The research, published in the open-access journal Nursing Open, addresses one of the most persistent and underappreciated problems in global critical care. Although intensive care units account for a small fraction of hospital beds worldwide, they generate more than 20 percent of all hospital-acquired infections. Among these, ventilator-associated pneumonia stands apart. Defined as pneumonia that develops 48 hours or more after endotracheal intubation, it strikes between 10 and 40 percent of mechanically ventilated patients globally, and in low- and middle-income countries the incidence can climb to as high as 47.9 cases per 1,000 ventilator days. Each episode prolongs intensive care stays, multiplies resource consumption, and increases the likelihood of death. Decades of clinical research have established that a constellation of simple, evidence-based interventions, often called prevention bundles, can slash these infection rates: elevating the head of the bed, meticulous oral hygiene, appropriate suctioning technique, judicious ventilator circuit management, and the use of endotracheal tubes equipped with subglottic secretion drainage. The tragedy, as the new study makes clear, is that in many resource-limited settings these interventions are simply not delivered consistently, and the reasons why are more complex than a lack of training alone.

To disentangle the relationship between nursing knowledge and systemic constraints, the research team employed an explanatory sequential mixed-methods design, one of the more rigorous architectures available for studying implementation problems in real-world clinical environments. The quantitative strand used a single-group quasi-experimental pre-test–post-test approach involving registered nurses from two intensive care units at the hospital: a four-bed General Intensive Care Unit staffed by 37 personnel and a six-bed Maternity Intensive Care Unit staffed by 27. Fifty-seven nurses completed the baseline knowledge assessment, using an eight-item multiple-choice questionnaire adapted from an established instrument developed by Labeau and colleagues, with one question about kinetic beds removed because that equipment does not exist at the study site. After the pre-test, all participants attended a structured three-hour workshop covering four thematic modules: the definition, aetiology, and pathophysiology of ventilator-associated pneumonia; evidence-based prevention bundles including patient positioning, oral hygiene, and circuit management; airway management and suctioning techniques; and intensive care-specific infection control principles. The content was validated in advance by two independent intensivists and senior nursing leadership. A post-test was administered within two weeks, completed by 56 nurses, and eight purposively selected participants then underwent semi-structured interviews designed to explain why the quantitative results looked the way they did.

The statistical results were striking. Mean knowledge scores rose from 3.63 out of 8 (standard deviation 1.57) before the workshop to 5.29 out of 8 (standard deviation 1.57) afterward, an independent-samples t-test yielding t(111) = −5.61, p < 0.001, with a mean difference of 1.65 points and a Cohen’s d of 1.06, which is conventionally classified as a large effect. A non-parametric Mann–Whitney U test confirmed the robustness of the finding (U = 748.5, p < 0.001). Perhaps more meaningful clinically was the transformation in competence categories. Before the workshop, only 24.6 percent of nurses scored in the high-competence range, while nearly a quarter fell into the low category. Afterward, the high-competence group swelled to 64.3 percent and the low group shrank to a single nurse, a redistribution that the chi-square test confirmed as highly significant (χ²(2, N = 113) = 22.43, p < 0.001). The largest item-level gains appeared precisely where baseline knowledge was weakest: correct responses about humidifier change frequency jumped by 17, open-versus-closed suction system knowledge by 16, patient positioning by 16, and awareness of endotracheal tubes with subglottic secretion drainage by 13.

Curiously, the factors one might expect to predict post-training performance did not. A multiple linear regression examining years of registered nurse experience, duration of intensive care service, and unit type found that none of these variables significantly predicted post-test scores, and the overall model explained a negligible 5.2 percent of the variance (F(3, 52) = 0.94, p = 0.428). The study’s demographic data help explain why. The nursing workforce was young, with a mean age of 31.6 years, overwhelmingly composed of registered general nurses (84.1 percent), and almost entirely lacking postgraduate critical care credentials, only 1.8 percent held such qualifications. More than three-quarters had five or fewer years of intensive care experience. The authors interpreted the null regression result through the lens of the qualitative interviews: when supervision is sparse, protocols are absent, and supplies are inconsistent, years of experience can accumulate without ever being reinforced against evidence-based standards, so experience alone stops being a reliable proxy for competence.

That interpretation was powerfully supported by the interview data. Nurses described a practice culture built on experiential learning and pragmatic task selection rather than standardized bundles. “What has helped is my experience in the ICU,” one participant explained. Another described a ward habit of routine mouth care for every ventilated patient, prioritized because it was feasible and perceived as effective. But the interviews also revealed the harsh material realities that constrain even the best-informed clinician. Nurses reported reusing suction catheters on multiple patients after washing them, hunting for scarce consumables, and losing power mid-suction. “You can even try to suction a patient then all of a sudden there’s no light,” one nurse recounted. Others described the absence of any written protocol for pneumonia prevention, with practice resting entirely on individual knowledge, and the weak standing of in-service training in the unit’s culture, where colleagues sometimes viewed education sessions as a waste of time. Supervisors, participants said, rarely came to observe practice, leaving “the system open for anyone to do what he or she thinks is the best.” Delayed laboratory feedback and families’ financial struggles to secure medications after the first week of hospitalization added further layers of difficulty.

The study was theoretically anchored in two influential frameworks from nursing and behavioral science: Patricia Benner’s Novice-to-Expert Model, which frames clinical competence as a developmental construct acquired primarily through experience rather than didactic instruction, and Bandura’s Self-Efficacy Theory, which holds that knowledge and confidence together drive the performance of specific behaviors. The findings map onto both frameworks in instructive ways. The overwhelmingly experiential nature of the nurses’ knowledge acquisition is consistent with Benner’s account of how competence develops, but it also explains why a single structured workshop could produce such large gains, because it filled gaps that years of unstructured bedside experience had never addressed. Meanwhile, the supervisory and accountability gaps described in the interviews illustrate why self-efficacy, however boosted by a mastery-oriented learning experience, cannot sustain consistent preventive behavior without institutional reinforcement.

The authors are appropriately candid about the study’s limitations. Because participant responses were not linked across assessment points, the improvement represents a group-level change rather than demonstrated within-individual gain, and the single-group design without a concurrent control group precludes strong causal inference. The single-site setting, convenience sampling, the two-week interval between training and post-test, and the low internal consistency of the adapted questionnaire (KR-20 of 0.32 pre-test and 0.42 post-test, reflecting a broad knowledge index rather than a unidimensional psychometric scale) all warrant caution. The study also measured knowledge rather than observed bedside performance or actual pneumonia incidence, leaving open the crucial question of whether the educational gains translate into fewer infections.

Nevertheless, the practical implications are difficult to ignore, and the authors frame them with unusual clarity. Education, they conclude, is necessary but insufficient. The most actionable levers for nursing leaders in similar settings are the introduction of locally feasible written prevention protocols and bedside checklists, routine audit-and-feedback cycles, structured supportive supervision, and, perhaps most fundamentally, dependable procurement of basic consumables such as suction catheters, closed-system circuits, and personal protective equipment. At the health-system level, reliable electricity and functional laboratory services emerge as prerequisites for infection prevention rather than optional luxuries. From an implementation science perspective, the study illustrates how individual capability, organizational readiness, available resources, and implementation climate interact to determine whether evidence-based practice takes hold, a dynamic well captured by frameworks such as the Consolidated Framework for Implementation Research.

In an era when global health attention has rightly focused on pandemic preparedness and antimicrobial resistance, this study is a reminder that some of the most consequential advances in patient safety may come from modest, low-cost interventions targeted at the frontline workforce, provided they are embedded within broader quality improvement efforts. A three-hour workshop, materials prepared from peer-reviewed literature and delivered with a projector, moved the majority of nurses from low or moderate competence to high competence in a setting where virtually none had formal critical care training. The next challenge, the authors argue, is to pair such education with the protocols, supervision, supplies, and infrastructure that allow knowledge to become practice, and to evaluate with paired, longitudinal designs whether combined training-plus-system-support strategies can ultimately reduce ventilator-associated pneumonia rates, shorten ventilator days, and save lives in the intensive care units that need it most.

Nurse interns are at a crucial juncture in their careers, where their educational experiences shape their future practices and beliefs. The study by Yang and Zhou focuses on understanding these foundational attitudes that future healthcare providers will carry into their professional lives. It is essential to comprehend not only how nursing interns view hospice care but also the underlying factors that influence these perceptions. This aspect is particularly vital as the healthcare industry gradually shifts towards more compassionate, person-centered approaches in end-of-life care.

The findings from the study reveal that a significant proportion of nursing interns exhibit ambivalence towards hospice care. While some interns recognize the importance of hospice care in providing comfort and support to patients with terminal illnesses, others harbor misconceptions that hinder their willingness to engage with this specialty. These varied perceptions suggest that pre-service education may need to be enriched with more explicit discussions surrounding hospice care, aiming to elevate its recognition among nursing students as a vital component of patient care.

One noteworthy finding is the influence of personal experiences on the attitudes of nursing interns. Many participants reported that previous encounters with terminally ill family members or friends significantly shaped their views on hospice care. These experiences elicited emotional responses that might either bolster the interns’ commitment to providing compassionate care or instill fear and apprehension about end-of-life scenarios. Understanding these personal narratives can help educators and health organizations create a more supportive learning environment that addresses these emotional dimensions.

Furthermore, the study highlighted the role of education and training in affecting attitudes toward hospice care. Nursing interns who received formal training in palliative care tended to express more positive views on hospice services than those who did not. This correlation underscores the necessity for integrating palliative care curriculum elements into nursing programs, thus ensuring that future nurses are equipped with the knowledge and skills to provide quality end-of-life care. Academic institutions need to explore innovative teaching methods that demystify hospice care and emphasize the benefits of such services for patients and their families.

Social and cultural factors were also identified as significant influencers of nursing interns’ attitudes towards hospice care. In Wuhu, societal beliefs about death and dying play a crucial role in shaping healthcare decisions. There exists a cultural milieu where open discussions about death are often avoided or stigmatized, impacting how young nurses perceive their responsibilities in providing end-of-life care. Addressing these societal and cultural challenges through educational initiatives could pave the way for more open dialogue regarding death, ultimately enhancing the quality of care provided to patients in hospice settings.

Additionally, the study revealed a clear disparity in attitudes based on gender as well. Female nursing interns expressed more empathy towards hospice care and a greater inclination to pursue careers in palliative nursing. This disparity draws attention to the necessity of addressing gender-based perceptions to ensure that all nursing students, regardless of gender, have equal opportunities to engage with hospice care. Engaging all interns equally and fostering an inclusive environment around palliative care education may help bridge this divide.

Moreover, peer influence emerged as a significant theme in shaping nursing interns’ attitudes. Interns who felt supported by their peers and mentors while discussing hospice care tended to be more optimistic and open toward the concept of end-of-life services. This finding suggests that mentorship programs and peer support systems should be emphasized within nursing education to foster healthier attitudes toward hospice care among nursing students. Incorporating collaborative learning approaches can nurture a sense of community among interns, where they feel safe to express their concerns and apprehensions about hospice care.

As healthcare continues to evolve, the emphasis on holistic and comprehensive patient care remains paramount. The study elucidates the necessity of preparing nursing interns to navigate the complexities of hospice care effectively. Future healthcare providers must be able to approach end-of-life care compassionately and knowledgeably, ensuring that patients are treated with dignity and respect throughout their final days. By addressing the influences that shape interns’ attitudes toward hospice care, educational institutions can produce well-rounded nursing professionals ready to enhance the quality of life for those facing terminal illnesses.

Another critical aspect that the study brings to light is the importance of public health campaigns in shaping societal attitudes towards hospice care. Community awareness initiatives could play an essential role in reducing misconceptions about hospice care and promoting a more favorable view of palliative services. Public campaigns can encourage discussions surrounding death and dying, helping to dismantle stigmas and foster a culture that embraces hospice care as a noble and vital aspect of healthcare.

The study underscores a broader movement within nursing to develop a workforce that exhibits empathy and understanding toward patients in need of hospice care. This aim requires not only enhanced educational practices but also systemic changes within healthcare policies that recognize the importance of training and resources dedicated to end-of-life care services. Collaboration among nursing schools, healthcare organizations, and community stakeholders can foster an integrated approach toward preparing interns to handle hospice care with sensitivity and professionalism.

In conclusion, the research conducted by Yang and Zhou highlights essential factors influencing nursing interns’ attitudes towards hospice care in Wuhu, China. By examining these attitudes and their determinants, we gain invaluable insights into the future landscape of nursing and end-of-life care. To cultivate a generation of compassionate healthcare providers, it is crucial to engage nursing students with reflective practices, supportive environments, and comprehensive education on hospice care. As the healthcare sector navigates challenges related to aging populations and increasing chronic diseases, enhancing understanding and appreciation for hospice care will be indispensable for delivering quality patient-centered services in the future.

Subject of Research: Nursing interns’ attitudes towards hospice care

Article Title: Attitudes and influencing factors of nursing interns towards hospice care in Wuhu, China: a cross-sectional study

Article References:

Yang, L., Zhou, Q. Attitudes and influencing factors of nursing interns towards hospice care in Wuhu, China: a cross-sectional study.
BMC Nurs 24, 1389 (2025). https://doi.org/10.1186/s12912-025-04024-6

Image Credits: AI Generated

DOI: https://doi.org/10.1186/s12912-025-04024-6

Keywords: Attitudes, Nursing Interns, Hospice Care, Palliative Care, Education, Wuhu, China, End-of-Life Care.