
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12522-4
10.1016/j.heliyon.2024.e36491
e36491
Research Article
Knowledge, attitudes, and practices regarding perioperative neurocognitive disorders among anesthesia practitioners
Luo Yi
Shen Zijin
Wang Haibin
Dong Rong sally9132@163.com
⁎
Department of Anesthesiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
⁎ Corresponding author. sally9132@163.com
16 8 2024
30 8 2024
16 8 2024
10 16 e364913 3 2024
14 8 2024
16 8 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Objectives

This study aimed to investigate the knowledge, attitudes, and practices (KAP) among anesthesia practitioners concerning perioperative neurocognitive disorders (PND).

Methods

This cross-sectional study enrolled anesthesia practitioners from 18 hospitals in China using s self-administered questionnaire between July and September 2023.

Results

A total of 200 (98.04 %) valid questionnaire were enrolled, the responders of which aged 36.56 ± 8.24 years, including 130 (65 %) females. The mean KAP scores were 12.28 ± 3.78 (possible range: 0 20),29.22 ± 3.28 (possible range: 8–40), and 29.32 ± 4.30 (possible range: 8–40), respectively. The path analysis demonstrated that number of daily surgical cases (β = 0.82, p = 0.018), education (β = 1.49, p < 0.001), and participation in a related research project (β = 1.32, p = 0.003) had direct effects on knowledge. Working in teaching hospital has direct effect on attitude (β = 1.82, p = 0.027). Furthermore, knowledge (β = 0.29, p < 0.001) and attitude (β = 0.20, p = 0.026) also have direct effects on practice.

Conclusions

Anesthesia practitioners had inadequate knowledge, positive attitude, and proactive practice towards PND. Number of daily surgical cases, education, participation in a related research project, and working in teaching hospital might have effects on their KAP.

Highlights

• Exploring KAP of anesthesia healthcare workers on perioperative neurocognitive disorders (PND).

• Inadequate knowledge but positive attitudes and proactive practices among anesthesia healthcare workers on PND.

• Tailored education needed for anesthesia healthcare workers to address knowledge gaps on PND and enhance patient care.

Keywords

Knowledge
Attitudes
Practices
Anesthesia practitioners
Perioperative neurocognitive disorders
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pmc1 Introduction

Perioperative neurocognitive disorders (PND) constitute a prevalent and serious complication in surgical patients, particularly in elderly patients [[1], [2], [3]]. Characterized by a decline in memory, attention, and speed of information processing, PND manifests both in acute forms and in prolonged forms, significantly impeding postoperative recovery and extending hospital stays, thereby contributing to elevated mortality rates [4]. The incidence of PND ranges from 41 to 75 % at 7 days to 18–45 % at 3 months postoperatively [5]. These disorders encompass pre- and post-operative reductions in hippocampus-dependent cognitive functions, involving disturbances in memory, consciousness, and attention, along with alterations in personality [6,7]. Recognizing the pervasive impact of PND underscores the imperative for comprehensive perioperative care strategies aimed at mitigating these cognitive complications and optimizing patient outcomes.

The Knowledge-Attitude-Practice (KAP) model exerts a pivotal influence on the formulation of health behaviors. Commonly utilized in conjunction with the KAP questionnaire, this framework facilitates a thorough assessment of the target population's knowledge, attitudes, and practices within the healthcare sector [8,9]. Additionally, it evaluates both the demand and acceptance of pertinent information. Central to the concept of health literacy, the model is founded on the essential principle that knowledge positively impacts attitudes, which subsequently inform and shape individual practices. Previous research has indicated that KAP related to postoperative delirium among Chinese cardiac surgery nurses are promising [10]. There is a noted need for improvement in their familiarity with screening tools and the implementation of perioperative nonpharmacological interventions. Moreover, their practice of delirium screening requires enhancement. Attitudes appear to serve as a mediator between knowledge and practice concerning postoperative delirium. However, the management of hyperactive delirium by registered nurses specializing in perioperative care in Australia does not reflect the ideal scenario [11]. Considering the vital role played by anesthesia practitioners in perioperative neurocognitive care, this study focuses on their responsibilities in anesthesia administration during surgical procedures, with potential impacts on perioperative neurocognitive disorders influenced by surgical and anesthetic factors. Additionally, through an assessment of the cognitive proficiency of anesthesia practitioners, the research aims to illuminate potential risks faced by patients during surgery, offering targeted recommendations for improving medicate of neurocognitive in the perioperative period. Furthermore, an understanding of the attitudes and practices of practitioners facilitates the identification of latent issues within existing practices, establishing a foundation for advancing superior perioperative care. It is noteworthy that, within this domain, there is a notable absence of KAP studies, highlighting the significance of investigating this specific healthcare provider group. Therefore, this study aimed to investigate the KAP among anesthesia practitioners concerning PND.

2 Methods

2.1 Study design and participants

This cross-sectional study enrolled anesthesia practitioners from 18 hospitals in Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine between July and September 2023. Inclusion criteria: 1) Obtain Chinese medical or nursing qualification certificate. 2) Commit and cooperate to complete the questionnaire survey. Those disagree with the informed consent was excluded. The study was approved by the appropriate Institutional Review Board of the Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Written informed consent was obtained from all subjects. This manuscript adheres to the applicable STROBE guidelines.

2.2 Questionnaire

The questionnaire was designed according to “Improving Perioperative Brain Health: Perioperative Management Teams”, “Perioperative Neurocognitive Disorders: From Postoperative to Preoperative, from Clinical Metrics to Biological Metrics”, and “Expert Consensus on Preventing and Treating Postoperative Delirium in Adults” along with relevant literature [12]. Subsequent to the initial draft, the questionnaire underwent refinement following feedback from domain experts and underwent a small-scale pilot test garnering 33 responses. The internal consistency of the questionnaire was assessed using Cronbach's α, yielding a robust value of 0.8551, affirming the reliability of the instrument. Supplementary Table 1 and Supplementary Fig. 1 presents the confirmatory factor analysis for each question [13].

The final questionnaire, presented in Chinese, encompassed four distinct dimensions for data collection, featuring a total of 43 items distributed across 12 in the basic information dimension, 11 in the knowledge dimension, 8 in the attitude dimension, and 13 in the practice dimension. During the subsequent statistical analysis, scores were assigned based on the number of items. In the knowledge dimension, responses “very knowledgeable,” “heard of,” and “not sure” were assigned 2, 1, and 0 points, respectively, resulting in a potential score range of 0–22. The attitude and practice dimensions primarily employed a five-point Likert scale, ranging from very positive (5 points) to very negative (1 point) for attitude dimension scoring. The scoring protocol for attitude encompassed assigning scores of a = 5, b = 4, c = 3, d = 2, e = 1 for items 1/2/4/7, and a = 1, b = 2, c = 3, d = 4, e = 5 for items 3/5/6/8, yielding a score range of 8–40. Meanwhile, the practice dimension adopted a scoring system where items 1–8 were scored a = 5, b = 4, c = 3, d = 2, e = 1, and items 9–13 were not scored but served for descriptive purposes, resulting in a potential score range of 8–40. Attaining scores exceeding 70 % of the maximum in each section indicated a satisfactory level of knowledge, positive attitude, and proactive practice [14].

2.3 Distribution and quality control

All research assistants in this study are members of the research team who underwent rigorous training covering various aspects such as the research theme, questionnaire content, guidelines for questionnaire distribution and collection, criteria for screening questionnaires, and data entry procedures. Utilizing convenient sampling, electronic questionnaires were disseminated to participants through academic conferences and WeChat groups. The subjects included in this study were divided into two parts: First, participants in an academic conference on anesthesia were encouraged to scan the QR code to complete the questionnaire, and there were about 300 registered participants at that time. Second, we send QR code through WeChat groups to the director of anesthesiology department of each hospital, who further encouraged their department staff to fill in the questionnaire, it is estimated that the total number of anesthesiology department staff of each hospital is about 800.

To ensure quality control, respondents were required to complete the questionnaire through WeChat login, limiting each IP address to one completed questionnaire. Questionnaires completed in less than 120 s, the option does not follow normal logic, any part of KAP questionnaire selects the same option were considered invalid questionnaire.

2.4 Statistical analysis

Data analysis was conducted using SPSS 22.0 (IBM, Armonk, NY, USA). Continuous data are presented as means and standard deviations (SD), while categorical data are expressed as n (%). Continuous variables underwent a normality test, with the t-test applied to normally distributed data for comparing two groups and ANOVA used for comparing three or more groups. In order to determine the path relationship among basic characteristics and KAP scores, path analysis was performed based on the following hypotheses: 1) Variables with significant differences in KAP scores between different subgroups of basic characteristics have an effect on KAP. 2) Knowledge have effects on attitude. 3) Knowledge and attitude have effects on practice. A two-sided P-value less than 0.05 was considered statistically significant.

3 Results

Initially, a total of 204 questionnaire were collected, including 2 responders with response time <120s, 1 case with options did not follow normal logic, and 1 case with two part of KAP questionnaire selects the same option. Leaving 200 (98.04 %) cases of valid questionnaire. Among them, 130 (65 %) were female, the mean age was 36.56 ± 8.24 years, and 102 (51 %) were 30–39 years old. 130 (65 %) were doctors, and 76 (38 %) had been working in their specialty for 10–15 years. 93 (46.5 %) reported 50–100 surgical cases daily in their medical Centre. The mean KAP scores were 12.28 ± 3.78 (possible range: 0–20),29.22 ± 3.28 (possible range: 8–40), and 29.32 ± 4.30 (possible range: 8–40), respectively. The knowledge score varied from participants with different occupation type (P＜0.001), education (P＜0.001), number of daily surgical cases at their medical center (P = 0.004), and research project status (P＜0.001). In terms of attitude score, there were difference among participants with different gender (P = 0.041), number of daily surgical cases at their medical center (P＜0.001), and whether their hospital a teaching hospital (P = 0.032). In addition, no significant differences were found in practice scores by demographic characteristics (Table 1).Table 1 Demographic characteristics and KAP scores.

Table 1Variables	N (%)	Knowledge Score	Attitude Score	Practice Score	
Mean ± SD	P	Mean ± SD	P	Mean ± SD	P	
N = 200								
Total Score		12.28 ± 3.78		29.22 ± 3.28		29.32 ± 4.30		
Gender			0.067		0.041		0.391	
 Male	70 (35)	11.57 ± 4.14		28.57 ± 3.36		29.82 ± 4.73		
 Female	130 (65)	12.65 ± 3.52		29.56 ± 3.18		29.04 ± 4.03		
Age (years)	36.56 ± 8.24							
Age (group)			0.353		0.316		0.953	
 <30	36 (18)	11.33 ± 3.74		28.66 ± 3.32		29.05 ± 4.18		
 [30,40)	102 (51)	12.33 ± 3.79		29.66 ± 2.92		29.5 ± 4.11		
 [40,50)	40 (20)	12.85 ± 3.87		28.95 ± 3.93		29.2 ± 5.43		
 ≥50	22 (11)	12.5 ± 3.52		28.5 ± 3.36		29.13 ± 3.01		
Occupation type			<0.001		0.639		0.638	
 Anesthesiologists	130 (65)	13.03 ± 3.93		29.11 ± 3.39		29.31 ± 4.11		
 Nurse	70 (35)	10.87 ± 3.02		29.4 ± 3.07		29.32 ± 4.63		
Education			<0.001		0.783		0.835	
 Bachelor's/College	128 (64)	11.21 ± 3.36		29.13 ± 3.40		29.32 ± 4.63		
 Master's	46 (23)	12.93 ± 3.69		29.52 ± 3.19		29.56 ± 3.67		
 Doctorate	26 (13)	16.30 ± 2.82		29.07 ± 2.81		28.88 ± 3.60		
Professional title			0.415		0.827		0.741	
 No Title	10 (5)	10.7 ± 3.62		28.5 ± 3.80		29.8 ± 4.77		
 Junior	44 (22)	12.27 ± 3.91		29.06 ± 3.15		28.68 ± 4.56		
 Intermediate	99 (49.5)	12.10 ± 3.68		29.45 ± 3.04		29.59 ± 4.20		
 Associate/Senior	47 (23.5)	12.97 ± 3.84		29 ± 3.78		29.23 ± 4.20		
Years of practice in the specialty			0.110		0.445		0.211	
 <5 years	38 (19)	11.23 ± 3.83		28.76 ± 3.37		28.47 ± 3.63		
 5–10 years	54 (27)	12.85 ± 4.51		29.29 ± 2.80		29 ± 3.85		
 10–15 years	76 (38)	12.05 ± 3.04		29.61 ± 3.42		30.15 ± 5.02		
 >20 years	32 (16)	13.06 ± 3.75		28.65 ± 3.56		28.87 ± 3.66		
Type of hospital			0.085		0.068		0.777	
 Tertiary Hospital	167 (83.5)	12.51 ± 3.73		29.41 ± 3.16		29.34 ± 4.13		
 Secondary Hospital	33 (16.5)	11.06 ± 3.79		28.21 ± 3.69		29.18 ± 5.12		
Teaching hospital			0.170		0.032		0.279	
 Yes	180 (90)	12.43 ± 3.71		29.38 ± 3.21		29.22 ± 4.13		
 No	20 (10)	10.85 ± 4.09		27.7 ± 3.58		30.2 ± 5.59		
Daily surgical cases			0.004		<0.001		0.103	
 <50 cases	46 (23)	10.65 ± 3.87		28.15 ± 3.50		28.43 ± 5.04		
 50–100 cases	93 (46.5)	12.45 ± 3.43		30.31 ± 2.82		29.94 ± 3.96		
 >100 cases	61 (30.5)	13.22 ± 3.86		28.34 ± 3.27		29.03 ± 4.09		
Participated in a related research project			<0.001		0.686		0.397	
 Yes	51 (25.5)	14.37 ± 3.52		29.37 ± 3.21		29.58 ± 3.98		
 No	149 (74.5)	11.55 ± 3.59		29.16 ± 3.30		29.22 ± 4.40		
Paper publication (Multiple choices)								
Has SCI papers	36 (18)							
Has papers in core journals	51 (25.5)							
Has papers in regular journals	44 (22)							
No publications	100 (50)							

The distribution of knowledge dimensions revealed that the questions with the highest number of participants choosing the “Well-known” option were “Preventive measures for delirium include immediately returning cognitive assistance devices (glasses, dentures, hearing aids, etc.) postoperatively. Protecting the patient's sleep-wake cycle is achieved through maintaining quietness, controlling lighting, and using earplugs. Encouraging the presence of relatives and friends or utilizing volunteer visits enhances social interaction. Relatives can assist in completing certain nursing tasks under supervision.” (K8) with 47.5 % On the other hand, the questions with the highest number of participants choosing the “Heard of” option were “Elderly surgical patients at risk of delirium should undergo delirium screening before emergency surgery and before leaving the Post-Anesthesia Care Unit (PACU). Subsequently, it is preferable to screen twice daily within 5 days or before discharge.” (K6) with 67.5 %. The distribution of responses on the attitude dimension showed that all participants agreed that PND are serious and should be taken seriously (A1). It is noteworthy that 44.5 % believed that PND are a side effect of surgery and cannot be avoided (A3), and 40 % believe that the overuse of sedation is unavoidable due to the patient's pain, discomfort, or inability to cooperate (A5). In addition, 84.5 % of participants agreed that PND are often overlooked in clinical anesthesia (A8). Participants had varied practices regarding preoperative (P1) and postoperative (P2) cognitive function screening, the largest proportion of participants (over 40 % in both cases) reported that it was only sometimes performed. When it comes to the factors that bring more attention to PND, the most common are patient factors (P9) and surgical factors (P10), 91.5 % and 92 % strongly agree or agree respectively (Table 2).Table 2 Distribution of Knowledge, Attitude, Practice Dimension, n (%).

Table 2Knowledge	N (%)	
Unclear	Heard of	Well-known	
1. Various forms of cognitive impairment during the perioperative period are categorized as PND. These include pre-existing cognitive dysfunction, acute postoperative delirium (within 7 days post-surgery), delayed neurocognitive recovery (within 30 days post-surgery), and postoperative neurocognitive disorders (from 30 days to 12 months post-surgery).

	8 (4)

	124 (62)	68 (34)	
2. Delirium and postoperative cognitive dysfunction are the most common perioperative complications in surgical patients aged 65 and older. PND prolongs hospitalization, increases the risk of severe complications, and reduces patients' quality of life.

	2 (1)

	109 (54.5)	89 (44.5)	
3. Postoperative cognitive dysfunction (POCD) is a common postoperative complication in elderly patients, characterized by mental confusion, anxiety, personality changes, and memory impairment. This postoperative change in personality, social skills, cognition, and skills is termed POCD.

	5 (2.5)

	107 (53.5)	88 (44)	
4. The diagnosis of POCD requires neuropsychological testing. International recommendations suggest the combined use of multiple dimensions of neuropsychological tests. In China, commonly used tests include the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). However, there is no internationally recognized test scale at present.

	27 (13.5)

	118 (59)	55 (27.5)	
5. Patients at risk of delirium and other perioperative cognitive dysfunction should undergo cognitive assessment, and the Mini-Cognitive Test (MiniCog) can be selected.

	37 (18.5)

	120 (60)	43 (21.5)	
6. Elderly surgical patients at risk of delirium should undergo delirium screening before emergency surgery and before leaving the Post-Anesthesia Care Unit (PACU). Subsequently, it is preferable to screen twice daily within 5 days or before discharge.

	39 (19.5)

	135 (67.5)	26 (13)	
7. Common delirium screening tools include the 4-Item Delirium Rapid Diagnostic Protocol, the Confusion Assessment Method, and the 3-Minute Diagnostic Interview for Confusion Assessment.

	42 (21)

	127 (63.5)	31 (15.5)	
8. Preventive measures for delirium include immediately returning cognitive assistance devices (glasses, dentures, hearing aids, etc.) postoperatively. Protecting the patient's sleep-wake cycle is achieved through maintaining quietness, controlling lighting, and using earplugs. Encouraging the presence of relatives and friends or utilizing volunteer visits enhances social interaction. Relatives can assist in completing certain nursing tasks under supervision.

	6 (3)

	99 (49.5)	95 (47.5)	
9. Many risk factors influence POCD, including advanced age, surgical type, anesthesia, and blood pressure.

	3 (1.5)

	119 (59.5)	78 (39)	
10. Postoperative delirium is the result of multiple factors working together. Common predisposing factors include advanced age, cognitive impairment or reduced cognitive reserve, reduced physiological reserve, decreased intake, comorbid diseases, the use of medications affecting mental activity preoperatively, alcoholism, or the use of a variety of preoperative medications.

	8 (4)

	133 (66.5)	59 (29.5)	
11. Adequate postoperative pain management is closely related to a reduced incidence of delirium. However, the use of meperidine for pain management should be avoided, and opioid medications should be titrated to the lowest effective dose to minimize side effects.

	8 (4)

	124 (62)	68 (34)	
Attitude	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	
1. PND are a very serious issue that requires adequate attention.

	147 (73.5)

	53 (26.5)	/	/	/	
2. Despite a busy workload, I believe that patients should receive sufficient cognitive care and attention.

	131 (65.5)

	60 (30)	9 (4.5)	/	/	
3. PND cannot be avoided and may be a side effect of surgery.

	26 (13)

	63 (31.5)	61 (30.5)	48 (24)	2 (1)	
4. I think more learning and training are needed for PND.

	125 (62.5)

	70 (35)	4 (2)	1 (0.5)	/	
5. I believe it is impossible to avoid overusing sedative medications because patients may experience pain, discomfort, or non-cooperation.

	15 (7.5)

	65 (32.5)	59 (29.5)	59 (29.5)	2 (1)	
6. I think it is more important to focus on the surgery itself rather than the patient's recovery process.

	16 (8)

	40 (20)	51 (25.5)	84 (42)	9 (4.5)	
7. I believe it is essential to actively explore various preventive measures and seek solutions to reduce the risk of patients developing neurocognitive disorders.

	127 (63.5)

	72 (36)	1 (0.5)	/	/	
8. I think PND are often overlooked in clinical anesthesia work.

	45 (22.5)

	124 (62)	24 (12)	6 (3)	1 (0.5)	
Practice	Always	Often	Sometimes	Rarely	Never	
1. Perform a simple cognitive screening for high-risk patients before surgery.

	18 (9)

	52 (26)	89 (44.5)	38 (19)	3 (1.5)	
2. Conduct cognitive function screening for high-risk patients in the recovery room or early postoperative period.

	10 (5)

	50 (25)	106 (53)	31 (15.5)	3 (1.5)	
3. Enhance cognition, provide compassionate care, strengthen perioperative care for high-risk individuals, offer a quiet and comfortable hospital environment, alleviate patient anxiety, and improve sleep quality.

	27 (13.5)

	69 (34.5)	89 (44.5)	13 (6.5)	2 (1)	
4. Minimize trauma and reduce the duration of surgery as much as possible during the procedure.

	28 (14)

	106 (53)	60 (30)	6 (3)	/	
5. Optimize anesthesia strategies, control the depth of anesthesia, reduce surgical stress, adjust the internal environment, and maintain hemodynamic stability.

This may involve reducing the use of inhaled anesthetics, using propofol or balanced anesthesia, and maintaining appropriate end-tidal CO2 levels.	80 (40)	92 (46)	21 (10.5)	7 (3.5)	/	
6. Provide effective postoperative pain management and encourage early mobilization of patients.

	65 (32.5)

	99 (49.5)	33 (16.5)	3 (1.5)	/	
7. Routine use of dexmedetomidine in the perioperative period for high-risk patients to prevent the occurrence of PND.

	99 (49.5)

	70 (35)	22 (11)	8 (4)	1 (0.5)	
8. Long-term monitoring and follow-up of cognitive function changes for patients who develop postoperative delirium.

	17 (8.5)

	38 (19)	71 (35.5)	72 (36)	2 (1)	
The following factors that make you pay more attention to the severity of PND are:	Very High	High	Moderate	Low	Very Low	
9. Patient Factors

Factors such as age, alcohol consumption, pre-existing cognitive impairment, anxiety, low education level, history of stroke, pre-existing comorbidities like anemia, hypoalbuminemia, electrolyte disturbances, etc.	104 (52)	79 (39.5)	13 (6.5)	4 (2)	/	
10. Surgical Factors

Factors such as extensive and invasive surgical procedures, intraoperative bleeding, and surgical duration.	79 (39.5)	105 (52.5)	16 (8)	/	/	
11. Patient Protocols or Management Processes

In-hospital or departmental clinical pathways used to guide or require perioperative management.	40 (20)	116 (58)	36 (18)	8 (4)	/	
12. Team Building

Establishing a perioperative team and conducting regular multidisciplinary team (MDT) discussions or improving communication among departments.	39 (19.5)	88 (44)	61 (30.5)	10 (5)	2 (1)	
13. Training and Learning

Regular training sessions and personal literature studies.	52 (26)	93 (46.5)	49 (24.5)	5 (2.5)	1 (0.5)	

In Pearson's correlation analysis, significant positive correlations were found between knowledge and attitude (r = 0.1425, P = 0.0442), knowledge and practice (r = 0.2959 P < 0.001), as well as attitude and practice (r = 0.2219, P = 0.0016), respectively (Table 3). The path analysis demonstrate a highly favorable model fit indices, suggesting a well-fitting model (Table 4), and shown that number of daily surgical cases (β = 0.82, p = 0.018), education (β = 1.49, p < 0.001), and whether participated in a research project status (β = 1.32, p = 0.003) had direct effects on knowledge. Working in teaching hospital direct effects attitude (β = 1.82, p = 0.027). Furthermore, knowledge (β = 0.29, p < 0.001) and attitude (β = 0.20, p = 0.026) were also identified as having a direct impact on practice (Table 5 and Fig. 1).Table 3 Pearson's correlation analysis.

Table 3	Knowledge	Attitude	Practice	
Knowledge	1			
Attitude	0.1425 (P = 0.0442)	1		
Practice	0.2959 (P＜0.001)	0.2219 (P = 0.0016)	1	

Table 4 Model fit.

Table 4Indicators	Reference	Results	
RMSEA	<0.08 Good	0.079	
SRMR	<0.08 Good	0.039	
TLI	>0.8 Good	0.721	
CFI	>0.8 Good	0.854	

Table 5 Path analysis results.

Table 5	Estimate	P	
Knowledge < -	Daily Surgical Cases	0.82	0.018	
Education	1.49	0	
Occupation Type	−0.96	0.086	
Participated in a related research project	1.32	0.03	
Attitude < -	Knowledge	0.11	0.069	
Gender	0.77	0.111	
Teaching Hospital	1.82	0.027	
Daily Surgical Cases	−0.54	0.116	
Practice < -	Knowledge	0.29	0	
Attitude	0.20	0.026	

Fig. 1 Path analysis.

Fig. 1

4 Discussion

Anesthesia practitioners have inadequate knowledge, positive attitude and proactive practice towards PND. Number of daily surgical cases, education, participated in a related research project, and working in teaching hospital might have effect on their KAP.

The identified knowledge gaps, as indicated by the mean knowledge score, underscore the pressing need for targeted educational interventions to enhance understanding within the anesthesia community. These findings align with broader trends in healthcare, emphasizing the importance of ongoing education to keep professionals abreast of evolving medical knowledge [15]. The significant differences in knowledge scores between anesthesiologists and nurses could be attributed to the depth of training and exposure to neurocognitive disorder management that anesthesiologists typically receive. In contrast, the uniformity in practice scores across both groups suggests that actual care practices might be more influenced by institutional protocols than individual professional knowledge, standardized procedures can minimize practice variability in clinical settings. Differences in the knowledge scores based on the type of hospital could reflect resource disparities, including access to training and continuing education opportunities. The correlation between daily surgical cases and KAP scores suggests that frequent, hands-on engagement in surgeries may lead to incremental learning and knowledge application. The influence of these factors on the acquisition of KAP highlighting the impact of professional roles and educational backgrounds on healthcare workers' awareness [16,17]. Encouragingly, proactive practices were demonstrated across the board. This positive inclination towards proactive practices aligns with a commitment to patient well-being but underscores the imperative to ensure these practices are informed by a solid foundation of knowledge [18,19].

The examination of anesthesia practitioners' knowledge distribution regarding PND highlights varied awareness levels across distinct dimensions. While a majority are well-acquainted with certain aspects, deficiencies exist in recognizing the categorization of cognitive impairments during the perioperative period, including pre-existing cognitive dysfunction, acute postoperative delirium, delayed neurocognitive recovery, and postoperative neurocognitive disorders. Additionally, notable gaps are evident in understanding the intricacies of postoperative cognitive dysfunction (POCD), the recommended neuropsychological testing for its diagnosis, and the selection of appropriate cognitive assessment tools for at-risk patients. Recognizing these deficiencies is crucial for developing targeted initiatives to enhance clinical practice. Initiatives may include structured educational programs addressing specific knowledge gaps, incorporating internationally recognized testing scales, and emphasizing the importance of cognitive assessment in at-risk patient populations [20,21]. Furthermore, interventions should focus on promoting awareness of preventive measures for delirium, addressing risk factors for POCD, and optimizing postoperative pain management to minimize delirium incidence [22,23].

The assessment of anesthesia practitioners' attitudes toward PND illuminates a spectrum of perspectives. While a substantial majority acknowledges the seriousness of PND and expresses a commitment to providing cognitive care despite a busy workload, notable concerns emerge. A segment of workers believes that PND cannot be entirely avoided inconsistent with the proactive stance recommended for preventive measures. Some respondents express reservations about the inevitability of overusing sedative medications, emphasizing the need for targeted education on alternative pain management strategies. These attitudes, particularly the belief that PND is often overlooked, reveal critical gaps in awareness and underscore the urgency of targeted interventions to foster a proactive and preventive mindset [24,25]. Initiatives should include comprehensive training programs emphasizing the significance of PND, the exploration of preventive measures, and strategies to avoid overreliance on sedative medications [[26], [27], [28]].

The evaluation of anesthesia practitioners' practices concerning PND reveals a range of approaches. While a majority regularly performs cognitive screenings for high-risk patients and implements cognitive function screening in the recovery period, there are notable gaps in other aspects. A significant portion emphasizes the importance of enhancing cognition, providing compassionate care, and optimizing anesthesia strategies, but some responses indicate infrequent adoption of practices such as minimizing trauma during surgery and routine use of dexmedetomidine for PND prevention. Additionally, the assessment of factors influencing attention to PND severity underscores a strong awareness of patient-related factors but reveals comparatively less emphasis on surgical factors and team-building strategies. This distribution of practices indicates a need for targeted interventions to standardize and enhance perioperative practices. Initiatives should encompass comprehensive training programs emphasizing the importance of consistent cognitive screenings, optimizing anesthesia strategies, and reinforcing attention to factors influencing PND severity. Moreover, encouraging regular multidisciplinary team discussions and fostering a culture of continuous learning and training can contribute to comprehensive and standardized perioperative neurocognitive care [29,30].

The correlation analysis and path analysis in this study reveal significant positive correlations between KAP among anesthesia practitioners. These findings suggest that a higher level of knowledge is associated with a positive attitude and proactive practice regarding PND. The path analysis indicates a well-fitting model, emphasizing the influence of certain factors on KAP. Factors such as the number of daily surgical cases, education level, and participation in research projects directly impact knowledge. Working in a teaching hospital directly influences attitude. Additionally, both knowledge and attitude have a direct impact on practice. This aligns with prior research emphasizing the interconnectedness of KAP in healthcare settings [31]. Recognizing these relationships is pivotal for targeted interventions aiming to enhance clinical practice. Initiatives should focus on improving knowledge through educational programs tailored to the identified influential factors, fostering positive attitudes through exposure to diverse clinical experiences, and translating this knowledge and attitude into proactive practices through targeted training sessions [32,33].

One limitation of this study is the reliance on self-reported data, which may introduce response bias. Participants might provide socially desirable answers or overstate their KAP regarding PND. Additionally, the data collected at a single point in time may not capture changes in KAP over time. Furthermore, the number of hospitals and participants included in this study was limited, potentially limiting the generalizability of findings to a broader healthcare context. Another important limitation is that the sampling method used was not entirely random, which could introduce selection bias and affect the representativeness of the sample.

In conclusion, anesthesia practitioners might have inadequate knowledge, positive attitude and proactive practice towards PND. Number of daily surgical cases, education, participated in a related research project, and working in teaching hospital might have effect on their KAP. In light of the study's outcomes, interventions are recommended to enhance clinical practices among anesthesia practitioners regarding PND. Addressing identified knowledge gaps is crucial, and educational initiatives should be tailored to fill these lacunae, emphasizing key PND-related aspects.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

The raw data that support the findings of this study are available from the corresponding author, Rong Dong, upon reasonable request.

CRediT authorship contribution statement

Yi Luo: Writing – review & editing, Writing – original draft, Project administration, Methodology, Conceptualization. Zijin Shen: Visualization, Resources, Project administration, Data curation. Haibin Wang: Visualization, Software, Data curation. Rong Dong: Writing – review & editing, Writing – original draft, Formal analysis, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following are the Supplementary data to this article.Multimedia component 1

Multimedia component 1

Multimedia component 2

Multimedia component 2

Acknowledgments

Not applicable.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e36491.
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References

1 Chen K. Monocyte NLRP3-IL-1β hyperactivation mediates neuronal and synaptic dysfunction in perioperative neurocognitive disorder Adv. Sci. 9 16 2022 e2104106
2 Huang C. Sevoflurane induces neurotoxicity in the animal model with alzheimer's disease neuropathology via modulating glutamate transporter and neuronal apoptosis Int. J. Mol. Sci. 23 11 2022
3 Shui M. Anomalous levels of CD47/signal regulatory protein alpha in the Hippocampus lead to excess microglial engulfment in mouse model of perioperative neurocognitive disorders Front. Neurosci. 16 2022 788675
4 Long Y. Effects of anesthetic depth on postoperative pain and delirium: a meta-analysis of randomized controlled trials with trial sequential analysis Chin Med J (Engl) 135 23 2022 2805 2814 36728598
5 Austin C.A. Association between postoperative delirium and long-term cognitive function after major nonemergent surgery JAMA Surg 154 4 2019 328 334 30649138
6 Miao H.H. Ginsenoside Rg1 attenuates isoflurane/surgery-induced cognitive disorders and sirtuin 3 dysfunction Biosci. Rep. 39 10 2019
7 Shen Y. Chemokine CXCL13 acts via CXCR5-ERK signaling in hippocampus to induce perioperative neurocognitive disorders in surgically treated mice J. Neuroinflammation 17 1 2020 335 33161894
8 Aljezawi M. Nurses' knowledge and attitude toward people with Alzheimer's disease: an exploratory study Nurs. Forum 56 4 2021 791 798 33993493
9 Paul P. Knowledge, awareness, and attitude of healthcare stakeholders on alzheimer's disease and dementia in Qatar Int. J. Environ. Res. Publ. Health 20 5 2023
10 Zhou C. Knowledge, attitude, and practice regarding postoperative delirium among cardiac surgery nurses: a cross-sectional multi-centre study J. Clin. Nurs. 32 15–16 2023 5046 5055 37173828
11 Igwe E.O. Perioperative knowledge, self-efficacy and clinical practices related to postoperative delirium care in older people across geographical regions in Australia Aust. J. Rural Health 32 2 2024 354 364 38456229
12 Peden C.J. Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team Br. J. Anaesth. 126 2 2021 423 432 33413977
13 Park J. Validation of the multiple disability multidimensional attitudes scale toward persons with disabilities Rehabil. Psychol. 68 2 2023 194 203 37023288
14 Lee F. Suryohusodo A.A. Knowledge, attitude, and practice assessment toward COVID-19 among communities in East Nusa Tenggara, Indonesia: a cross-sectional study Front. Public Health 10 2022 957630
15 Vieira C. Serious game design and clinical improvement in physical rehabilitation: systematic review JMIR Serious Games 9 3 2021 e20066
16 Wang X. Association of off-the-job training with work performance and work-family conflict among physicians: a cross-sectional study in China BMJ Open 12 1 2022 e053280
17 Ohta R. Maejma S. Sano C. Nurses' contributions in rural family medicine education: a mixed-method approach Int. J. Environ. Res. Publ. Health 19 5 2022
18 Clarkson P. An interprofessional approach to pressure ulcer prevention: a knowledge and attitudes evaluation J. Multidiscip. Healthc. 12 2019 377 386 31213822
19 Zhou H. Zhao R. Yang Y. A qualitative study on knowledge, attitude, and practice of nursing students in the early stage of the COVID-19 epidemic and inspiration for nursing education in mainland China Front. Public Health 10 2022 845588
20 Hong Y.J. Development of a home-based cognitive test for cognitive monitoring in subjective cognitive decline with high risk of Alzheimer's disease Medicine (Baltim.) 102 9 2023 e33096
21 Kepecs D.M. Does chronic kidney disease-induced cognitive impairment affect driving safety? Can J Kidney Health Dis 5 2018 2054358118777133
22 Xin J. Activation of the lateral habenula-ventral tegmental area neural circuit contributes to postoperative cognitive dysfunction in mice Adv. Sci. 9 22 2022 e2202228
23 Zhang X.P. High-fat treatment prevents postoperative cognitive dysfunction in a hyperlipidemia model by protecting the blood-brain barrier via Mfsd2a-related signaling Mol. Med. Rep. 20 5 2019 4226 4234 31545471
24 Ishizawa Y. Does preoperative cognitive optimization improve postoperative outcomes in the elderly? J. Clin. Med. 11 2 2022
25 Xu X. Perioperative neurocognitive dysfunction: thinking from the gut? Aging (Albany NY) 12 15 2020 15797 15817 32805716
26 Ahmad N.A. Postnatal depression and intimate partner violence: a nationwide clinic-based cross-sectional study in Malaysia BMJ Open 8 5 2018 e020649
27 Hong Y. Ulinastatin Alleviates repetitive ketamine exposure-evoked cognitive impairment in adolescent mice Neural Plast. 2022 2022 6168284
28 Kubota C. Relation between perinatal depressive symptoms, harm avoidance, and a history of major depressive disorder: a cohort study of pregnant women in Japan Front Psychiatry 10 2019 515 31404277
29 Bužgová R. Kozáková R. Juríčková L. The unmet needs of family members of patients with progressive neurological disease in the Czech Republic PLoS One 14 3 2019 e0214395
30 Xu L. Inhibition of adult hippocampal neurogenesis plays a role in sevoflurane-induced cognitive impairment in aged mice through brain-derived neurotrophic factor/tyrosine receptor kinase B and neurotrophin-3/tropomyosin receptor kinase C pathways Front. Aging Neurosci. 14 2022 782932
31 Afaya A. Mapping evidence on knowledge of breast cancer screening and its uptake among women in Ghana: a scoping review BMC Health Serv. Res. 22 1 2022 526 35443647
32 Koni A. A cross-sectional evaluation of knowledge, attitudes, practices, and perceived challenges among Palestinian pharmacists regarding COVID-19 SAGE Open Med 10 2022 20503121211069278
33 Noroozi F. Salt consumption and blood pressure in rural hypertensive participants: a community filed trial Sci. World J. 2022 2908811
