess nurses’ knowledge of and attitudes towards cancer patients’ emotional and psychosocial issues and what skills they had in addressing their patients’ psychosocial needs. The KAPb was developed using the Delphi method [18], in which experts in the field (authors RM, JC, SEL, and EHK) together with nursing experts (including author ENKA) conceptualized the initial pool of 23 items based on aspects of the three measures (K, A, Pb) they deemed essential in the psychosocial care of cancer patients. These items were then refined by 20 nurses in two focus groups; the final KAPb version
Table 1 Demographic characteristics of participants Variable
n (%)
Male Ethnicity Chinese Malay Indian Othersa Nursing experience AN Senior AN/PAN SN Senior SN NM/NC Senior NM/NC APN Registered nursesb Years in oncology 0–4.99 years
4 (2)
5–9.99 years ≥ 10 years Previous specialty training in oncology Working in outpatient clinics Present oncology nursing division Medical oncology Radiation oncology
74 (41) 41 (23) 19 (11) 46 (25) 32 (18) 12 (7) 59 (33) 58 (32) 14 (8) 4 (2) 1 (1) 136 (76) 96 (53) 48 (26) 36 (20) 82 (46) 63 (35) 177 (98) 3 (2)
AN assistant nurse, PAN principal AN, SN staff nurse, NM nurse manager, NC nurse clinician, APN advanced practice nurse a
This category consisted of foreign-trained nurses from the Philippines, China, India, Malaysia, and Vietnam
b Registered nurses are considered those who are SN and above; enrolled nurses are AN/senior AN/PAN
administered to participants in the present study consisted of 23 items on a five-point Likert-type scale that determined nurses’ responses from “1” (strongly disagree) to “5” (strongly agree). Demographic information was also collected. Participants were asked to complete the KAPb at four time points relative to the standardized training previously described: T1 (4 weeks pre-training), T2 (immediately posttraining), T3 (6 weeks post-training), and T4 (12 weeks posttraining). Of the 180 participants that completed the measures at T1, 154 nurses completed the questionnaire at all time points (14 % attrition); these were used for the subsequent analyses. There were no differences in T1 KAPb scores between nurses who completed and did not complete all four measures. Ethics The study had ethics approval from the National University of Singapore’s Institutional Review Board. All participants
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provided informed consent prior to their inclusion in the present study, and responses on the questionnaire were anonymized to promote accurate self-reporting. Data analyses Statistical analyses were computed using IBM SPSS 20.0 (Chicago, IL, USA). Statistical significance was fixed at .05 unless otherwise stated, and all data were assumed normal. Separate one-way repeated-measures analyses of variance (ANOVAs; with Greenhouse–Geisser corrections where necessary) were conducted to compare changes in knowledge, attitudes, and practice behaviors from T1 to T4. Post-hoc Bonferroni corrections were also used to adjust for multiple comparisons. Mixed-model ANOVAs were conducted to ascertain the effects of demographic variables on KAPb, and differences were investigated via independent-samples t-tests.
Results Preliminary analyses An exploratory factor analysis was conducted on the data with 180 nurses using principal axis factoring with Promax rotation and a factor loading criteria of at least .35 without crossloadings. Analyses revealed a shorter version of the KAPb with 15 items and four domains, namely, “Theoretical Knowledge” (four items, α=.61), “Applied Knowledge” (four items, α=.79), “Attitudes” (three items, α=.58), and “Practice Behavior” (four items, α=.82). This 15-item version and the four aforementioned composite domain scores were used for subsequent analyses. Because the Theoretical Knowledge and Attitudes domains had somewhat low internal consistencies, further analyses were required to investigate changes between items. Table 2 details the descriptive statistics of the subscale domains and relevant individual items of the KAPb across the four time points. Figure 1 details the mean domain scores per item to facilitate comparison between KAPb subscales. Efficacy of training program Theoretical Knowledge There were no significant changes in participants’ Theoretical Knowledge domain or items across all time points (p>.05). This suggested that the training course did not significantly improve nurses’ theoretical knowledge; scores on the KAPb for theoretical knowledge remained high (mean scores across time points ranged 16.3–16.7 of a possible 20). Applied Knowledge There was, however, a significant improvement in participants’ applied knowledge pre- and posttraining (F[2.64, 404.28]=106.67, Mse=4.81, p
ORIGINAL ARTICLE
Knowledge, attitudes, and practice behaviors (KAPb) of nurses and the effectiveness of a training program in psychosocial cancer care Rathi Mahendran & Joanne Chua & Chao Xu Peh & Haikel A. Lim & Emily N. K. Ang & Siew Eng Lim & Ee Heok Kua
Received: 28 October 2013 / Accepted: 17 February 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Psychosocial distress in oncology patients may significantly interfere with their health outcomes and quality of life. Nurses work closely with their patients and are in the best position to screen for distress and provide timely intervention. It is thus important for nurses working in oncology settings to be equipped and prepared to address distressing psychosocial issues. The present study aims to investigate the impact of a training program in psychosocial care on nurses’ knowledge, attitudes, and clinical practice behaviors. Methods A total of 180 nurses working in medical oncology and radiation oncology departments at the National University Cancer Institute Singapore underwent a training program in psychosocial care as part of their continuing nursing education curriculum. One hundred fifty four of these nurses completed a self-designed questionnaire on nurses’ knowledge, attitudes, R. Mahendran (*) : J. Chua : E. H. Kua Department of Psychological Medicine, National University Hospital, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, Singapore 119228 e-mail: [email protected] R. Mahendran : C. X. Peh : H. A. Lim : E. H. Kua Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, Singapore 119228 E. N. K. Ang : S. E. Lim National University Cancer Institute, Singapore, National University Health System, NUHS Tower Block, Level 7, 1E Kent Ridge Road, Singapore, Singapore 119228 E. N. K. Ang Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, MD11, Level 2, 10 Medical Drive, Singapore, Singapore 117597
and practice behaviors (KAPb) at all four time points: baseline, post-training, and at 6 and 12 weeks post-training, respectively. Results The self-designed KAPb questionnaire proved adequate for this study. Positive gains on applied knowledge and practice behaviors were sustained over a 12-week period. There were no changes in theoretical knowledge. A decreasing trend in attitudes was noted, although this was specific to the participants’ attitudes toward the importance of emotional concerns as compared to physical concerns in cancer treatment. Enrolled nurses seemed to have higher starting levels of theoretical knowledge than their registered counterparts were. There were no other differences on demographic variables in relation to the efficacy of the training program. Conclusions The training program was successful in improving the applied knowledge and practice behaviors of nurses in providing psychosocial care for cancer patients. However, further refinement to the program, with particular attention to nurses’ existing training and years of clinical nursing experience, would enhance staff empowerment and care improvement. Keywords Oncology nursing . Psychosocial care . Training program . Asia
Introduction Psychosocial support for cancer patients is recognized as a crucial aspect integral to quality cancer care [1, 2]; patients’ psychosocial health needs must be identified and care plans appropriately developed, yet psychosocial support and care is firstly often delayed, or not offered, for various reasons. Psychological issues are sometimes undetected or dismissed as normal reactions to the serious illness [3]. Secondly,
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misdiagnoses sometimes arise because of the presence of delirium or poorly controlled pain and emotional distress [4, 5]. A third issue is the diagnostic complexity that occurs when many of the psychological symptoms, such as fatigue, loss of energy and appetite, and interrupted sleep in major depressive disorders, for example, overlap with those of the medical condition [6]. Nurses in oncology settings have greater opportunities for patient interactions as they are often the first to meet patients, orientate them to the clinic setting, and undertake various screenings. Their knowledge of, and ability to, recognize and identify presenting symptoms becomes an important step in the delivery of timely and holistic care. Equally important are nurses’ attitudes towards psychological issues of their patients and their skill sets in providing basic emotional support. However, in Singapore, nurses are often not empowered or formally trained in managing the emotional distress of their patients. While it may be similar elsewhere, Singapore’s context of having non-specialist nurses caring for oncology patients results in a heterogeneous cohort striated by both seniority and experience. Further, nurses in Singapore did not previously routinely screen oncology patients for distress and psychological issues until a recent Healthcare Quality Improvement and Innovation (HQI2F) Project was started in 2012, making screening an integral part of cancer care [7]. As it was important to have staff trained to recognize and identify distress and other psychiatric conditions, a training program was planned and developed in consultation with nursing leadership prior to the introduction of screening patients for distress. This study, thus, sought to investigate the effectiveness of a training program in improving nurses’ knowledge, attitudes, and practice behaviors towards psychosocial care in cancer patients. Training programs for nurses in psychosocial care Despite the importance placed on cancer patients’ psychosocial health, a review of the extant literature did not surface contemporaneous training programs specific to the psychosocial care of cancer patients that were designed for nurses. This, however, may not be due to a lack of training programs: it is more likely that such programs are integrated into formal general and specialty training in educational institutions as well as professional continuing education courses instead of initially being conceptualized as research per se. Regardless, the closest to the proposed training program are two studies conducted and reviewed as detailed in the following discussion. The first is a three-day mental health training program in the UK that sought to improve nurses’ confidence in dealing with mental health calls, knowledge of mental health issues, and attitudes to mental health [8]. The training course was centered on improving skill sets, for example, in patient-
centered interviewing, risk assessment, and problem formulation. Nurses who underwent the training reported significantly increased confidence in dealing with mental health calls and felt more positive towards their role in treating depressed patients. The training, however, did not examine the actual practice behaviors that those nurses engaged in as part of their routine care; in addition, the study also reported no significant impact on improving nurses’ knowledge about mental health. The other study, done in Sweden, examined the effects of a 12-h nurse training course in improving six oncology nurses’ confidence, knowledge, and skill sets in assessing psychosocial problems in cancer patients [9]. Despite the limitations of a very small sample, the authors found that participants reported that the training course not only improved their knowledge and skills regarding the assessment and management of distress but also improved their confidence in handling such psychosocial issues. A recently published review of training programs targeted at nurses found that the more effective programs were those of longer duration, incorporating didactic components of theoretical knowledge and practical application as well as facilitator feedback in small group format [10]. The present training program This two-hour standardized training program was aimed at (a) reviewing and enhancing existing psychosocial care skills that nurses had already gained as part of their nursing training, (b) enabling nurses to recognize distress and psychological disorders frequently associated with cancer, and (c) empowering them to provide support for patients and refer them for further assessment and treatment as needed. Given the heterogeneous sample of nurses working in oncology settings at NCIS, this program was targeted at the general nurses with the intent to subsequently develop more training programs. Components of this exploratory training were drawn from various sources such as the basic training curriculum in psychosocial oncology developed by the International PsychoOncology Society [11] and the general model of psychosocial interventions in cancer survivorship [12]. The training consisted of two segments: 1. A didactic session, which provided information on screening tools such as the distress thermometer [13], symptoms of distress, anxiety, and depression, and clinical scenarios of patient presentations. Nurses were also taught relaxation techniques such as progressive muscle relaxation [14, 15], and controlled breathing [16, 17]. This was done in groups of approximately 20 to 25 nurses. 2. Smaller groups of between six and ten nurses who were provided clinical scenarios for experiential learning through role playing. These groups were facilitated by
Support Care Cancer
psychiatrists and psychologists. Training sessions were standardized with prepared material and delivered by the same team of psychologists and psychiatrists. In this study, we hypothesized that (a) the training program would improve and sustain oncology nurses’ knowledge, attitudes, and practice behaviors and (b) individual differences (e.g., specialty training) would be predictive of any changes in knowledge, attitudes, and practice behavior.
Methods Participants All nurses working in medical and radiation oncology inpatient and ambulatory settings at the National University Cancer Institute, Singapore (NCIS), were provided this training as part of their continuing nursing education program and were invited to participate in this study. All 180 nurses (97 % female; 41 % ethnically Chinese) who underwent training volunteered to participate in this study. Registered nurses accounted for three quarters of the participants (76 %), 86 % of whom were staff or charge nurses, 13 % were head nurses, and one was an advance practice nurse. The remaining 24 % were enrolled nurses (or assistant nurses and senior assistant nurses in Singapore). Slightly more than half (54 %) were general medical nurses with no specialty training; of the remaining oncology nurses, 53 % had worked in oncology for less than 4 years. Most participants worked in inpatient settings (65 %), and nearly all were from medical oncology as there were only four nurses in the radiation oncology department, three of whom participated in the study. Table 1 displays the demographic information of this population. Instrument and procedures A review of the literature revealed no suitable instruments to investigate the efficacy of the program on the three measures: knowledge (K), attitudes (A), and practice behaviors (Pb). Thus, a self-report questionnaire specific to the needs of the study, the Knowledge, Attitudes, and Practice Behaviors Scale (KAPb), was developed for the purposes of this study to assess nurses’ knowledge of and attitudes towards cancer patients’ emotional and psychosocial issues and what skills they had in addressing their patients’ psychosocial needs. The KAPb was developed using the Delphi method [18], in which experts in the field (authors RM, JC, SEL, and EHK) together with nursing experts (including author ENKA) conceptualized the initial pool of 23 items based on aspects of the three measures (K, A, Pb) they deemed essential in the psychosocial care of cancer patients. These items were then refined by 20 nurses in two focus groups; the final KAPb version
Table 1 Demographic characteristics of participants Variable
n (%)
Male Ethnicity Chinese Malay Indian Othersa Nursing experience AN Senior AN/PAN SN Senior SN NM/NC Senior NM/NC APN Registered nursesb Years in oncology 0–4.99 years
4 (2)
5–9.99 years ≥ 10 years Previous specialty training in oncology Working in outpatient clinics Present oncology nursing division Medical oncology Radiation oncology
74 (41) 41 (23) 19 (11) 46 (25) 32 (18) 12 (7) 59 (33) 58 (32) 14 (8) 4 (2) 1 (1) 136 (76) 96 (53) 48 (26) 36 (20) 82 (46) 63 (35) 177 (98) 3 (2)
AN assistant nurse, PAN principal AN, SN staff nurse, NM nurse manager, NC nurse clinician, APN advanced practice nurse a
This category consisted of foreign-trained nurses from the Philippines, China, India, Malaysia, and Vietnam
b Registered nurses are considered those who are SN and above; enrolled nurses are AN/senior AN/PAN
administered to participants in the present study consisted of 23 items on a five-point Likert-type scale that determined nurses’ responses from “1” (strongly disagree) to “5” (strongly agree). Demographic information was also collected. Participants were asked to complete the KAPb at four time points relative to the standardized training previously described: T1 (4 weeks pre-training), T2 (immediately posttraining), T3 (6 weeks post-training), and T4 (12 weeks posttraining). Of the 180 participants that completed the measures at T1, 154 nurses completed the questionnaire at all time points (14 % attrition); these were used for the subsequent analyses. There were no differences in T1 KAPb scores between nurses who completed and did not complete all four measures. Ethics The study had ethics approval from the National University of Singapore’s Institutional Review Board. All participants
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provided informed consent prior to their inclusion in the present study, and responses on the questionnaire were anonymized to promote accurate self-reporting. Data analyses Statistical analyses were computed using IBM SPSS 20.0 (Chicago, IL, USA). Statistical significance was fixed at .05 unless otherwise stated, and all data were assumed normal. Separate one-way repeated-measures analyses of variance (ANOVAs; with Greenhouse–Geisser corrections where necessary) were conducted to compare changes in knowledge, attitudes, and practice behaviors from T1 to T4. Post-hoc Bonferroni corrections were also used to adjust for multiple comparisons. Mixed-model ANOVAs were conducted to ascertain the effects of demographic variables on KAPb, and differences were investigated via independent-samples t-tests.
Results Preliminary analyses An exploratory factor analysis was conducted on the data with 180 nurses using principal axis factoring with Promax rotation and a factor loading criteria of at least .35 without crossloadings. Analyses revealed a shorter version of the KAPb with 15 items and four domains, namely, “Theoretical Knowledge” (four items, α=.61), “Applied Knowledge” (four items, α=.79), “Attitudes” (three items, α=.58), and “Practice Behavior” (four items, α=.82). This 15-item version and the four aforementioned composite domain scores were used for subsequent analyses. Because the Theoretical Knowledge and Attitudes domains had somewhat low internal consistencies, further analyses were required to investigate changes between items. Table 2 details the descriptive statistics of the subscale domains and relevant individual items of the KAPb across the four time points. Figure 1 details the mean domain scores per item to facilitate comparison between KAPb subscales. Efficacy of training program Theoretical Knowledge There were no significant changes in participants’ Theoretical Knowledge domain or items across all time points (p>.05). This suggested that the training course did not significantly improve nurses’ theoretical knowledge; scores on the KAPb for theoretical knowledge remained high (mean scores across time points ranged 16.3–16.7 of a possible 20). Applied Knowledge There was, however, a significant improvement in participants’ applied knowledge pre- and posttraining (F[2.64, 404.28]=106.67, Mse=4.81, p
