Occupational Category and Professional Title Influencing the Knowledge,Attitudes and Practice (KAP) of Quality Training: A Cross-Sectional Survey From a Tertiary General Hospital

Abstract

Quality improvement is an international priority, and quality education and training are important parts of hospital quality management. The aim of this study was to understand the knowledge, attitudes and practices (KAP) and its influencing factors related to quality training in medical staff. A questionnaire survey was conducted by convenience sampling to assess the KAP of quality training in Taizhou Enze Medical Center. Principal component analysis was used to extract factors from the questionnaire. Descriptive statistics (frequency, median, mean), Kendall grade correlation analysis, and Mann–Whitney U tests were used to analyze the data. A total of 205 staff members participated in the questionnaire survey. For the 5 factors of the KAP scale, the highest score was factor F4, recognition and support for quality training (mean = 90.55, median = 100), followed by factor F3, perceived benefits (mean = 84.46, median = 85.65). Relatively lower scores were found for factor F2, quality knowledge learning and mastery (mean = 63.09, median = 63.89), and F5, quality management practices and sharing (mean = 82.07, median = 75.00). There was a correlation between the 5 factors. The scores of F2 (quality knowledge learning and mastery) for staff with senior professional titles were higher than those for staff with intermediate professional titles or below. The score of F3 (perceived benefits of quality training) in medical technicians and nurses was higher than in doctors and administrative personnel. Our findings showed that the respondents’ attitude toward quality training was positive, but their knowledge mastery and practice behaviors should be further improved. Occupational category and professional title were the influencing factors of the quality training KAP. Therefore, hospital should conduct quality management training at a wider scope according to the competency requirements of different groups, and further optimize the improvement and innovation system.

Keywords

health knowledge attitudes practice training programs quality improvement surveys and questionnaires medical staff

What do we already know about this topic?

Quality improvement is an international priority, and quality education and training are important parts of hospital quality management.

How does your research contribute to the field?

Occupational category and professional title were the influencing factors of the quality training KAP.

What are your research’s implications toward theory, practice, or policy?

Quality management training should be conducted at a wider scope according to the competency requirements of different groups.

Introduction

Hospital quality management is important for hospitals, health care staff and patients. Quality education and training is one of the main tasks of hospital quality management, and medical personnel need to learn how to design improvements to services.^1,2 Hospital quality management training can help medical staff grasp the knowledge and the skills of quality management, strengthen the quality awareness, and improve the efficiency and quality of medical work. And then, medical staff can provide a more safe, effective and humanize medical services for their patients, which can improve the competitiveness of the hospital. In the criteria of rank hospital appraisal in China, it is proposed that hospital and department leaders should participate in management training regularly and be able to use quality management tools to improve their management level.

Quality management tools, such as the Plan-Do-Check-Act (PDCA) Cycle, Quality Control Circles (QCC) and Lean, have been used in the health care industry worldwide, which have been found to effectively improve medical quality, safety, and processes and to increase work efficiency.^3-8

Taizhou Enze Medical Center has 4 campuses (Taizhou Hospital, Enze Hospital, Rehabilitation Hospital, and Maternity Hospital) with more than 4000 beds and over 7000 employees. In 2001, Taizhou Hospital cooperated with General Electric Company of the United States (GE) to establish the first Six Sigma quality management training center in the Asia-Pacific region and launched the first Six Sigma Green Belt training class. Subsequently, the medical center continuously introduced improvement tools such as rationalization suggestion activities, 5S management, clinical pathways, and lean, forming a comprehensive lean continuous improvement model. Quality training courses were conducted every year in our hospital, including Lean Six Sigma classes and quality basic classes. The training method was theoretical training followed by mentoring participants to conduct an improvement project, with a training period of 6 to 9 months. Up to date, a total of 523 hospital staff have participated in the quality training course.

In China, many hospitals have conducted quality management education and training. However, few studies have evaluated the effectiveness of the quality management education and training. In the KAP model, changes to human behavior have 3 continuous processes, including acquiring knowledge, generating belief (attitude) and forming behavior (practice). KAP theory has been widely used in the field of health education.^9-12 In this study, KAP theory was applied to design a questionnaire to understand the knowledge, attitudes and practices and the influencing factors related to quality training. The finding of this study could provide decision-making basis for the next round of training course design in our medical center, and might provide a reference for peers to optimize the system of the quality management education and training.

Materials and Methods

Participants

This cross-sectional study was conducted in Taizhou Enze Medical Center from February to March 2023. The participants were the medical staff who had attended the quality training courses in Taizhou Enze Medical Center. Personnel who have never participated in quality training were excluded.

There were 26 questions in the questionnaire, requiring at least 130 samples calculated by 5 times the numbers of questions.¹³ According to literature reports, assuming a minimum response rate of 25%, 520 questionnaires were planned to send out.

An online survey platform called Wenjuanxing was used to generate the weblink for the questionnaire. The survey was distributed to the participants via WeChat groups, which had been set up during the quality training courses and included a total of 523 members. Prior to survey distribution, a trained investigators explained the study’s purpose and the main contents of the questionnaire. The informed consent of the subjects was obtained in the first page of the questionnaire. Respondents could only start the survey after checking “agree” under the informed consent form. Each participant had the right to decide whether to participate in the study and could withdraw from the study at any time. If the participants had any questions about the questionnaire, they could contact the investigators via telephone or WeChat. All individual’s personal information has been desensitized and the electronic data were maintained by the research team.

Study Tool

We have held quality training for more than 20 years, and met the bottleneck of continual improvement in recent years, The team launched a brainstorming session and used a cause and effect diagram to find out the possible influencing factors of quality training (Figure 1).

Figure 1.

Cause and effect diagram for the problems in quality training.

Based on the theory of KAP, a questionnaire was designed on the quality management training. The questionnaire was divided into 3 parts: (1) the demographics of the respondents, (2) the staff’s knowledge, attitudes, and practices related to quality training, and (3) suggestions for quality training courses.

The thematic framework of the quality training survey was shown in Figure 2. For knowledge, 2 themes were included: the evaluation of quality training courses (4 questions) and the daily learning of quality knowledge (2 questions). For attitude, 2 themes were included: perceived benefits (2 questions) and recognition and support for the quality training courses (2 questions). For practice, there were 2 questions in the theme of practice and sharing.

Figure 2.

The thematic framework of the quality training survey.

Scoring of Questions

There were several possible options in response to each question, and respondents chose an answer based on their recollection of quality training experience and their own feelings. The responses were scored. For example, for the option “Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree”, positive questions were assigned 1, 2, 3, 4, and 5 points, respectively. The options “never, rarely, sometimes, often” were assigned 1, 2, 3, and 4 points, respectively. On a scale of 1 to 10, option 1 = 1, 2 = 2. . ., and choice 10 = 10 points. The higher the score, the better level of the quality training KAP.

To unify the scale and facilitate comparison, the digitized scores were converted into percentile scores using the following formula¹⁴:

Score = [(X-min) / (Max-min)] * 100

For example, for assignments 1 to 5, Max = 5 and min = 1. For assignments 1 to 10, Max = 10, and min = 1.

Statistical Analysis

Excel 2013 was used for data entry, and SPSS 23.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Cronbach’s α was used to evaluate the internal consistency of the scale, and exploratory factor analysis was used to test the structural validity. Descriptive statistics (frequency and percentage) were used for the respondents’ characteristics. Descriptive statistics (minimum, maximum, mean, standard deviation and median) were used to describe the scores of each item and factor.

Because the scores of each factor did not follow a normal distribution, the correlation between factors was analyzed by Kendall grade correlation. The basic information of the respondents was grouped according to different characteristics, the median (lower quartile – upper quartile) form was used to describe the scores of different groups, and 2 or K independent-samples nonparametric tests (Kruskal–Wallis test) were used to compare the scores of different groups. P < .05 was considered statistically significant.

Results

Characteristics of Subjects

The response rate for this study was 39.20% (205/523). A majority (65.85%, 135) of the respondents were from Taizhou Hospital, followed by Enze Hospital (28.29%, 58). The respondents were from different departments, with internal medicine departments accounting for 33.66% (69), surgery departments accounting for 36.10% (74) and medical technology departments accounting for 15.61% (32). The majority of the respondents were female (67.80%, 139) and aged 30 to 49 years (90.24%, 185). Most of the respondents had a high professional title (66.83%, 137) and management experience (77.07%, 158). The respondents’ characteristics were presented in Table 1.

Table 1.

Respondents’ Characteristics.

Variable	ParticipantsNo. (%)
Campus
Taizhou Hospital	135 (65.85)
Enze Hospital	58 (28.29)
Others	12 (5.85)
Department category
Department of internal medicine	69 (33.66)
Department of surgery	74 (36.10)
Medical technology department	32 (15.61)
Administrative department	30 (14.63)
Gender
Male	66 (32.20)
Female	139 (67.80)
Age, years
≤30	2 (0.98)
30-39	91 (44.39)
40-49	94 (45.85)
50-59	17 (8.29)
≥60	1 (0.49)
Occupational category
Doctor	68 (33.17)
Nurse	96 (46.83)
Pharmacist/technician	18 (8.78)
Administrative personnel	23 (11.22)
Professional title
Junior or below	5 (2.77)
Intermediate	63 (30.73)
Vice-senior	93 (45.37)
Senior	44 (21.46)
Management experience (years)
1-4	68 (33.17)
5-9	40 (19.51)
10-19	43 (20.98)
≥20	7 (3.41)
Never	47 (22.93)
Current position
Hospital leader	4 (1.95)
Middle manager	127 (61.95)
Management assistant	32 (15.61)
Reserve manager	35 (17.07)
Others	7 (3.41)

Of the 205 respondents, 198 (96.59%) completed the theoretical training. Of the 198 participants, 151 (76.26%) had participated in quality training in the past 5 years.

Reliability and Validity of the Quality Training KAP Scale

The Cronbach’s α coefficient of the KAP scale in the study was 0.86, indicating that the questions had high internal consistency. KMO = 0.78 and Bartlett’s test of sphericity P < .001 showed that the data were suitable for factor analysis. The principal component analysis method was used to extract factors, the number of factors was set according to the theoretical framework of the research, and “Promax” was used to rotate the factors. According to the factor loading matrix, the factor structure was determined. The factors were named F1, evaluation of quality training courses; F2, quality knowledge learning and mastering; F3, perceived benefits; F4, recognition and support for quality training; and F5, quality management practice and sharing. The factors obtained from the analysis were consistent with the preset model, indicating good structural validity.

Knowledge, Attitudes, and Practice Scores

The scores of the 5 factors and 12 core questions of quality training KAP are shown in Table 2. The highest score was F4, recognition and support for quality training (mean = 90.55, median = 100), followed by F3, perceived benefits (mean = 84.46, median = 85.65). The relatively lower scores were F2, quality knowledge learning and mastery (mean = 63.09, median = 63.89) and F5, quality management practices and sharing (mean = 82.07, median = 75.00).

Table 2.

Item and Factor Scores of Quality Training KAP.

	n	Minimum	Maximum	Mean	Standard deviation	Median
F1, evaluation of quality training courses	198	0.00	100	80.30	16.16	81.25
Q1 Training courses suiting for work and personal development	198	0.00	100	81.19	18.76	75.00
Q2 The training course’s difficulty moderate	198	0.00	100	76.89	19.50	75.00
Q3 Through training, I have acquired new knowledge and ideas applicable to my work	198	0.00	100	84.72	17.55	75.00
Q4 Through training, I have mastered the management methods and tools	198	0.00	100	78.41	19.78	75.00
F2, quality knowledge learning and mastering	205	27.78	100	63.09	14.89	63.89
Q5 Daily acquisition of quality management knowledge	205	33.33	100	67.64	16.40	66.67
Q6 Sufficient knowledge to carry out quality management activities	205	0.00	100	58.54	19.18	50.00
F3, perceived benefits	205	34.72	100	84.46	12.38	85.65
Q7 Quality training is a great help to my management	205	25.00	100	84.15	16.38	75.00
Q8 The benefits of the department from quality management activities	205	34.57	100	84.77	12.11	86.42
F4, recognition and support for quality training	205	0.00	100	90.55	13.61	100
Q9 It is necessary for managers to receive quality management training	205	0.00	100	90.00	14.56	100
Q10 I will actively encourage the department’s key personnel to participate in quality training	205	0.00	100	91.10	13.89	100
F5, quality management practice and sharing	205	25.00	100	82.07	16.24	75.00
Q11 I have continuously applied the quality management knowledge I have learned to the operation management of the department	205	25.00	100	83.54	15.86	75.00
Q12 I shared my quality management knowledge with colleagues in the department and guided them to carry out improvement projects	205	25.00	100	80.61	18.50	75.00

Factor Correlation Analysis

The correlation coefficient between F1 and F3 is .53, indicating a moderate positive correlation between the evaluation of the quality training course and the perceived benefit. The correlation coefficient between F3 and F4 is .48, indicating a moderate positive correlation between the perceived benefit and attitude toward quality training. The correlation coefficients between F5 and the other 4 factors are greater than 0.40, indicating a moderate correlation between behavior and knowledge, and between behavior and attitude.

Analysis of Influencing Factors

According to the characteristics of the respondents, the scores of the 5 factors of quality training KAP were shown in Table 3. The score of F1(evaluation of quality training courses) in the respondents with less than 4 years of management experience was higher than the respondents with more than 4 years of management experience (P < .05). The score of F1 (evaluation of quality training courses) in the respondents who had attended quality training within 2 years was higher than the respondents who had attended quality training more than 2 years ago (P < .05). The score of F2 (quality knowledge learning and mastering) in the respondents with senior title professionals was higher than these respondents with intermediate or below groups (P < .05). The score of F3 (perceived benefits) in medical technicians and nurses was higher than in doctors and administrative personnel (P < .05). The score of F4 (recognition and support for quality training) in Taizhou Hospital was lower than in the branch campuses (P < .05).

Table 3.

Influencing Factors Analysis of the Quality Training KAP.

	F1, evaluation of quality training coursesM (P25, P75)	F2, quality knowledge learning and masteringM (P25, P75)	F3, perceived benefitsM (P25, P75)	F4, recognition and support for quality trainingM (P25, P75)	F5, quality management practice and sharingM (P25, P75)
Campus
Taizhou Hospital	81.25 (75.00, 87.50)	62.50 (52.78, 75.00)	85.65 (77.62, 94.44)	100 (75.00, 100)	75 (75 100)
Other campuses	81.25 (75.00, 93.75)	63.89 (58.33, 75.35)	86.27 (78.24, 94.44)	100 (87.50, 100)	87.5 (75 100)
Z	−1.65	−0.62	−0.27	−2.13	−0.34
P	.10	.53	.79	.03*	.74
Occupational category
Doctor	81.25 (75.00, 87.50)	63.89 (52.78, 76.39)	81.94 (74.69, 93.21)	100 (75.00, 100)	75 (75 100)
Nurse	81.25 (75.00, 93.75)	58.34 (52.78, 70.84)	86.96 (80.71, 96.14)	100 (75.00, 100)	75 (75 100)
Pharmacist/technicians	81.25 (75.00, 93.75)	70.83 (58.33, 72.22)	92.90 (80.86, 95.37)	100 (75.00, 100)	87.5 (75 100)
Administrative personnel	75.00 (56.25, 93.75)	63.89 (52.78, 76.39)	81.94 (72.68, 93.21)	100 (75.00, 100)	87.5 (75 100)
χ²	3.52	2.87	9.79	0.94	1.05
P	.32	.41	.02*	.82	.79
Management experience (years)
1-4	84.38 (75.00, 93.75)	59.72 (52.78, 75.00)	87.50 (80.09, 94.44)	100 (75.00, 100)	75 (75 100)
5-9	75.00 (68.75, 85.94)	58.33 (45.83, 73.96)	81.02 (73.46, 93.21)	87.50 (75.00, 100)	81.25 (75 100)
≥10	81.25 (68.75, 87.50)	70.14 (58.33, 75.35)	83.26 (79.32, 93.98)	100 (84.38, 100)	75 (75 100)
χ²	7.35	3.78	4.62	3.50	0.45
P	0.03*	0.15	0.10	0.17	0.80
Professional title
Intermediate title or below	81.25 (75.00, 93.75)	58.33 (52.78, 70.83)	87.89 (80.25, 94.91)	100 (75.00, 100)	75 (75 100)
Vice-senior title or above	81.25 (70.31, 92.19)	69.44 (53.47, 76.39)	82.56 (76.70, 93.83)	100 (75.00, 100)	75 (75 100)
Z	−1.49	−2.03	−1.30	−0.64	−0.64
P	.14	.04*	.19	.52	.52
How many years has it been since you last attended a training class?
1-2	87.50 (75.00, 95.31)	61.81 (57.29, 76.39)	87.89 (80.56, 97.22)	100 (75.00, 100)	81.25 (75 100)
3-5	75.00 (68.75, 87.50)	63.89 (52.78, 75.00)	82.56 (76.39, 94.14)	100 (75.00, 100)	75 (75 100)
6-10	81.25 (68.75, 87.50)	58.33 (53.82, 70.83)	83.18 (77.47, 92.75)	100 (75.00, 100)	75 (75 100)
>10	81.25 (71.88, 96.88)	70.83 (58.33, 76.39)	82.56 (77.93, 95.68)	100 (75.00, 100)	87.5 (75 100)
χ²	9.63	3.22	4.61	0.64	1.69
P	.02*	.36	.20	.89	.64

The difference between groups was statistically significant (P less than 0.05).

Discussion

Training and Knowledge

Respondents who had held management position within 4 years or had participated in quality training within 2 years had higher evaluations on the quality training. A possible reason was that newly hired managers and reserve managers were the target groups for the quality training. They had participated in the quality training recently and still had strong memories of it, which might lead them to give a high evaluation to the quality training course. In addition, questionnaire survey was carried out after each quality training program. According to the problems which was found in the survey, we optimized the course content, the training methods and the quality training system.¹⁵

Among the 5 factors, the score of F2 (learning and mastering quality knowledge) was lowest, which was indicated that the hospital staff’s quality knowledge was insufficient. Their motivation of continuous quality learning should be further stimulated. The score of F2 (quality knowledge learning and mastery) in respondents with senior professional titles was higher than in these respondents with intermediate professional titles or below. It might be due to staffs with senior professional titles had more opportunities to participate in various quality training. They might be greatly affected by the quality culture of hospitals and had cultivated the habit of actively acquiring quality knowledge.

Training was a long-term work, which was not an activity completing at one time. The organizational environment of hospital was constantly changing and posing challenges for managers. Competency-based educational approach might contribute to reducing the theory-practice gap and promoting continuous competency development.^16,17 Hospitals should formulate quality training contents in categories according to knowledge and skill needs of different positions. For example, the training contents for staff with intermediate or below professional title were mainly quality tools and methods, such as 5S and 7 Quality Control Tools, which aimed to improve staff’s ability of problem solving related to their positions or processes. For personnel with senior professional title, training courses were designed based on systematic approaches to problem-solving, such as performance excellence model, TQM, Six Sigma, and lean production.

Attitude

According to literature reports, Lean Six Sigma method was widely used in the operating room and medical technology department,^18,19 which was consistent with this study. The score of F3 (perceived benefits of quality training) in medical technicians and nurses was higher than in doctors and administrative personnel, which might be related to project selection, project scope and success of improvement. For example, the laboratory department used the lean tool of Takt Time to shorten the waiting time for the blood drawing window, and the radiology department successfully carried out projects to shorten the waiting time for examination by using value stream maps. Nursing staff were extensively involved in hospital and department improvement projects, such as reducing nursing defects and improving medical service processes and patient experience. Their success stories were shared within and outside the hospital, and then provided recognition and motivation.

Among the 5 factors, the score of F4 (recognition and support for quality training) was the highest, which indicated that medical staff had a positive attitude toward quality training overall. The respondents in the branch campuses scored higher on recognition and support of quality training than these respondents in Taizhou Hospital. The branch campuses’ development history was shorter, and their management cadres were relatively younger than Taizhou Hospital. However, each campus in the medical center were required to implement homogenized management. Therefore, managers in branch campuses might have a higher desire for training.

The hospital should further optimize the improvement and innovation system, including the project management procedures (project selection, project approval, tracking and summarizing) and recognition system.

Practice

There is a correlation between behavior and knowledge, and between behavior and attitude, which conforms to the KAP model theory. Knowledge is the foundation of behavior change, and belief and attitude are the driving forces of behavior change. The behavior score of medical technicians (median = 87.50) and administrative personnel (median = 87.50) were higher than that of doctors (median = 75.00) and nurses (median = 75.00). Administrative personnel had an advantage in coordinating resources to solve problems, and the medical technology sectors were more likely to implement improvements successfully than doctors and nurses in clinical department. Juran’s Quality Handbook mentioned that uncertainty might reduce the confidence of quality improvements.²⁰ Hospitals should make further authorization in quality improvement, solve the barriers of cross-departmental improvement and build a culture of continuous improvement. In addition, the busy daily clinical work might impact the doctors and nurses to participate in improvement.^21,22 In this study, 41.95% (86) of the respondents believed that the main obstacle of participating in quality training and completing the improvement project was time insufficient. It was important to mobilize the enthusiasm of medical staff to participate in quality management.²³

This study reflected that the resources allocation such as human and time for clinicians and nurses was inadequate or improper in the practice of quality improvement. The structure of project team members should be optimized, especially for cross functional projects. Administrative personnel who have received quality training could join the project team to empower the clinical team, and play a role in problem definition, data collection and statistical analysis, so that clinicians and nurses can devote more time and energy to process improvement.

Limitations

There are several limitations to this study. Firstly, selection bias might have been introduced in this study due to the questionnaire was voluntary. Secondly, some respondents participated in the quality training in an earlier year, which might introduce recall bias in the evaluation. Thirdly, the questionnaire was conducted in the campuses of Taizhou Enze Medical Center, and other hospitals in the area were not included, which might affect the research results.

Conclusion

The results of this study showed that the respondents’ attitude toward quality training was positive, but their knowledge mastery and practice behaviors should be further improved. Occupational category and professional title were the influencing factors of the quality training KAP. Therefore, hospital should conduct quality management training at a wider scope according to the competency requirements of different groups, and further optimize the improvement and innovation system.

Supplemental Material

sj-doc-1-inq-10.1177_00469580241249425 – Supplemental material for Occupational Category and Professional Title Influencing the Knowledge, Attitudes and Practice (KAP) of Quality Training: A Cross-Sectional Survey From a Tertiary General Hospital

Supplemental material, sj-doc-1-inq-10.1177_00469580241249425 for Occupational Category and Professional Title Influencing the Knowledge, Attitudes and Practice (KAP) of Quality Training: A Cross-Sectional Survey From a Tertiary General Hospital by Ling-Feng Zhu, Xi-Feng Wang, Hai-Xiao Chen, Qiao Liu, Lin-Hong Zhu and Qian-Shan Ying in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-doc-2-inq-10.1177_00469580241249425 – Supplemental material for Occupational Category and Professional Title Influencing the Knowledge, Attitudes and Practice (KAP) of Quality Training: A Cross-Sectional Survey From a Tertiary General Hospital

Supplemental material, sj-doc-2-inq-10.1177_00469580241249425 for Occupational Category and Professional Title Influencing the Knowledge, Attitudes and Practice (KAP) of Quality Training: A Cross-Sectional Survey From a Tertiary General Hospital by Ling-Feng Zhu, Xi-Feng Wang, Hai-Xiao Chen, Qiao Liu, Lin-Hong Zhu and Qian-Shan Ying in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors acknowledge Yu Zhang for help with language editing.

Author Contributions

Ling-Feng Zhu: Conceptualization, Writing - Review & Editing; Xi-Feng Wang: Formal analysis; Hai-Xiao Chen: Project administration; Qiao Liu: Data Curation; Lin-Hong Zhu: Writing - Original Draft; Qian-Shan Ying: Investigation. All authors contributed to the article and approved the submitted version.

Data Availability

Data are available on request to the corresponding author.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval and Consent

This study exempted from ethical approval, although informed consent was obtained from the participant before carrying out the study.

ORCID iD

Lin-Hong Zhu

Supplemental Material

Supplemental material for this article is available online.

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