Status of knowledge, attitude and practice of clinical nurses towards the intrahospital transport of critically ill patients: A cross‐sectional study

Abstract Aims To explore the knowledge, attitudes and practice status of the intrahospital transport (IHT) of critically ill patients among clinical nurses and their influencing factors. Design Cross‐sectional study. Methods A questionnaire determined the nurses' knowledge, attitudes and practice scores. The questionnaire was used for data collection in a tertiary hospital from 10 January to 17 January 2023. Multivariate regression analysis was also used to evaluate the related factors of IHT of critically ill patients in different dimensions. Results Out of 670 distributed questionnaires, 612 nurses returned the completed questionnaire. The scores of KAP were (9.72 ± 1.61), (42.91 ± 4.58) and (82.84 ± 1.61), respectively. Pearson's correlation analysis showed that knowledge, attitude and behaviour scores were positively correlated. Variables that were associated with the scores of transfer knowledge were the scores of transfer practice, different departments and the scores of transfer attitude. The score of practice, number of IHT and received hospital‐level training had statistical significance on the nurses' attitude scores. Furthermore, the score of the attitude and transport knowledge had statistical significance on the nurses' practice. Conclusion The findings indicate a clear need for clinical nurses' knowledge of IHT of critically ill patients, especially in the emergency department (ED) and ICU. In addition, nurses need to be more active in transporting critically ill patients. Managers should enhance nurses' confidence in the IHT of critically ill patients and promote clinical nurses to establish a correct and positive attitude. Impact The findings of this study benefit nursing managers in understanding the current situation of IHT of critically ill patients. Managers should apply new training methods to nursing education and develop a multi‐level training program that is systematic, comprehensive and demand‐oriented. Patient or Public Contribution The participants of this study were nurses and this contribution has been explained in the Data collection section. There was no patient contribution in this study.

Intrahospital transport (IHT) is the transport of patients between different units in the hospital (Haydar et al., 2019).Critically ill patients are defined as patients whose vital signs are unstable, whose condition is complex, serious and changing rapidly and whose lives may be in danger at any time (Veiga et al., 2019).
However, to further clarify the diagnosis or treatment needs of critically ill patients, IHT is inevitable (Haydar et al., 2019).Due to various factors such as members of the transport team, equipment and environment involved in the IHT process, IHT becomes a complex, high-risk procedure that can directly or indirectly cause adverse events (AEs) (Hu et al., 2021).According to a literature report (Venkategowda et al., 2014), the total incidence of transportrelated AEs is 21.2%-67.9%and the incidence of serious AEs that require interventions such as administration of vasopressors, fluid boluses or even CPR may be as high as 4.2%-9.1%.However, according to a recent systematic review and meta-analysis (Murata et al., 2022), AEs during IHT have been reported to occur in 6%-70% of cases.Although reported AE occurrence rates in IHT vary widely.This may be related to the difference of nursing quality and the different definitions of AEs.The most common AEs are severe hypotension, decreased consciousness requiring intubation, increased intracranial pressure and respiratory cardiac arrest (An et al., 2022).In addition, AEs can threaten the patient's safety, lead to a deterioration of the patient's clinical condition (Ling et al., 2023;Parmentier-Decrucq et al., 2013) and increase the length of hospitalisation duration and cost (Ling et al., 2023;Schwebel et al., 2013).In all published guidelines, the role of the medical practitioners, specifically the nurse, in preventing possible complications is pivotal (Critical Care Medicine Branch of Chinese Medical Association., 2010; Warren et al., 2004;Whiteley et al., 2011;Williams et al., 2020).To ensure the timeliness and safety of IHT for these patients, it is urgent to standardise and optimise the IHT process (Lu et al., 2022) and and to investigate the knowledge, attitude and practice (KAP) of nurses in this process (Alamanou & Brokalaki, 2014).

| Background
As the direct caregivers of patients, nurses play an essential role in all key links of IHT of critically ill patients (Sharafi et al., 2020).
Nurses are actively involved in intrahospital transportation from planning, equipment preparation and manipulation and evaluation of the process.By identifying AEs and modifying risk factors, nurses can improve patients' safety as they provide continuous care and are close to the patient (Sharafi et al., 2020).Nurses' knowledge, positive nursing attitude and standardised nursing behaviour can significantly improve the safe transportation of critically ill patients (Shields et al., 2015;Song et al., 2022).Despite nurses playing a vital role in IHT, the previous studies primarily focus on procedures, equipment and guidelines of IHT.Thus, our current understanding of clinical nurses' knowledge, attitude and behaviour regarding IHT of critically ill patients is limited.
Additionally, the development of medical resources in hospitals in different cities is unbalanced and nurses' levels of knowledge, attitude and behaviour are different.
In recent years, most of the studies on the IHT of critically ill patients have been performed in the ICU and the emergency department (ED) and few have been performed in other departments.
According to a cross-sectional study, a total of 480 nurses from 12 adult intensive care units in China participated, 75% of respondents expressed that IHT was a source of stress and increased workload (Song et al., 2022).This stress and workload could negatively affect their performance and threaten the patient's safety.Additionally, Hu et al. (2021) conducted a cross-sectional study on the current status of IHT of critically ill patients and emergency nurses' perception of IHT across China.The study found that some nurses in emergency rooms were still unaware of the risks of IHT; 19.3% considered all nurses competent enough to perform IHT of critically ill patients without special training and 7.6% even considered nursing students capable of the task.Moreover, research from O' Leary et al. (2018) has confirmed that it is not uncommon for nurses with inadequate supervision and training to participate in the IHT.Several studies have been conducted on the risks associated with IHT and checklists have been developed based on evidence and expert opinions (Bergman et al., 2020;Brunsveld-Reinders et al., 2015;Murata et al., 2022).However, the percentage of aEs has not yet been reduced to zero (Hashemian et al., 2023).Therefore, pursuing a study on nurses' level of knowledge, attitude and behaviour is essential to inform any efforts to promote critically ill patient safety during IHT.
This study investigated the status of clinical nurses' knowledge, attitude and practice about IHT of critically ill patients and identified influencing factors.The findings from this study will help identify gaps in nurses' knowledge and competencies, thereby providing insights into developing future IHT education and practice interventions.

Patient or Public Contribution:
The participants of this study were nurses and this contribution has been explained in the Data collection section.There was no patient contribution in this study.

K E Y W O R D S
attitude, behaviour, critically ill patients, intrahospital transport, knowledge, nurse | 3 of 10 DONG et al.

| Aims
This study explored nurses' knowledge, attitude and practice in IHT of critically ill patients.The objectives were to: examine the status of clinical nurses' knowledge, attitude and practice about IHT of critically ill patients.

| Design
A cross-sectional design using an anonymous online survey was conducted.

| Samples and setting
The statistical population of this study includes all nurses from a tertiary hospital in Zhejiang, China.This tertiary hospital in China is a general hospital with a bed capacity exceeding 1200, providing specialist health services and serving as a medical hub for multiple regions.This hospital receives national and international patients and it has a mandate to treat patients and serve as a teaching hospital.The clinical nurses who volunteered to participate in this study in the hospital were selected using the convenient sampling method.
Participants' eligibility criteria were as follows: (1) registered nurse; (2) clinical working time ≥0.5 years; (3) volunteer to participate in this study.Exclusion criteria were: (1) nurses from other hospitals who come to our hospital for further study and student nurses; (2) nurses who do not participate in the IHT of critically ill patients; (3) incomplete information.
The sample size was computed using the statistical formula of Yamane (1967), which states that, for any given population, the required sample size is calculated by: where: n = the required sample size; N = the known population size; and e = the margin error, which is =0.05.Finally, 612 nurses were included in this study.

| Data collection
Data were collected during 10-17 January 2023.Participants were recruited through a three-step process: (1) An email invitation to the study was first sent to the nursing leaders, comprising a letter to invite all registered nurses to participate and the survey's hyperlink to access the survey.(2) The nursing leaders disseminated the study invitation to the head nurses.(3) The head nurses disseminated the study invitation to the nurses.The online survey was collected using 'Wen juanxin' and piloted to ensure user-friendliness, ease of electronic interface and effective response collection.2019) was developed through a literature review, combined with several guides (Warren et al., 2004;Whiteley et al., 2011), literature (Brunsveld-Reinders et al., 2015;Song et al., 2022) and several guides and literature (Brunsveld-Reinders et al., 2015;Song et al., 2022;Warren et al., 2004;Whiteley et al., 2011).To use the questionnaire, the questionnaire's principal designer's permission was obtained, following which the tool underwent a forward and backward translation process.The English translation and the original version were then compared by independent translators.Finally, based on the theory of KAP (Bettinghaus, 1986), a group of eight experienced nurses evaluated the translated versions' relevance and utility.Some questions were removed, others adapted.The formal questionnaire of this study was developed after two rounds of expert letters and pre-investigation.Notably, a 42-item questionnaire was created.

| Instruments
The questionnaire consists of three dimensions: KAP.Before the formal investigation, 20 nurses were randomly selected for preinvestigation.The content validity of the final version of the questionnaire (I-CVI) had a value of 0.781, the Cronbach's a for subscales ranged from 0.751 to 0.823 and the Kaiser-Meyer-Olkin (KMO) value was 0.71, with good reliability and validity.The dimension of knowledge includes 13 items, 5 single-choice and 8 multiple-choice questions and the total score is 13 points.The higher the score, the higher the nurses' cognitive level of IHT of critical patients.The dimensions of attitude and practice were evaluated by a 5-point Likert scale.The dimension of attitude includes 11 items, with scores ranging from 11 to 55.The higher the score, the more positive the nurses' transport attitude towards critical patients and the higher their willingness to accept it.The dimension of practice includes 18 items with scores ranging from 18 to 90.The higher the score, the more standardised the behaviour of nurses when transporting critically ill patients.Scoring rate = average score/perfect score *100%, scoring rate >80% is good (positive), scoring rate 60%-80% is medium (neutral) and scoring rate < 60% is poor (negative) (Mukabagire, 2019).

| Ethical review
This study was approved by the Zhejiang University School of Medicine the Fourth Affiliated Hospital Research Ethics Committee (K2023043).Participation in the survey occurred voluntarily and completing and submitting the online survey implied the participant's consent.No personally identifiable data was collected.
Confidentiality and anonymity about the survey responses were assured for all the participants.

| Data analysis
For all statistical analyses, the IBM SPSS Statistics for Windows Version 23.0 was used (IBM Corporation).Mean and standard deviations (SD), proportions and percentages were computed to summarise the participants' demographic characteristics, knowledge, attitude and behaviour scores.Independent sample t-test and oneway analysis of variance (ANOVA) were used to examine the differences in nurses' knowledge, attitude and behaviour scores among the various categorical demographics.
Pearson product-moment correlation coefficients were calculated to examine the correlation between knowledge, attitude and behaviour.To explore factors influencing nurses' knowledge, attitude and behaviour scores (dependent variable), the variables found to be statistically significant in the univariate linear regression analyses were used as independent variables in the subsequent multiple linear regression analysis.In all other analyses, the level of statistical significance was set at 0.05.

| Nurse characteristics
Out of 670 questionnaires distributed, 612 nurses returned questionnaires completed, corresponding to a response rate of 91.3%.
The demographic characteristics of the participants are presented in Table 1.The purpose for IHT includes 41.3% being transferred from the ward to ICU, 39.4% operated on or intervened, 11.3% transferred from the emergency room to the ward, 11.3% transferred from the emergency room to ICU and 18.6% transferred from ICU to ward.The first three types of AEs related to the deterioration of critically ill patients during IHT were the SPO 2 decreases by≥5% or <90% (9.7%), consciousness change (4.4%) and changes in respiratory frequency and respiratory pattern (4.4%).Furthermore, the first three types of AEs involving technology related to critically ill patients during IHT were insufficient oxygen supply (4.4%), monitor disconnection (3.6%) and insufficient battery shortage of transhipment instruments and equipment (3.4%).

| Correlation analysis of knowledge, attitude and practice of IHT of critically ill patients
Pearson correlation analysis showed a positive correlation between knowledge and attitude scores (r = 0.204, p < 0.01).Notably, the scores of knowledge are positively correlated with practice (r = 0.206, p < 0.01) and the scores of practice are positively correlated with attitude (r = 0.411, p < 0.01).

| Comparison of KAP scores of nurses with different characteristics on IHT of critically ill patients
Using nurses' general data as independent variables, this study analysed the differences in knowledge, attitude and practices of nurses with different characteristics about IHT of critically ill patients.

| Factors affecting nurses' KAP scores on IHT of critically ill patients
KAP scores were taken as dependent variables to explore the influencing factors of nurses' KAP on IHT of critically ill patients.
Additionally, the statistically significant factors in univariate and correlation analyses were taken as independent variables and multiple linear stepwise regression analyses were carried out.The assignment methods of independent variables are shown in Table 4 and the scores of KAP were entered with the original values.

| DISCUSS ION
The results of this survey show that only 32.8% of the clinical nurses were reported to have a high level of knowledge, indicating that the nurses' knowledge of IHT for critically ill patients still has room for improvement, consistent with the findings of other studies (Hu et al., 2021).Among the items in the knowledge questionnaire of this study, the top three items were 'Preparation of stuff before IHT', 'Evaluation content before IHT' and 'Administration of medication during transportation' with scores of (0.96 ± 0.20), (0.94 ± 0.24) and (0.94 ± 0.25), respectively.This may be related to applying and optimiseng the transfer checklist for critically ill patients in the hospital.In previous studies (Williams et al., 2020), a checklist was useful in improving safety in transporting a critically ill patient population.The above three items are required in the transfer checklist, used as a check tool for nurses before transfer.Moreover, clinical nurses evaluate and complete the preparation work for critically ill patients before transfer according to the items in the checklist one by one.
The three Items with the lowest scores were 'You are transporting a mechanically ventilated patient to CT Scan and you do not have a portable mechanical ventilator.How do you ensure continuous ventilation for the patient?', 'What is the acceptable minimum level of oxygen in the oxygen cylinder for safe transport of the critically ill patient?' and 'When you are ready to transport critically ill patients, which of the following personnel will you inform?', with scores of (0.45 ± 0.50), (0.32 ± 0.47) and (0.25 ± 0.43), respectively.
A possible reason was that the nurses included are not just working at the ICU.Thus, these results suggest that nurses didn't have enough comprehensive knowledge about the IHT of critically ill patients and could not skillfully apply it to clinical transport practice.
The scores of the IHT knowledge in the ICU and Emergency room (9.40 ± 1.62) were lower than in Other departments (9.84 ± 1.59).
In general, nurses in the ED and ICU should be more proficient in the knowledge of transporting critically ill patients.A possible TA B L E 4 Independent variable assignment table.Another cross-sectional study showed that the AEs encountered by nurses during IHT of critically ill patients would also reduce their confidence (Jia et al., 2016) and increase their pressure (Ringdal, Chaboyer & Stomberg, 2015;Song et al., 2022) (Bergman et al., 2020).In doing so, they can enhance nurses' confidence in the IHT of critically ill patients, promote clinical nurses to establish a correct and positive attitude and ensure the transfer safety of critically ill patients.

Departments
Compared with the attitude score, the score of practice was higher.Despite the lack of IHT knowledge and transport experience, most nurses had a positive or neutral attitude towards it, which showed that nurses could realise the importance of transporting critically ill patients and seriously implement its related processes.
The results indicate that the better the nurses master the relevant knowledge, the more positive their attitude and the more standardised their transport behaviour.Thus, this suggests that nurses's knowledge level of IHT can affect their attitude and behaviour.It The summary and evaluation after IHT can provide a basis for the subsequent improvement of the IHT procedure and evaluate the rationality of members' composition, the effectiveness of communication and the pertinence and predictability of planned measures.
In addition, effective assessment and grading of the risk of patient transport and prompt preparation according to the actual situation can aid the reasonable allocation of medical resources and further improve the safety of transport, thereby enabling better treatment of critically ill patients (Ling et al., 2023).

| Limitations
We developed and tested a questionnaire strictly focused on nurses' KAP towards IHT.Furthermore, our results might not be generalisable because this was a cross-sectional study with convenience sampling.This survey is only carried out among clinical nurses in one hospital and the sample size is limited, which needs further expansion.Finally, desirability bias might have existed in our study because we used a self-reporting questionnaire.
general characteristics of the participants (department, gender, age, education level, general nursing experience, professional title, job grade) and work-related characteristics (whether they had participated in-hospital transport of critically ill patients, received IHT education or training, method of acquiring knowledge, whether the condition of critically ill patients has deteriorated during IHT and technology-related or other AEs have occurred during IHT) was collected using a selfreport questionnaire.2.5.2 | Questionnaire in assessing nurses's knowledge, attitude and practice of the IHT The questionnaire mainly referred to the scale compiled by Brunsveld-Reinders et al. (2015) and Mukabagire ( Multiple linear regression examining factors affecting nurses' knowledge, attitude and practice of IHTof critically ill patients.
should be noted that because the score of IHT practice behaviour in this study is not in the form of on-site observation, it may lead to a high score if nurses score it themselves.The study results showed that the last two scores of the practice dimension items were 'I made a comprehensive evaluation of the transshipment work after IHT' and 'I know the area where I can get first-aid equipment on the IHT route'.It means that nurses have a low awareness of the first-aid equipment available during IHT, which suggests that managers should pay attention to training first-aid equipment acquisition methods and managing eye-catching signs.There is no comprehensive evaluation summary after IHT, which suggests that managers should give weight to the quality control of the whole IHT process.

level of knowledge, attitude and practice of nurses on intrahospital transportation
Demographics characteristics of nurses.Special departments: Endoscopy room, Haemodialysis room, Operating room.N0: A newly graduated nurse who has joined the work.N1: Nurses who have worked in clinical practice for 1 year or more, obtained college education or above and obtained the qualification certificate of nurses.It is also necessary to meet the necessary requirements.N2: Nurses who have worked in clinical practice for 3 years or more and have the title of junior nurse or above.It is also necessary to meet the necessary requirements.N3: Nurses who are in charge of nurses and above.It is also necessary to meet the necessary requirements.

n Knowledge dimension Attitude dimension Practice dimension Score (X ± s) Statistics p Score (X ± s) Statistics p
Univariate analysis of influencing nurses' knowledge, attitude and practice about the transport of critically ill patients (n = 612).Different upper letters (a,b and c) in the same column indicate statistical significance among groups (p<0.05;Anova and Tukey post test).And the same letters means no sianificance (p>0.05).
of people participating in hospital-level training and emergency nurses (63.2%) and ICU nurses (60.0%) had the highest frequency of number of IHT>5 in 1 year.This shows that there were more opportunities to participate in the practice of transporting critically ill patients and related training in the ED and ICU.Therefore, hospital administrators should provide adequate training for nurses, especially in other departments except ED and ICU and make emergency plans and drills in advance for accidents in the transfer process logical burden in critically ill patients' IHT.The study observed that the number of IHT and received hospital-level training statistically impacted the attitude scores.The results showed that the number of IHT>5 and receive hospital-level training in the hospital, the more positive the nurses' attitude towards the IHT of critically ill patients would be.In the study, ICU (58.2%) was the department with the largest number