Background

Worldwide, nurse practitioners (NPs) constitute a rapidly growing workforce in response to the severe shortages of healthcare professionals and the increasing demands of primary care in the context of an increasingly aging population with chronic illness and multimorbidity [1, 2]. NPs were first introduced in the USA in 1965 and now represent the largest workforce in absolute and relative size in the total nursing workforce [3]. Subsequently, NPs rapidly expanded to other countries, such as Canada, the UK, Ireland, the Netherlands, Australia, and New Zealand [4, 5]. Abundant evidence consistently shows NPs’ feasibility, safety, cost-effectiveness, and sustainability in the provision of quality health services [4, 5]. Nurses have been documented to provide equivalent and even superior services than physicians by numerous studies [6,7,8], and a scoping review concluded that NPs were able to provide 67–93% of all primary care services [4]. There is a consistent body of evidence showing a wide range of benefits of NPs, including decreased patient waiting time, improved patient outcomes, decreased hospitalization and readmission rates, shortened length of hospital stay and visits, reduced congestion in tertiary hospitals, reduced healthcare costs, and increased patient, family, and provider satisfaction [9,10,11].

China represents one-fifth of the world’s population and has a rapidly growing aging population. The number of older Chinese people aged over 60 years was 254 million in 2019 and is projected to increase to 402 million by 2040, accounting for 28% of the total population [12]. Older people are at high risk of chronic conditions and comorbidities that require chronic care [13], and it is estimated that an extra 14.02 million older Chinese people will need long-term care by 2030 [14]. Non-communicable diseases (NCDs), such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, known as the “Big 4”, have become the leading causes of death in China, accounting for 80% of total deaths [15]. Multimorbidity is also common, with an estimated prevalence of 62.1% among Chinese adults aged 45 years and older [16]. Therefore, community-based care is urgently needed to address the increasing care demand for NCDs, which can be managed at home rather than in hospitals [5].

Nurses represent China’s largest healthcare workforce, with 5.2 million registered nurses, accounting for 47.4% of all healthcare workers in China [17]. The considerable potential of NPs in bridging the healthcare gaps has been increasingly recognized by the Chinese government. NPs’ essential roles in the provision of quality healthcare have been emphasized and advocated in multiple national strategic plans and documents, such as Healthy China 2030 and Healthy China Action Plan [18]. In response to the increasing demand for NPs, China developed the first NP educational program in Nanjing in 2015 [19] and the first master-degree NP program in Beijing in 2017 [20]. In 2019, China launched its first NP in-service training program, which was co-sponsored by Peking University and the China Medical Board, enrolling only 20 students from six provinces [21]. All these policies and programs represent important landmarks of NP education and development in China.

In addition to developing education and training programs at the system level, it is also crucial to understand the knowledge and attitudes toward NPs among nurses at the personal level. Senior nurses refer to nurses who have over ten years of working experience, usually with management titles and duties, due to their advanced experiences and skills in clinical nursing, patient communication, and emergency response [22]. Senior nurses represent the backbone of clinical nursing staff and are most prepared and qualified to become NPs. Senior nurses’ engagement in NPs is crucial to the successful implementation and wide popularization of NPs in China. According to the Theory of Planned Behavior (TPB), an individual’s behavioral intentions are shaped by three core components: attitudes, subjective norms, and perceived behavioral control, among which attitudes are the most proximal predictors of behaviors [23,24,25]. Negative attitudes toward NPs among senior nurses may constitute a significant obstacle to successfully introducing and developing NPs in the hospital. It is thus imperative to understand whether senior nurses know about and are willing to take on the roles of NPs in a Chinese context.

NPs are still in the stage of establishment and continuous development in China, and research related to NPs in China is limited. Li et al. [26] conducted a survey among nearly 5,000 nurse managers in Hunan Province to investigate their attitudes toward NPs. Their results showed that 94.75% believed that it was necessary to conduct NP programs, and 79.49% believed that NPs had a bright future in employment [26]. However, China also faces challenges in developing and expanding NPs similar to the Western countries, such as restrictions in the scope of practice (e.g., prescription rights) and resistance from physicians due to distrust of NPs’ abilities and worry of being replaced [27]. In addition, China faces unique challenges in recruiting and retaining NPs in primary care settings, and there is insufficient evidence on the feasibility, quality, and cost-effectiveness of NPs in China [28].

A comprehensive understanding of senior nurses’ knowledge of and attitudes toward NPs, as well as a full exploration of their perceived facilitators and barriers to NPs, is essential to inform future policy and research efforts to strengthen NPs and build a stronger healthcare workforce in China. Nevertheless, no standard assessment tools are available to measure the knowledge, attitudes, facilitators, and barriers towards NPs in the Chinese culture. Additionally, no study has comprehensively captured these concepts among senior nurses in China. To bridge these research gaps, we conducted the current study to assess senior nurses’ knowledge, attitudes, and perceived facilitators and barriers toward NPs in China using a self-developed and culture-specific assessment tool. The specific goals were as follows: (1) to develop the Knowledge and Attitudes towards Nurse Practitioners Questionnaire (KANPQ) that is suitable to a Chinese culture based on the Delphi method; (2) to examine senior nurses’ knowledge and attitudes toward NPs; (3) to explore the factors that influence senior nurses’ attitudes toward NPs; and (4) to identify facilitators and barriers to the successful development of NPs based on senior nurses’ perception.

Methods

Study design and participants

A multicenter, cross-sectional study was conducted in Hunan Province from December 2021 to January 2022. The sample size was calculated according to the form for the cross-sectional study: n = Z2P (1 − P) / E2, where P was the proportion of participants who held positive attitudes towards NPs. As no study has reported senior nurses’ attitudes toward NPs in China, we assumed P to be 50%. Z was set as 1.96 at a confidence interval of 95%; the allowable error was set as 5%, leading to a sample size of 384. Considering a rejection or loss-to-follow-up rate of 8%, we expanded our final sample size to 417.

A multistage cluster-sampling method was adopted to identify subjects. In the first stage, Hunan Province was stratified into the following four areas based on economic development: Chang-Zhu-Tan, Dongting Lake, Southern Hunan, and Western Hunan. In the second stage, two tertiary hospitals were randomly selected from each area using a random number produced in the computer, leading to 8 tertiary hospitals as our sampling frame. Finally, a certain number of senior nurses that were proportional to the total number of senior nurses in each tertiary hospital were randomly selected from each hospital using a computer-based random number, leading to 420 nurses as our final sample. Details of participant recruitment are shown in Fig. 1. Inclusion criteria included: (1) aged ≥ 18 years old; (2) formally registered nurse; (3) with a professional title of supervisor nurse or above; (4) working in nursing areas in a tertiary hospital for ≥ 10 years; (5) with normal cognitive and mental functions to complete the questionnaire. We excluded nurses who were absent for the past six months due to studying abroad, sick leave, maternity leave, etc., and those who were unable to complete the study due to severe physical or mental illness. Among the 420 eligible senior nurses, 412 completed the survey with valid questionnaires, leading to an effective response rate of 98%.

Fig. 1
figure 1

Flowchart of participant recruitment

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Instrument

A Knowledge and Attitudes towards Nurse Practitioners Questionnaire (KANPQ) was developed for this study using the Delphi method. The initial version of the questionnaire was developed based on literature review and brainstorming by the research team, which was then reviewed and modified through two rounds of expert consultation. The expert group comprised a total of 18 experts in the fields of clinical nursing, nursing management, nursing education, clinical medicine, and scale development. Inclusion criteria for experts were as follows: 1. with more than ten years of working experience in their expertise field; 2. holding a master’s degree or above; 3. with a professional title of senior or above; 4. having high academic achievements in NP-related fields; 5. familiar with the study area and scale development process and able to provide valuable opinions; 6. voluntarily participating in the study and willing to complete each questionnaire round.

During the two rounds of expert consultation, 56 expert opinions were collected, based on which we modified 27 items and deleted one item and one dimension. The expert familiarity coefficient, determination coefficient, authority coefficient, and Kendall coordination coefficient (ω) for the two rounds were 0.718/0.713, 0.919/0.931, 0.824/0.819, and 0.449/0.472, respectively (P < 0.05 for all). In addition, we invited two experts in nursing management, two in clinical nursing, and one in nursing education to peer review the questionnaire. The questionnaire was then pilot-tested among a convenience sample of 30 senior nurses at a tertiary general hospital in Changsha City, and their working departments included internal medicine, surgery, obstetrics and gynecology, pediatrics, and infectious diseases. The average completion time of the questionnaire was 5 to 15 min.

Based on the expert opinions and pilot test, the final version of KANPQ was formed, which included 30 items under three dimensions: knowledge, attitudes, and facilitators & barriers (supplementary file S1). The knowledge dimension included 22 items assessing participants’ understanding of NPs in terms of the following six domains: duties (8 items), core competencies (4 items), entry criteria (1 item with 2 optional answers), training (3 items), certification (3 items), and values (3 items). Each item was rated on a 5-point Likert scale ranging from 1 “not at all” to 5 “very much.” The total score ranged from 22 to 110, with a higher score indicating better knowledge of NPs. To facilitate cross-study comparisons, the score was further transformed into percentages based on previously published thresholds for knowledge scores [26, 29, 30], with a score of < 60%, 60-85%, and > 85% indicating low, moderate, and high levels of knowledge, respectively. The knowledge dimension demonstrated good internal consistency in the study, with a Cronbach’s α coefficient of 0.85 and a test-retest reliability coefficient of 0.71 (P < 0.01).

The attitude dimension included two items asking about the participants’ perception of the necessity to develop NPs in China and their willingness to become NPs in the future. Each item was rated on a 5-point Likert scale ranging from 1 “not at all” to 5 “very much.” The total score ranged from 2 to 10, with a higher score indicating a more positive attitude toward NPs. The attitude dimension demonstrated good internal consistency in the study, with a Cronbach’s α coefficient of 0.95 and a test-retest reliability coefficient of 0.80 (P < 0.01). The facilitators and barriers dimension included six questions asking about the participants’ opinions of factors that promote or hinder the development of NPs in China. Each question had multiple choices, and participants could circle as many as they wanted based on their perspectives and experiences.

Data collection

The study was approved by the Ethics Review Committee of the Xiangya Hospital of Central South University (No. 202107120). All data were collected through the WeChat-based online survey platform Sojump (http://www.sojump.com), which provides professional online research services, including questionnaire design and distribution, data collection and analysis, and result reporting [31]. The participants were approached and recruited through the nursing department of each hospital, which assigned a fixed nurse researcher to assist in distributing electronic questionnaires and answering questions from the participants. There were unified instructions to explain the research background, purpose, significance, filling method, and confidentiality principle. Informed consent to participate was obtained from all of the participants in the study, and the participants completed the questionnaire online. In order to obtain true and reliable data, the participants completed the questionnaires anonymously and privately at their convenience. To ensure the validity of the response, the Sojump was preset to be answered only once by each WeChat account or IP address, with no missing, unlogic, or out-of-range item in each questionnaire. In addition, we excluded questionnaires with logically confusing answers, with obviously specific answering patterns, or with a completion time of less than 150 s.

Data analysis

Data were analyzed using IBM SPSS version 25.0. We used means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Comparisons of the KANPQ knowledge and attitude scores by different sample characteristics were conducted using two-sample independent t-tests for two-group comparisons and one-way ANOVA for multiple-group comparisons. Pearson correlation was used to determine the degree of association between the KANPQ knowledge and attitude. Variables statistically significant in univariate analysis were then included in multivariate analysis. Multiple linear regression analysis was conducted to analyze the factors associated with the senior nurses’ attitudes toward NPs. The 95% confidence interval (CI) was estimated, and the P-value < 0.05 was considered significant.

Results

Participant characteristics and associations with the KANPQ score

Table 1 shows participants’ sociodemographic characteristics and compares the KANPQ knowledge and attitude scores by these characteristics. Among the 412 senior nurses, most were female (94.90%), married (93.69%), with a bachelor’s degree (81.55%), and with a professional title of supervisor nurse (81.80%). Only 10.68% had administrative duties, and slightly over one-third were specialist nurses (37.14%). The largest proportion of senior nurses had been working for 10–15 years (54.61%), were from the surgery department (44.18%), and had a monthly income of 7,000–9,000 Yuan (33.50%).

Table 1 Comparison of the KANPQ scores by sample characteristics
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Further comparison of the KANPQ knowledge and attitude scores by sample characteristics showed significant differences in knowledge scores by education and significant differences in attitude scores by education, professional title, and administrative title. Senior nurses with higher education had higher knowledge of NPs (P = 0.003) and held more positive attitudes toward NPs (P < 0.001). In addition, senior nurses with higher professional titles (P = 0.004) and administrative duties (P = 0.001) had more positive attitudes toward NPs.

The KANPQ score

Tables 2 and 3 show the descriptives of the KANPQ score. The average KANPQ knowledge score was 68.56 ± 22.69, and the scores of the six dimensions of duties, core competence, entry criteria, training, certification, and values were 24.61 ± 8.54, 13.08 ± 4.46, 3.05 ± 1.14, 8.89 ± 3.21, 9.15 ± 3.37, and 9.68 ± 3.29, respectively. Most senior nurses demonstrated a high level of KANPQ knowledge (55.09%), yet over one-third presented poor knowledge (34.71%). Among the 22 items regarding the knowledge of NPs, senior nurses scored highest on item 12, “NP requires rich experiences” (3.30 ± 1.15). They also had high knowledge of the core competence and leadership ability required from NPs and the values of NPs to nurses, as reflected in the high scores of items 10, 11, and 22. However, senior nurses scored lowest on item 16, “NPs must complete at least 500 hours of clinical practice” (2.92 ± 1.14). They also had poor knowledge of the NP restrictions and the areas most in need of NPs abroad, as reflected in low scores of items 5 & 6.

Table 2 Score and grade of the KANPQ
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Table 3 Item score of the KANPQ knowledge
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Table 2 also shows that the average KANPQ attitude score was 7.79 ± 1.72, and the scores of necessity and willingness items were 3.83 ± 0.95 and 3.96 ± 0.95, respectively. Over two-thirds (65.3%) of senior nurses considered it necessary to develop NPs in China, followed by 28.6% holding a neutral position, and only 6.1% thinking NPs were unnecessary. In addition, most senior nurses expressed willingness to become NPs (69.9%), followed by 24.8% holding a neutral position, and only 5.3% were unwilling to become NPs. Additionally, Pearson’s correlation analysis showed a significant positive association between the KANPQ knowledge and attitude score (r = 0.404, P<0.01).

Factors associated with KANPQ attitude

Table 4 shows the results of multivariate linear regression with the KANPQ attitude score as the dependent variable, the KANPQ knowledge score, and all sociodemographic characteristics that were significant in the univariate analysis as the independent variables. The regression model identified two significant factors associated with KANPQ attitudes: KANPQ knowledge and professional titles. Senior nurses with higher KANPQ knowledge (β = 0.029, P < 0.001) and higher professional titles (β = 0.412, P = 0.046) had more positive attitudes toward NPs.

Table 4 Multivariate analysis of the influencing factors of the KANPQ attitude
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Facilitators and barriers to NP development

Table 5 shows a list of facilitators and barriers to the implementation of NP roles in China as endorsed by the senior nurses. There were four facilitators identified, and the most reported one was establishing an NP education and training system (93.69%), followed by increasing public awareness of NPs (91.99%), legalization of NPs (90.29%), and inclusion of NPs into medical insurance plans (87.38%). In addition, senior nurses identified 16 barriers covering policy (3 items), education (4 items), and the perspectives of the patients (2 items), physicians (2 items), and nurses (5 items). The most reported barrier was patients’ lack of knowledge and trust in NPs (96.84%), followed by a lack of polity and regulations to support NPs (92.48%) and a lack of education and training (91.99%).

Table 5 Facilitators and barriers to NP development in China
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Discussion

This study fills in a significant research gap in NPs in China by developing a comprehensive measurement tool to assess senior nurses’ knowledge and attitudes toward NPs, explore factors associated with senior nurses’ attitudes toward NPs, and identify their perceived facilitators and barriers to the development of NPs in China. Our study showed that most senior nurses had moderate knowledge and positive attitudes toward NPs. Senior nurses with higher levels of NP-related knowledge and professional titles had more positive attitudes towards NPs. Facilitators of the NP implementation were mainly focused on NP training, legalization, public campaigns, and incorporation into insurance. The study also identified some systematic barriers related to the training and policy of NPs and personal obstacles related to the perspectives of various stakeholders, such as the patients, doctors, and nurses.

Our study showed that most senior nurses had a moderate master of NP-related knowledge, including all six dimensions of duties, core competence, entry criteria, training, certification, and values. Notably, approximately one-third of senior nurses still had poor knowledge of NPs, ranging from 26.21% for core competencies to 35.92% for duties and entry criteria. There is scant literature focusing on senior nurses’ knowledge of NPs in China. For the first time, our study identified significant knowledge gaps related to various aspects of NPs among Chinese senior nurses. These findings are consistent with the existing few studies showing generally low knowledge of NPs among different health professionals from various departments in various countries [26, 32]. Specifically, our study showed that senior nurses had a poor understanding of the duties, entry criteria, and certification related to NPs.

Given that the NPs are relatively new in China and are still in the stage of establishment and continuous development, it is understandable that ambiguity and unclarity exist in many aspects of the NP roles [5]. Our findings suggest that more systematic efforts are needed to promote NP development in China. Some countries, such as the United States, Canada, and Australia, have relatively well-developed NP systems regarding educational preparation, role legitimacy, capacity requirements, the scope of practice, certification, evaluation, and promotion [5]. China may learn from these countries and think globally but act locally to adapt the NP models from other countries to fit its specific legislative requirements and local conditions [5, 18]. In addition, more education and training programs are needed to improve senior nurses’ knowledge of NPs, as education is the most potent and effective way to strengthen knowledge directly. There has been a diversity of educational models being proposed in the literature with well-established benefits in improving the knowledge and skills of NPs as well as improving patient outcomes and satisfaction [33,34,35].

Despite significant knowledge gaps, most senior nurses showed positive attitudes toward NPs, with over two-thirds thinking it imperative to develop NPs in China and expressing a strong willingness to become NPs. These findings are congruent with the literature showing wide acceptance of NPs by various health professionals [26, 36]. NPs serve as physician substitutes and liaise between the patients and the health care team. Li et al.’s [26] study showed that nearly 80% of nurses held positive attitudes toward the career prospects of NPs in China. Our findings were further strengthened by several qualitative studies on NPs’ perceptions and beliefs about their profession, which covered various aspects, such as regulations around NPs, organizational support, and leadership roles [36, 37]. All these findings highlight the essential roles of NPs in delivering competent, high-quality, and cost-effective care.

In addition, our multivariate analysis has identified two variables that were independently associated with senior nurses’ attitudes toward NPs: professional title and knowledge of NPs. Higher professional titles indicate more educational investment, more training opportunities, more clinical practice, and richer clinical experience, which may lead to higher confidence and competence in becoming NPs and, thus, more positive attitudes toward NPs [38, 39]. These findings suggest that nurses with lower professional titles may need more education and training related to NPs and should be more empowered and prepared to become NPs in the future. The finding that senior nurses with higher knowledge of NPs had more positive attitudes toward NPs is in line with the abundant evidence showing a positive association between knowledge and attitudes in various knowledge, attitude, and practice (KAP) studies [40, 41]. Lack of considerable knowledge related to NPs has been identified as a major barrier to the initiation of NP roles by accumulated evidence [32]. A major implication of these findings is that education on NPs should be strengthened to foster positive attitudes toward NPs among senior nurses.

Our study has identified a wide range of facilitators and barriers to the successful implementation of NPs in China. Over 90% of senior nurses perceived the following three critical contributory factors for promoting NP development: developing the NP education system, increasing public awareness of NPs, and initiating laws and regulations to legitimize NPs. In addition, multi-level factors involving the individual, organizational, practice, and systems levels have been identified as barriers impeding the development and integration of NPs in China’s health system. The most frequently reported barrier is related to the patient’s lack of understanding and trust in NPs’ competence in providing quality care (96.84%), followed by no available laws and regulations related to NPs (92.48%) and lack of a well-developed educational system for NPs (91.99%). These facilitators and barriers overlap each other just like two sides of a coin.

Our findings echo those reported by several most recent literature reviews showing an extensive list of various barriers and facilitators of NP implementation, including legislation and policy, role responsibilities and autonomy, stakeholder understanding and support, interpersonal relationships, supervision and leadership, and funding and reimbursement, etc. [32, 42, 43]. Our findings add further evidence of the multiple influential factors for implementing NPs from both personal and organizational levels, as well as provide helpful guidance for future actions to promote NPs. It is suggested that continuous political, social, economic, and individual efforts are needed to facilitate the successful development of NPs in China, which may be realized by initiating laws, developing public campaigns, strengthening education, enhancing collaboration, and increasing reimbursement.

This study has several limitations. First, the cross-sectional study design may hinder us from drawing causal relationships between senior nurses’ attitudes and associated factors. Further longitudinal study designs are needed to address this problem. Second, our study participants were senior nurses recruited from tertiary hospitals in Hunan Province using a convenience sampling method, which may limit the representativeness of the sample and the generalization of the study results. Future population-based studies recruiting nurses in various areas of China are warranted to get a nationally representative sample. Third, the evaluation of knowledge and attitudes related to NPs was based on a self-developed assessment tool that has not been widely used and validated by international studies. Though the scale was developed to fit the Chinese context and showed good reliability and validity by our research team in a previous study, further validation among other populations in other countries is needed. Fourth, the assessment of senior nurses’ perceived facilitators and barriers was based on a structured questionnaire instead of unstructured interviews, which may limit the scope of responses and miss some critical information. Future studies may consider conducting a mixed-method study to combine both quantitative questionnaires and qualitative interviews to get a more comprehensive picture. Finally, we only included limited variables in exploring factors associated with senior nurses’ attitudes toward NPs and identified only two significant factors. Future studies should consider adding a broad range of potential factors to comprehensively understand associated factors that shape senior nurses’ attitudes toward NPs.

Implications

As the first study to comprehensively investigate senior nurses’ knowledge and attitudes toward NPs in China, our findings provide essential political, research, and clinical implications to improve the development and implementation of NPs in China. First, the government should develop legislation and regulations focusing on NPs, with national strategies and plans in place to provide a clear direction to the development of NPs, including their roles, scope of practice, entry criteria, certification, funding, reimbursement, etc. Second, nursing education should be strengthened, focusing on developing and popularizing NP educational programs, including designing courses, strengthening clinical education and preceptorship, and evaluating teaching effects. Third, multidisciplinary and multisector collaborations should be encouraged and enhanced to nurture positive relationships within the medical team, especially between physicians and nurses, strengthening communication, respect, trust, and co-decision-making. Fourth, more public campaigns are needed to improve the public’s knowledge and awareness of NPs, with a particular focus on eliminating misunderstandings about the safety and effectiveness of NPs’ practice.

Conclusion

Our study suggests that senior nurses’ knowledge of NPs is moderate, and there is still much room for improvement. Senior nurses with higher professional titles and more knowledge of NPs have more positive attitudes toward NPs. To promote the implementation of NP roles in China, we need more education and training programs, more supportive policies and regulations, and more understanding from the patients, doctors, and nurses. Our findings provide important insights into Chinese senior nurses’ knowledge and attitudes toward NPs and helpful guidance to inform policy priorities for developing further quality improvement programs to strengthen the education, research, and services of NPs in the future.