
==== Front
Support Care Cancer
Support Care Cancer
Supportive Care in Cancer
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Springer Berlin Heidelberg Berlin/Heidelberg

39289183
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10.1007/s00520-024-08823-6
Research
Knowledge, attitudes, practices, and barriers of oncology nurses in promoting physical activity in cancer survivors: a cross-sectional survey in China
Liu Yun 1
Wang Xiangying wxyly19891016@163.com

2
Li Xin 3
Pan Ning 4
Dong Shuxian 1
Wang Fen 1
Mao Xuehui maoxuehui99@163.com

1
1 https://ror.org/05jb9pq57 grid.410587.f Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingshi Road, Jinan, 250021 China
2 https://ror.org/05jb9pq57 grid.410587.f Department of Orthopedic Oncology Surgery, Shandong Cancer Hospital and Institute Affiliated to Shandong First Medical University and Shandong Academy of Medical Science, Jinan, 250021 China
3 https://ror.org/03wnrsb51 grid.452422.7 0000 0004 0604 7301 Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014 China
4 https://ror.org/05jb9pq57 grid.410587.f Department of Urologic Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingshi Road, Jinan, 250021 China
18 9 2024
18 9 2024
2024
32 10 6698 3 2024
17 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Purpose

To explore the knowledge, attitudes, and practices of Chinese nurses in promoting physical activity among cancer survivors and the relationships between these attributes and to identify the factors hindering nurses’ clinical practice.

Methods

Nurses from oncology-related departments of 10 public tertiary hospitals in Shandong Province completed self-administered questionnaires that included information about demographics; knowledge, attitudes, and practices of physical activity promotion; and barriers to clinical practice. The STROBE statement for observational studies was applied.

Results

A total of 502 valid questionnaires were obtained. The average standardized scores of knowledges, attitudes, and practice were 75.33%, 82.36%, and 62.60%, respectively. Oncology specialist nurses and nurses who had received relevant training had higher levels of knowledge, nurses from general hospitals reported higher levels of practice, and nurses who had learned the relevant guidelines were better in terms of knowledge, attitude, and level of practice. Attitude had a statistically significant mediating effect between knowledge and practice. Lack of time, lack of multidisciplinary clinical teams, and lack of clear guidelines were the most frequently reported barriers to practice.

Conclusion

In China, nurses have a moderate level of knowledge and practice in promoting physical activity among cancer survivors, but a positive attitude. Numerous barrier factors present challenges in nurses’ clinical practice. Attitude plays a partial mediating role between knowledge and practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-024-08823-6.

Keywords

Cancer survivor
Physical activity
Nurses
Attitude
Knowledge
Practice
issue-copyright-statement© Springer-Verlag GmbH Germany, part of Springer Nature 2024
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pmcIntroduction

Cancer is a major disease that seriously threatens human life and health. According to statistics, there were 19.3 million new cancer cases and 9.96 million deaths worldwide in 2020 [1], and the incidence and mortality of cancer will continue to increase. It is estimated that the number of new cancer cases worldwide will increase by 47% in 2040 compared with 2020. With the development and improvement of cancer screening and treatment, an increasing number of cancer patients are able to live with the tumor for longer periods of time. However, most may experience the physical, psychological, or social side-effects as a result of cancer and cancer-associated treatments that seriously affect the quality of life, such as pain, fatigue, depression, and sleep disturbance [2, 3] and may experience cancer recurrence at any stage of post-cancer survival.

Healthy lifestyle changes, such as regular physical activity (PA), have been shown to provide significant health benefits to cancer survivors during treatment and recovery, such as reduced anxiety, depression, and mortality, as well as improved physical functioning and quality of life [4–6]. Therefore, several guidelines recommend that cancer survivors engage in at least 150 min of moderate-intensity physical activity per week [7–9]. However, previous studies have shown that the physical activity levels of cancer survivors are overwhelmingly low. In a study by Matias, the majority of patients (53.3%) reported reducing, quitting, or never engaging in PA after cancer diagnosis [10]. An Italian study found that the percentage of cancer survivors who were physically inactive was as high as 93% [11]. In Korea, 27.7% of cancer patients appear to be sufficiently active [12]. A cross-sectional study in China reported that only 25.8% of cancer survivors met the present physical activity recommendations [13].

Multiple studies have identified that professional support from healthcare providers (HCPs) plays a crucial role in promoting physical activity among cancer survivors. As shown in Finsher’s study, patients who received physical activity advice from HCPs had higher levels of physical activity and were more likely to meet guideline recommendations than those who did not receive physical activity guidance [14]. Tarasenko also found that professional physical activity support from HCPs can reduce the prevalence of inactivity in cancer survivors by 8.3% [15]. This is because HCPs are the main source of information for cancer patients and are often regarded as authorities on the subject. Education, guidance, and supervision from HCPs can stimulate the motivation and health behaviors of cancer survivors to a certain extent as well as improve their physical activity adherence. Additionally, HCPs can use their professional knowledge and skills to identify, reduce, or even remove the obstacle factors that hinder patients’ physical activity participation, such as psychological distress and physical discomfort symptoms, so as to eliminate cancer survivors’ doubts about their own competence and concerns about the safety of the physical activity and remove the decision-making involved in being active or inactive. Therefore, more and more scholars have proposed that physical activity should be considered a routine supportive care strategy throughout the entire treatment and rehabilitation process of cancer patients to promote their health and well-being.

Unfortunately, the clinical practice of HCPs remains unsatisfactory. Only 31% of the 15,254 people diagnosed with colorectal cancer in the UK recalled having received any physical activity advice as part of their cancer care [14]. In a study by Orange, although 52% of patients recalled receiving advice, only 30% of those patients received guidance on types of physical activity [16]. Similar findings were reported in China. For example, several cancer survivors in a qualitative study reported that they had not received professional physical activity guidance [17]. Therefore, the promotion of HCP clinical practices has become an important issue that needs to be urgently addressed by policymakers and hospital managers worldwide.

Previous studies have attempted to examine what drives poor clinical practice among healthcare providers and have identified obstacle factors such as unclear delineation of responsibilities between different disciplines, lack of knowledge, negative attitude, and lack of organizational support [18–20]. However, none of these studies were performed in China, and most of the findings were based on data from a mixed sample of healthcare professionals from different disciplines (including oncologists, sports medicine specialists, and oncology nurses). In China, clinical health promotion mainly relies on nurses due to the relatively short supply of doctors and because the discipline of sports medicine is still in its initial stages of development. This implies that clinical nurses may have a greater potential to promote physical activity in cancer survivors in clinical practice. However, to the best of our knowledge, there is a limited understanding of the clinical practices of Chinese nurses, and little information is available on the knowledge and attitude of nurses in recommending physical activity to cancer survivors.

Knowledge, attitudes, and practices (KAP) theory is one of the theoretical models widely used in health promotion, nursing management, nursing education, and other fields to explore people’s behaviors and explain their changes [21]. According to KAP theory [22], changes in people’s practices are divided into three sequential processes: acquiring knowledge, generating attitudes, and forming practice. There is a causal relationship among the three: knowledge is the basis of a behavior change, and belief and attitude serve as momentum for a behavior change. In other words, knowledge can influence practices either directly or indirectly through attitude, and this has been confirmed by KAP studies in other fields [23, 24]. However, the relationship between physical activity promotion knowledge, attitudes, and practices has not been tested among clinical nurses. Therefore, it is essential to gain an in-depth understanding of nurses’ knowledge, attitudes, and practices regarding the promotion of physical activity in cancer survivors and to test the mediating effect of attitudes between knowledge and practice in order to provide evidence for the development of scientific intervention strategies to improve nurses’ clinical practice.

Aims

This study aimed to (1) examine Chinese nurses’ knowledge, attitudes, and practices regarding physical activity promotion in cancer survivors; (2) identify the factors influencing their knowledge, attitudes, and practices; (3) test the mediating role of attitudes between knowledge and practice; (4) and explore the barriers present in their practices.

Methods

Research design

This cross-sectional study was conducted between May and September 2022, and its reporting conforms to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist.

Setting and participants

This study was performed using the convenience sampling approach in 10 public tertiary hospitals in Shandong Province, China, including 9 comprehensive hospitals and 1 cancer hospital. Based on our cross-sectional study design, the sample size was estimated using the formula n=Z1-α/22SD2d2 [25]. To determine the SD value, we first recruited 60 nurses for the pre-experiment, which showed that the standard deviation (SD) of the total score of the KAP questionnaire was 18.17. Assuming the probability of type I error α = 0.05, Z1-α/2 = 1.96, acceptable error d = 1.5, and considering a sample loss rate of 20%, the required sample size was calculated to be at least 301. Obviously, this also meets the requirement of a sample size of at least 200 cases for structural equation modeling analysis to obtain stable model parameter estimates [26]. Clinical nurses who met the following criteria were invited to participate in this study: (a) obtained a Nursing Practice Certificate issued by the Ministry of Health of China, (b) was currently working in an oncology-related department ≥ 1 year, and (c) volunteered to take part in the study. Refresher nurses or nursing students were excluded.

Data collection

Electronic and paper questionnaires were used for data collection. Consent of the nursing department leaders of each hospital was first obtained; then, the head nurse of each department distributed questionnaires to the eligible nurses. The questionnaires were accompanied by an informed consent statement, and the purpose, significance, and requirements of the study were explained. Participants began answering after confirming their understanding. In addition, in the background program of the electronic questionnaire, all items except open-ended questions were set as required to ensure data integrity, and each IP address was restricted to filling in the questionnaire only once to avoid repeated data submission.

Instruments

Demographic variables

Demographic variables collected from the participants included gender, age, level of education, technical title, position, type of hospital, training experience (Have you received any relevant training? Yes or no), whether they were an oncology specialist nurse (yes or no), and whether they had learned the relevant guidelines (yes or no).

Knowledge-attitude-practice questionnaire for nurses to promote physical activity in cancer survivors

The questionnaire used in this study was developed by our subject team under the guidance of KAP theory. During the entire questionnaire preparation process, we strictly followed the standard procedures for questionnaire development. It should be noted that although KAP is widely used in the field of behavior change, the key concepts of “attitude” and “practice” are not clearly defined. For the purpose of our study, we defined the three key terms: knowledge refers to the understanding of any topic related to physical activity or physical activity promotion in cancer survivors; attitude refers to any preconceived ideas, feelings, or beliefs that a nurse may have about physical activity in cancer survivors and about practices related to physical activity promotion; practice refers to any possible practice or behavior associated with promoting physical activity in cancer survivors. According to Bettinghaus [22], attitude is a multidimensional structure, and using only a generalized attitude measure is not likely to produce high correlations with behavior. Therefore, we chose to evaluate the attitude of the whole range of possible practices of nurses.

The preliminary database of questionnaire items was formed through an extensive review of the literature, references to items from other similar studies, and consultation with experts to ensure that information about nurses’ knowledge, attitudes, and practices regarding the promotion of physical activity in cancer survivors was captured to the greatest extent possible. We used survey data from 289 samples for item analysis and exploratory factor analysis and then re-selected 268 samples for confirmatory factor analysis. Following these steps, a questionnaire with 30 items including three dimensions was finally formed. These dimensions were knowledge (11 items), attitude (7 items), and practice (12 items). Although we noted that item 16 may be more reflective of nurses’ self-efficacy, given the multidimensional nature of attitudes and the high correlation of this item with behavioral beliefs, we ultimately decided to retain this item based on the experience of similar studies [27, 28]. All three dimensions were rated on a 5-point Likert scale, with scores ranging from 1 to 5 from “unknown” to “very aware” for the knowledge dimension, from “strongly disagree” to “strongly agree” for the attitude dimension, and from “never do this” to “always do this” for the practice dimension. Higher scores indicate a higher level of a nurse’s knowledge, attitude, and practice in the promotion of physical activity among cancer survivors. Cronbach’s alpha coefficients for knowledge, attitude, and practice dimensions were 0.919, 0.879, and 0.962, respectively. Cronbach’s alpha coefficient of the total questionnaire was 0.950, the split-half reliability coefficient was 0.682, and the retest reliability was 0.900. The content validity of the questionnaire, as evaluated by 13 experts, showed that the item-level content validity index (I-CVI) was 0.833 to 1.00, the scale-level CVI/average (S-CVI/Ave) was 0.969, and the scale-level CVI/universal agreement (S-CVI/UA) was 0.800.

Due to the fact that knowledge, attitude, and behavior are latent variables that cannot be directly observed and a lack of widely used standardized measurement tools, there were no standardized criteria for classifying knowledge as poor, moderate, or good. For comparison, we converted the scores of each dimension into standardized scores and, based on the experience of previous researchers, defined standardized scores < 60% as poor, 60–79% as moderate, and > 79% as good [29]. The calculation formula is as follows: Standardized score for each dimension = actual score for this dimension/theoretical maximum × 100%.

Survey regarding barriers

Based on a review of previous literature, we listed 13 barriers that may affect nurses’ clinical practice: lack of time; lack of effective referral mechanism; lack of multidisciplinary team with physical activity professionals (e.g., sports medicine specialists and physiotherapists); lack of communication and cooperation with doctors; lack of relevant continuing education and training courses for nurses; concerns about potential safety risks of physical activity for cancer survivors (e.g., falls); lack of specific and clear guidelines; lack of educational materials for cancer survivors (e.g., brochures); lack of systematic physical activity intervention plans for different cancer types; lack of supportive programs for cancer survivors to participate in (e.g., physical activity classes and supervised exercise programs); lack of spaces and facilities for cancer survivors to engage in physical activity; lack of policy support; and lack of ability to obtain relevant guidelines and literature. Participants could choose one or more options with which they agreed, and this section was not scored.

Ethical considerations

The study obtained approval from the Ethics Committee of Shandong First Medical University. Data collection was initiated after obtaining consent from the heads of the nursing department and relevant departments of the investigated hospitals. Participants were informed of the purpose, significance, and process of the study and that they had the right to withdraw at any time.

Statistical analysis

SPSS 26.0 and AMOS 26.0 software were used for the statistical analysis. Continuous variables were statistically described using means and standard deviations (SD), and qualitative data were described as frequencies and percentages. Independent samples t-tests and one-way analyses of variance (ANOVA) were used to analyze differences in nurses’ knowledge, attitudes, and practice scores across demographic characteristics. The Pearson correlation coefficient was used to test the correlation between knowledge, attitudes, and practices. Finally, we developed a structural equation model using the AMOS 26.0 software with knowledge as the independent variable, attitude as the mediator variable, and practice as the dependent variable. We used the maximum likelihood method to modify, fit, and verify the model and used the Bootstrap method to test whether attitude has a mediating effect between knowledge and practice. A p-value lower than 0.05 was considered statistically significant.

Results

Demographic characteristics of participants

A total of 530 nurses from oncology-related departments participated in this study, and 502 valid questionnaires were collected, with an effective recovery rate of 94.7%. Of the participants, the vast majority were female (89.8%), and 68.6% of the nurses were in the age group of 25–35 years. The educational level of the participants was predominantly bachelor's degree (85.8%), and their technical title was primarily senior nurse (38.5%) or supervisor nurse (38.8%). Most of the participants were from general hospitals, 85.5% were general clinical nurses. Of the participants, 26.3% were oncology specialist nurses, 15.9% reported they had received relevant training on physical activity promotion for cancer survivors, and 19.1% reported they had learned the relevant guidelines (Table 1). Table 1 Differences in knowledge, attitude, and practice regarding physical activity promotion among nurses with multiple characteristics

Variable	N (%)	Knowledge	Attitudes	Practice	
Mean ± SD	Test results	Mean ± SD	Test results	Mean ± SD	Test results	
Gender	
   Male	51 (10.2)	3.86 ± 0.61	t = 1.042	3.88 ± 0.70	t =  − 3.132	2.95 ± 0.88	t =  − 1.509	
   Female	451 (89.8)	3.76 ± 0.66	p = .298	4.15 ± 0.56	p = .002**	3.15 ± 0.92	p = .132	
Age	
   ≤ 25	39 (7.7)	3.84 ± 0.63	F = 2.095	4.05 ± 0.58	F = 1.175	3.41 ± 0.85	F = 1.246	
   25–30	159 (31.7)	3.88 ± 0.65	p = .080	4.09 ± 056	p = .321	3.16 ± 0.93	p = .290	
   31–35	185 (36.9)	3.69 ± 0.66		4.10 ± 0.58		3.07 ± 0.92		
   36–40	65 (12.9)	3.72 ± 0.69		4.22 ± 0.63		3.10 ± 0.97		
   ≥ 41	54 (10.8)	3.71 ± 0.66		4.22 ± 0.60		3.06 ± 0.86		
Education	
   Tertiary education or below	40 (8.0)	3.88 ± 0.65	F = 0.638	4.13 ± 0.64	F = 1.332	3.27 ± 0.87	F = 1.516	
   Bachelor degree	431 (85.8)	3.75 ± 0.66	p = .529	4.13 ± 0.56	p = .265	3.13 ± 0.92	p = .221	
   Postgraduate or above	31 (6.2)	3.80 ± 0.67		3.95 ± 0.69		2.89 ± 0.93		
Technical title	
   Nurse	77 (15.3)	3.93 ± 0.64	F = 2.321	4.07 ± 0.54	F = 1.675	3.32 ± 0.91	F = 2.516	
   Senior nurse	193 (38.5)	3.77 ± 0.69	p = .074	4.12 ± 0.53	p = .172	3.17 ± 0.94	p = .058	
   Supervisor nurse	195 (38.8)	3.73 ± 0.64		4.17 ± 0.61		3.00 ± 0.92		
   Associate chief nurse or above	37 (7.4)	3.62 ± 0.54		3.95 ± 0.70		3.18 ± 0.73		
Position	
   General nurse	429 (85.5)	3.79 ± 0.66	t = 1.678	4.15 ± 0.56	t = 2.367	3.14 ± 0.94	t = .541	
   Head nurse	73 (14.5)	3.65 ± 0.61	p = .094	3.95 ± 0.68	p = .020*	3.08 ± 0.76	p = .590	
   Are you a oncology specialist nurse?								
   Yes	132 (26.3)	3.91 ± 0.58	t = 2.983	4.06 ± 0.56	t =  − 1.230	3.11 ± 0.89	t =  − .353	
   No	370 (73.7)	3.71 ± 0.67	p = .003**	4.14 ± 0.58	p = .219	3.14 ± 0.93	p = .724	
Type of hospital	
   General hospital	425 (84.7)	3.77 ± 0.66	t = .245	4.13 ± 0.58	t = .906	3.18 ± 0.92	t = 2.979	
   Specialist hospital	77 (15.3)	3.75 ± 0.66	p = .807	4.06 ± 0.59	p = .365	2.85 ± 0.86	p = .003**	
Have you received any relevant training?	
   Yes	80 (15.9)	4.08 ± 0.55	t = 4.676	4.13 ± 0.55	t = .176	3.31 ± 0.86	t = 1.949	
   No	422 (84.1)	3.71 ± 0.66	p < 0.001***	4.12 ± 0.58	p = .860	3.10 ± 0.92	p = .052	
Have you ever learned relevant guidelines?	
   Yes	96 (19.1)	4.17 ± 0.47	t = 8.576	4.25 ± 0.55	t = 2.581	3.43 ± 0.95	t = 3.594	
   No	406 (80.9)	3.67 ± 0.66	p < 0.001***	4.09 ± 0.58	p = .010*	3.06 ± 0.90	p < 0.001***	
Abbreviations: SD standard deviation, F analysis of variance (ANOVA), t, independent-sample t-test

*p < 0.05; **p < 0.01; ***p < 0.001

Nurses’ knowledge, attitudes, and practice regarding physical activity promotion in cancer survivors

As shown in Table 2, the average standardized scores of knowledge, attitude, and practice were 75.33%, 82.36%, and 62.60%, respectively, indicating that, overall, the participants had a more positive attitude but a moderate level of knowledge and clinical practice. It is striking that a significant proportion of nurses have poor practice (42.4%). The specifics of each dimension are shown in Figs. 1, 2, and 3. Figure 1 reflects nurses’ responses to each item in the knowledge dimension: half of the nurses indicated that they were unaware of guidelines for physical activity levels for cancer survivors, 42% were not familiar with the classifications of physical activity intensity, and 41% were unaware of assessment tools related to physical activity. However, the nurses had a higher level of knowledge regarding the definition, benefits, and progressive principles of physical activity. The majority of nurses held more positive attitudes toward promoting physical activity in cancer patients, but 26% were not confident in their ability to provide appropriate physical exercise recommendations based on cancer survivors’ physical conditions, interests, etc. (Fig. 2). The results shown in Fig. 3 are discouraging, only 35 to 43% of nurses reported that they often or always proactively assess the physical activity level and readiness of cancer survivors, provide individualized guidance, dynamically adjust physical activity plans, identify and resolve obstacle factors, and provide multidisciplinary collaboration and follow-up services. Only 37% of the nurses considered promoting physical activity among cancer survivors to be an important part of their work, and 40% of the nurses were willing to actively learn the knowledge about physical activity. Table 2 Nurses’ knowledge, attitudes, and practices related to physical activity promotion

Dimension	Standardized scores	Classification [N (%)]	
Poor	Moderate	Good	
Knowledge	75.33%	59 (11.8)	247 (49.2)	196 (39.0)	
Attitude	82.36%	12 (2.4)	167 (33.3)	323 (64.3)	
Practice	62.60%	213 (42.4)	181 (36.1)	108 (21.5)	

Fig. 1 Participants’ responses on each item of the knowledge dimension

Fig. 2 Participants’ responses on each item of the attitude dimension

Fig. 3 Participants’ responses on each item of the practice dimension

Mean differences in knowledge, attitudes, and practice across demographic characteristics

There were statistically significant differences in knowledge scores between nurses who had received relevant training and those who had not (t = 4.676, p < 0.001), as well as between oncology specialist nurses and non-oncology specialist nurses (t = 2.983, p = 0.003). Oncology specialist nurses and nurses who had received relevant training had higher knowledge levels. Female nurses had a more positive attitude than male nurses (t =  − 3.132, p = 0.002), and nurses in general hospitals had higher practice scores compared to nurses in tumor specialist hospitals (t = 2.979, p = 0.003). In addition, it should be noted that there were significant differences in knowledge (t = 8.576, p < 0.001), attitude (t = 2.581, p = 0.010), and practice (t = 3.594, p < 0.001) scores between nurses who had learned the physical activity-related guidelines and those who had not; nurses who had learned the guidelines had higher levels of knowledge and practice and a more positive attitude. Other demographic characteristics such as age, education, and technical title had no significant effect on knowledge, attitude, and practice scores (Table 1).

Correlation analysis of knowledge, attitude, and practice

The results of Pearson’s correlation analysis showed a significant positive correlation between knowledge and attitude (r = 0.497, p < 0.001), knowledge and practice (r = 0.456, p < 0.001), and attitude and practice (r = 0.403, p < 0.001) (Table 3). Table 3 Correlation matrix for knowledge, attitudes, and practice

	Knowledge	Attitude	Practice	
Knowledge	1			
Attitude	0.497**	1		
Practice	0.456**	0.403**	1	
**p < 0 .001

Mediating effect of attitudes between knowledge and practice

We constructed an initial structural equation model with knowledge as the independent variable, practice as the dependent variable, and attitude as the mediating variable using the AMOS software (Fig. 4), and the maximum likelihood method was used to fit the model. The fitting results of the initial model showed that the model needed to be optimized (χ2 = 1545.791, df = 402, χ2/df = 3.845, RMSEA = 0.075, NFI = 0.856, IFI = 0.889, TLI = 0.880, CFI = 0.889). According to the correction index, four paths e6–e7, e26–e27, e28–e29, and e19–e20 were added to the model one by one in each round of model correction, so as to obtain the final model (Fig. 5), with the parameters meeting the reference standard (χ2 = 1185.115, df = 398, χ2/df = 2.978, RMSEA = 0.063, NFI = 0.890, IFI = 0.924, TLI = 0.916, CFI = 0.924), indicating that the modified model is well adapted (Table 4).Fig. 4 The initial model of knowledge, attitudes, and practices regarding nurses promoting physical activity in cancer survivors

Fig. 5 The final model of knowledge, attitudes, and practices regarding nurses promoting physical activity in cancer survivors

Table 4 Model fit indices

Model	χ2	df	χ2/df	RMSEA	NFI	IFI	TLI	CFI	Path added	
Initial model	1545.791	402	3.845	0.075	0.856	0.889	0.880	0.889		
Modified model I	1415.511	401	3.530	0.071	0.868	0.902	0.893	0.901	e6–e7	
Modified model II	1325.723	400	3.314	0.068	0.876	0.910	0.902	0.910	e26–e27	
Modified model III	1237.831	399	3.102	0.065	0.885	0.919	0.911	0.919	e28–e29	
Modified model IV	1185.115	398	2.978	0.063	0.890	0.924	0.916	0.924	e19–e20	
Abbreviations: χ2 chi-square, df degree of freedom, RMSEA root mean square error of approximation, NFI normed fit index, IFI incremental fit index, TLI non-normed fit index, CFI comparative fit index

The bootstrap method was used for the mediation effect test, and we set up a repeated sampling of 2000 times to calculate the direct, indirect, and total effects. If the bootstrap 95% confidence interval of the path coefficient did not include zero, the effect was significant; otherwise, the effect was not significant. The results showed that the upper and lower limits of the bootstrap 95% confidence intervals of the direct and total effects of knowledge on practice did not contain zero, indicating that the direct and total effects were significant. The upper and lower limits of the bootstrap 95% confidence interval for the mediating effect of attitude between knowledge and practice did not contain 0, indicating that the mediating effect is significant (Table 5). Therefore, it can be concluded that attitude plays a partial mediating role between knowledge and practice. Table 5 Analysis of the mediating effect of attitude between knowledge and practice

Effects	Path	Point estimates	SE	95%CI	
Upper bounds	Lower bounds	
Direct effects	Knowledge → Attitude	0.365	0.056	0.469	0.252	
Indirect effects	Knowledge → Attitude → Practice	0.125	0.031	0.190	0.069	
Total effects	Knowledge → Attitude	0.490	0.045	0.568	0.391	
Abbreviations: SE standard error, CI confidence interval

Barriers

Table 6 shows the frequency with which each barrier was reported by participants. Lack of time, lack of a multidisciplinary team that included physical activity professionals, and lack of specific and clear guidelines were reported by a high percentage of nurses. Table 6 Barriers reported by nurses in the practice of promoting physical activity in cancer survivors

Barrier	N (%)	
Lack of time	382 (76.1)	
Lack of effective referral mechanism	289 (57.6)	
Lack of multidisciplinary team with physical activity professionals (e.g., sports medicine specialists, physiotherapists)	367 (73.1)	
Lack of communication and cooperation with doctors	245 (48.8)	
Lack of relevant continuing education and training courses for nurses	274 (54.6)	
Concerns about potential safety risks of physical activity for cancer survivors, e.g., falls	252 (50.2)	
Lack of specific and clear guidelines	341 (67.9)	
Lack of educational materials for cancer survivors, e.g., brochures	156 (31.1)	
Lack of systematic physical activity intervention plans for different cancer types	195 (38.8)	
Lack of supportive programs for cancer survivors to participate in, e.g., physical activity classes, supervised exercise programs	244 (48.6)	
Lack of spaces and facilities for cancer survivors to engage in physical activity	213 (42.4)	
Lack of policy support	311 (62.0)	
Lack of ability to obtain relevant guidelines and literatures	212 (42.2)	

Discussion

The results of this study showed that nurses who had learned the physical activity guidelines had better knowledge; unfortunately, only 19.1% of the participants had learned these guidelines. This shows that there is considerable room for improvement in nurses’ ability to obtain literature and information, and the accessibility of information resources in medical institutions, suggesting that the cultivation of nurses’ information literacy should be emphasized to enhance their information retrieval and acquisition abilities. Hospital authorities should increase the construction of digital libraries and open electronic databases, so as to facilitate nurses’ access to guidebooks related to physical activities. The current study also found that nurses who had received relevant training had a higher level of knowledge. Therefore, attention should be paid to nurses’ continuing education through setting up scientific training courses and carrying out multi-channel and diversified education methods to enhance their knowledge of physical activity related to cancer survivors. As physical activity promotion programs involve expertise in multiple disciplinary areas, multidisciplinary education may be a promising strategy as it allows nurses to gain interdisciplinary, multi-professional, and multi-perspective knowledge, which in turn facilitates the construction of nurses’ knowledge systems [30]. As we expected, oncology specialist nurses had a higher level of knowledge than non-oncology specialist nurses, which may be due to the fact that these nurses have more opportunities to be exposed to cutting-edge knowledge and concepts in the field during their specialist training. However, only a few nurses could obtain this specialized training due to the constraints of talent training policies and financial investment in various medical institutions, as evidenced by the fact that the proportion of oncology specialist nurses who participated in this study was only 15.3%. In this regard, nursing managers should actively create an organizational culture that supports collaboration, information-sharing, and joint learning, in order to facilitate knowledge flow within the nursing team, thereby improving nurses’ learning and knowledge [31].

In general, the participants’ attitudes were positive, reflecting a strong sense of responsibility and professional identity among the nurses. However, we should be aware that this may be related to the influence of social expectations. Female nurses were found to have more positive attitudes than male nurses, and similar results have been reported in previous studies; however, the exact reason for this difference is unclear [32]. In this study, nurses primarily reported low confidence in their ability to provide physical activity advice to cancer survivors. There are multiple reasons that may explain this, such as a lack of knowledge and skills, concerns about patient safety [33], and the influence of the inherent “rest paradigm” [34]. To this end, we suggest that health management departments and academic organizations should be oriented toward cultivating nurses’ competencies when carrying out relevant training, such as the ability to collect health information, physical activity level assessment, health and physical fitness assessment, sports risk assessment, and the ability to formulate and implement personalized physical activity intervention plans. Trainers need to provide nurses with tailored, specific methodological guidance and integrate “learning” and “use” so that nurses are effectively equipped with professional skills related to physical activity promotion. One unexpected finding of the current study was that head nurses had more negative attitudes than general nurses. The reason for this may be that the introduction of a new element into a situation where the existing working model is relatively stable will inevitably lead to innovations in working methods and processes, which may have an impact on nursing management. This indicates an urgent need to enhance the head nurses’ awareness and understanding of the importance of promoting physical activity for cancer survivors and to encourage them to overcome the inertia of previous practices in order to actively lead organizational change.

The nurses in this study had low practice scores in all aspects of promoting physical activity among cancer survivors. Although in recent years, more and more clinical nursing scholars in China have begun to consciously conduct research aimed at improving clinical practices, such as summarizing research evidence [35] and exploring physical activity intervention programs [36, 37], there is still a long way to go before these studies can be translated into routine practice. In this study, the type of hospital significantly affected the nurses’ levels of practice, with nurses in general hospitals having a better level of practice than those in tumor specialist hospitals. A probable reason for this is that the disciplinary setting of general hospitals is more complete than that of specialized hospitals, which can provide strong disciplinary support for promoting physical activity in cancer survivors. Previous studies have shown that national policy guidance is an important driving factor for improving nurses’ clinical practice [38]. In 2016, the “ Healthy China 2030” released by the State Council of China proposed the promotion of a disease management and health service model that integrates sport and healthcare to improve physical inactivity in clinically ill populations [39]; however, this has not yet been elevated to a national action plan. A set of carefully designed health action strategies is urgent and necessary, as it can provide a paradigm for provinces and regions to develop physical activity promotion plans and implement action programs. These strategies should take into account the differences in the level of medical care, the distribution of professionals, and the level of health literacy of the population among provinces and regions. The government should also actively promote the development of evidence-based guidelines for the care of cancer survivors that are tailored to China’s national context so that healthcare providers can increase their focus on physical activity promotion and facilitate a shift in the focus of survivorship care. In addition, poor clinical practices may be partly attributed to nurses’ limited professional autonomy. In China, the physician-nurse relationship still largely follows the “dominant-subordinate” model, resulting in nurses relying on medical advice for many of their nursing activities [40]. Moreover, the ambiguous definition of nurses’ professional scope results in nurses possibly facing professional risks when implementing physical activity intervention. Therefore, it is recommended that China’s healthcare administration put more effort into clearly defining the professional scope of nurses and dividing the rights and responsibilities involved in medical cooperation to improve nurses’ practice autonomy and flexibility.

The results of the study showed that knowledge, attitude, and practice were pairwise correlated and that attitude played a partially mediating role between knowledge and practice. This indicates that nurses’ knowledge not only directly affects clinical practice but also influences practice through the mediating role of attitude, which is consistent with the KAP theory. It is suggested that in order to improve the clinical practice of physical activity promotion, extra attention should be paid to fostering positive attitudes among nurses, in addition to adopting a variety of strategies to enhance their knowledge. Healthcare administrations and hospitals may need to make efforts in the following areas: strengthen the education of nurses to help them form a correct understanding of physical activity promotion; create an organizational climate advocating the promotion of physical activity, with specific and effective organizational support mechanisms, increase nurses’ motivation [41]; identify and address negative factors affecting nurses’ attitudes in order to ensure the long-term stability of nurses’ behavioral intentions; and provide nurses with sustained technical supports to improve their self-efficacy.

As in previous studies, lack of time was the most frequently reported barrier factor by participants [18]. Insufficient human resources for nurses and increased nursing workload due to a decrease in the average length of patient stay may be the main reasons for nurses’ lack of time [42]. Management departments and decision-making agencies should focus on integrating physical activity promotion into daily nursing workloads, so as to avoid the promotion of physical activity in cancer survivors becoming a competitive matter in daily clinical practice and to reduce the workload related to physical activity promotion. The lack of multidisciplinary teams that include physical activity professionals (e.g., sports medicine specialists and physiotherapists) and the lack of clear guidelines were the next two most reported barrier factors. It has been suggested that due to the high heterogeneity of risk and comorbidities among cancer survivors, it is unrealistic to apply a generalized physical activity guideline to all patients [43, 44], as this would make it difficult for healthcare providers to give scientific physical activity recommendations based on individual factors. Therefore, national health authorities should issue cancer-specific physical activity guidelines, giving clear physical activity guidelines according to different cancer types, treatment stages, physical conditions, and comorbidities. Hospitals should formulate corresponding work programs and procedures according to local conditions with the guidance of national guidelines so that nurses’ clinical practice can be rule-based. In addition, the development of sports medicine, rehabilitation medicine, and other disciplines should be accelerated to supplement nurses’ insufficient knowledge and time constraints, so that every cancer survivor can ultimately receive safe and effective guidance on physical exercise.

Limitations

This study had several limitations. First, the main challenge with the use of the structural equation model in this cross-sectional study was the inability to establish inferred causality, and it is recommended that relevant longitudinal studies be conducted in the future to clarify this. Second, this study used a convenience sampling method and only surveyed nurses in 10 tertiary hospitals in Shandong Province, which may affect the generalizability of the results and cannot be generalized to other provinces or countries. Third, the Likert scale we used may have limitations in reliability, for example, participants may have different interpretations of different anchor points on the scale, and this response bias may lead to variability in the results. Finally, as all data in this study were self-reported by the participants, some may be unwilling to disclose their true knowledge, attitudes, and practices or may be influenced by social expectations to over-report, so we should be cautious in interpreting the results of the study.

Conclusion

Given the ideal position of nurses in promoting physical activity in cancer survivors, revealing and analyzing nurses’ knowledge, attitudes, and practices has far-reaching implications. The results of this study show that nurses’ knowledge is at an intermediate level, and there is room for improvement in their knowledge of physical activity standards for cancer survivors, classification of physical activity intensity, and physical activity assessment tools. The nurses’ positive attitudes are encouraging, but their overall levels of practice are disappointing. Policy and organizational and personal barriers posed serious challenges for nurses in clinical practice. Lack of time, lack of multidisciplinary team with physical activity professionals (e.g., sports medicine specialists and physiotherapists), and lack of clear guidelines are the most frequently reported barriers. The present study also identified the mediating role of attitude between knowledge and practice, suggesting that cultivating positive attitudes in nurses should be seriously emphasized. Our findings suggest that to improve the poor practices of nurses in China, health administration departments and medical institutions need to take action in multiple dimensions, including health action strategies, guidelines and policies, resource support (human resources, information resources, and material resources), organizational culture, continuing education, medical cooperation modes, and discipline development.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary file1 (DOC 37.5 KB)

Acknowledgements

We appreciate all of the nurses who participated in this study.

Author contributions

Yun Liu and Xuehui Mao led the study; Yun Liu, Xin Li and Fen Wang performed data collection; Yun Liu and Xaingying Wang analyzed the data; Yun Liu, Ning Pan and Shuxian Dong contributed valuable intellectual content to the discussion; Yun Liu and Xiangying Wang drafted the first version of the manuscript and it was critically reviewed by all the other authors.

Funding

This study was supported by the Natural Science Foundation of Shandong Province (ZR2022MH264). The project leader, Ms. Xuehui Mao, was the corresponding author of our study and was responsible for project supervision and administration.

Data availability

The data used to support the findings of this study are available from the corresponding author upon request.

Declarations

Ethics approval

The study followed the ethical principles of the Declaration of Helsinki and was approved by the Ethics Committee of Shandong First Medical University (R202207260115).

Consent to participate

Written informed consent was obtained from all individual participants included in the current study.

Consent for publication

Participants signed an informed consent regarding publishing their data.

Conflict of interest

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Sung H Ferlay J Siegel RL Laversanne M Soerjomataram I Jemal A Bray F Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries CA: Cancer J Clin 2021 71 209 249 10.3322/caac.21660 33538338
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F (2021) Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: Cancer J Clin 71:209–249. 10.3322/caac.2166033538338
2. Deshields TL Penalba V Liu J Avery J Comparing the symptom experience of cancer patients and non-cancer patients Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 2017 25 1103 1109 10.1007/s00520-016-3498-2
Deshields TL, Penalba V, Liu J, Avery J (2017) Comparing the symptom experience of cancer patients and non-cancer patients. Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 25:1103–1109. 10.1007/s00520-016-3498-2
3. Wu HS Harden JK Symptom burden and quality of life in survivorship: a review of the literature Cancer Nurs 2015 38 E29 54 10.1097/ncc.0000000000000135 24831042
Wu HS, Harden JK (2015) Symptom burden and quality of life in survivorship: a review of the literature. Cancer Nurs 38:E29-54. 10.1097/ncc.000000000000013524831042
4. Friedenreich CM Neilson HK Farris MS Courneya KS Physical activity and cancer outcomes: a precision medicine approach Clin Cancer Res: An Off J Am Assoc Cancer Res 2016 22 4766 4775 10.1158/1078-0432.Ccr-16-0067
Friedenreich CM, Neilson HK, Farris MS, Courneya KS (2016) Physical activity and cancer outcomes: a precision medicine approach. Clin Cancer Res: An Off J Am Assoc Cancer Res 22:4766–4775. 10.1158/1078-0432.Ccr-16-0067
5. Liska TM Kolen AM The role of physical activity in cancer survivors’ quality of life Health Qual Life Outcomes 2020 18 197 10.1186/s12955-020-01448-3 32571351
Liska TM, Kolen AM (2020) The role of physical activity in cancer survivors’ quality of life. Health Qual Life Outcomes 18:197. 10.1186/s12955-020-01448-332571351
6. van Putten M Husson O Mols F Luyer MDP van de Poll-Franse LV Ezendam NPM Correlates of physical activity among colorectal cancer survivors: results from the longitudinal population-based profiles registry Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 2016 24 573 583 10.1007/s00520-015-2816-4
van Putten M, Husson O, Mols F, Luyer MDP, van de Poll-Franse LV, Ezendam NPM (2016) Correlates of physical activity among colorectal cancer survivors: results from the longitudinal population-based profiles registry. Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 24:573–583. 10.1007/s00520-015-2816-4
7. Rock CL Thomson CA Sullivan KR Howe CL Kushi LH Caan BJ Neuhouser ML Bandera EV Wang Y Robien K Basen-Engquist KM Brown JC Courneya KS Crane TE Garcia DO Grant BL Hamilton KK Hartman SJ Kenfield SA Martinez ME Meyerhardt JA Nekhlyudov L Overholser L Patel AV Pinto BM Platek ME Rees-Punia E Spees CK Gapstur SM McCullough ML American Cancer Society nutrition and physical activity guideline for cancer survivors CA: Cancer J Clin 2022 72 230 262 10.3322/caac.21719 35294043
Rock CL, Thomson CA, Sullivan KR, Howe CL, Kushi LH, Caan BJ, Neuhouser ML, Bandera EV, Wang Y, Robien K, Basen-Engquist KM, Brown JC, Courneya KS, Crane TE, Garcia DO, Grant BL, Hamilton KK, Hartman SJ, Kenfield SA, Martinez ME, Meyerhardt JA, Nekhlyudov L, Overholser L, Patel AV, Pinto BM, Platek ME, Rees-Punia E, Spees CK, Gapstur SM, McCullough ML (2022) American Cancer Society nutrition and physical activity guideline for cancer survivors. CA: Cancer J Clin 72:230–262. 10.3322/caac.2171935294043
8. Patel AV Friedenreich CM Moore SC Hayes SC Silver JK Campbell KL Winters-Stone K Gerber LH George SM Fulton JE Denlinger C Morris GS Hue T Schmitz KH Matthews CE American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control Med Sci Sports Exerc 2019 51 2391 2402 10.1249/mss.0000000000002117 31626056
Patel AV, Friedenreich CM, Moore SC, Hayes SC, Silver JK, Campbell KL, Winters-Stone K, Gerber LH, George SM, Fulton JE, Denlinger C, Morris GS, Hue T, Schmitz KH, Matthews CE (2019) American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control. Med Sci Sports Exerc 51:2391–2402. 10.1249/mss.000000000000211731626056
9. National Comprehensive Cancer Network (2024) NCCN Clinical Practice Guidelines in Oncology. Survivorship. NCCN website. https://www.nccn.org/guidelines/guidelines-detail?category=3&id=1466. Accessed Aug 2024
10. Matias M Baciarello G Neji M Di Meglio A Michiels S Partridge AH Bendiane MK Fizazi K Ducreux M Andre F Vaz-Luis I Fatigue and physical activity in cancer survivors: a cross-sectional population-based study Cancer Med 2019 8 2535 2544 10.1002/cam4.2060 30864301
Matias M, Baciarello G, Neji M, Di Meglio A, Michiels S, Partridge AH, Bendiane MK, Fizazi K, Ducreux M, Andre F, Vaz-Luis I (2019) Fatigue and physical activity in cancer survivors: a cross-sectional population-based study. Cancer Med 8:2535–2544. 10.1002/cam4.206030864301
11. Avancini A Pala V Trestini I Tregnago D Mariani L Sieri S Krogh V Boresta M Milella M Pilotto S Lanza M Exercise levels and preferences in cancer patients: a cross-sectional study Int J Environ Res Public Health 2020 17 5351 10.3390/ijerph17155351 32722265
Avancini A, Pala V, Trestini I, Tregnago D, Mariani L, Sieri S, Krogh V, Boresta M, Milella M, Pilotto S, Lanza M (2020) Exercise levels and preferences in cancer patients: a cross-sectional study. Int J Environ Res Public Health 17:5351. 10.3390/ijerph1715535132722265
12. Park JH Lee DH Kim SI Kim NK Jeon JY Moderate to vigorous physical activity participation associated with better quality of life among breast and colorectal cancer survivors in Korea BMC Cancer 2020 20 365 10.1186/s12885-020-06819-z 32357850
Park JH, Lee DH, Kim SI, Kim NK, Jeon JY (2020) Moderate to vigorous physical activity participation associated with better quality of life among breast and colorectal cancer survivors in Korea. BMC Cancer 20:365. 10.1186/s12885-020-06819-z32357850
13. Kang DQ Li Y Chen ZQ Liu Q Su CX Guo H Yue SJ Correlates of physical activity in colorectal cancer patients based on health promotion model Cancer Nurs 2020 43 E264 e272 10.1097/ncc.0000000000000725 32813487
Kang DQ, Li Y, Chen ZQ, Liu Q, Su CX, Guo H, Yue SJ (2020) Correlates of physical activity in colorectal cancer patients based on health promotion model. Cancer Nurs 43:E264-e272. 10.1097/ncc.000000000000072532813487
14. Fisher A Williams K Beeken R Wardle J Recall of physical activity advice was associated with higher levels of physical activity in colorectal cancer patients BMJ Open 2015 5 e006853 10.1136/bmjopen-2014-006853 25922098
Fisher A, Williams K, Beeken R, Wardle J (2015) Recall of physical activity advice was associated with higher levels of physical activity in colorectal cancer patients. BMJ Open 5:e006853. 10.1136/bmjopen-2014-00685325922098
15. Tarasenko YN Miller EA Chen C Schoenberg NE Physical activity levels and counseling by health care providers in cancer survivors Prev Med 2017 99 211 217 10.1016/j.ypmed.2017.01.010 28131780
Tarasenko YN, Miller EA, Chen C, Schoenberg NE (2017) Physical activity levels and counseling by health care providers in cancer survivors. Prev Med 99:211–217. 10.1016/j.ypmed.2017.01.01028131780
16. Orange ST Gilbert SE Brown MC Saxton JM Recall, perceptions and determinants of receiving physical activity advice amongst cancer survivors: a mixed-methods survey Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 2021 29 6369 6378 10.1007/s00520-021-06221-w
Orange ST, Gilbert SE, Brown MC, Saxton JM (2021) Recall, perceptions and determinants of receiving physical activity advice amongst cancer survivors: a mixed-methods survey. Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 29:6369–6378. 10.1007/s00520-021-06221-w
17. Liu Y Wang Y Tian M Li X Liu F Experiences of physical activity in colorectal cancer patients with permanent enterostomy: a qualitative study J Nurs Sci 2022 37 25 28 10.3870/j.issn.1001-4152.2022.03.025
Liu Y, Wang Y, Tian M, Li X, Liu F (2022) Experiences of physical activity in colorectal cancer patients with permanent enterostomy: a qualitative study. J Nurs Sci 37:25–28. 10.3870/j.issn.1001-4152.2022.03.025
18. Keogh JW Pühringer P Olsen A Sargeant S Jones LM Climstein M Physical activity promotion, beliefs, and barriers among Australasian oncology nurses Oncol Nurs Forum 2017 44 235 245 10.1188/17.Onf.235-245 28222085
Keogh JW, Pühringer P, Olsen A, Sargeant S, Jones LM, Climstein M (2017) Physical activity promotion, beliefs, and barriers among Australasian oncology nurses. Oncol Nurs Forum 44:235–245. 10.1188/17.Onf.235-24528222085
19. Nadler M Bainbridge D Tomasone J Cheifetz O Juergens RA Sussman J Oncology care provider perspectives on exercise promotion in people with cancer: an examination of knowledge, practices, barriers, and facilitators Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 2017 25 2297 2304 10.1007/s00520-017-3640-9
Nadler M, Bainbridge D, Tomasone J, Cheifetz O, Juergens RA, Sussman J (2017) Oncology care provider perspectives on exercise promotion in people with cancer: an examination of knowledge, practices, barriers, and facilitators. Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 25:2297–2304. 10.1007/s00520-017-3640-9
20. Shea KM Urquhart R Keats MR Physical activity and cancer care in the Atlantic Canadian provinces: an examination of provider beliefs, practices, resources, barriers, and enablers J Cancer Educ: Off J Am Assoc Cancer Educ 2020 35 946 953 10.1007/s13187-019-01546-x
Shea KM, Urquhart R, Keats MR (2020) Physical activity and cancer care in the Atlantic Canadian provinces: an examination of provider beliefs, practices, resources, barriers, and enablers. J Cancer Educ: Off J Am Assoc Cancer Educ 35:946–953. 10.1007/s13187-019-01546-x
21. Li W Liu J Yu G Xu J Application of the knowledge-belief-practice model in nursing practice: current status and prospects J Nurs Sci 2015 30 107 110 10.3870/hlxzz.2015.06.107
Li W, Liu J, Yu G, Xu J (2015) Application of the knowledge-belief-practice model in nursing practice: current status and prospects. J Nurs Sci 30:107–110. 10.3870/hlxzz.2015.06.107
22. Bettinghaus EP Health promotion and the knowledge-attitude-behavior continuum Prev Med 1986 15 475 491 10.1016/0091-7435(86)90025-3 3774779
Bettinghaus EP (1986) Health promotion and the knowledge-attitude-behavior continuum. Prev Med 15:475–491. 10.1016/0091-7435(86)90025-33774779
23. Zheng S Zhao L Ju N Hua T Zhang S Liao S Relationship between oral health-related knowledge, attitudes, practice, self-rated oral health and oral health-related quality of life among Chinese college students: a structural equation modeling approach BMC Oral Health 2021 21 99 10.1186/s12903-021-01419-0 33676475
Zheng S, Zhao L, Ju N, Hua T, Zhang S, Liao S (2021) Relationship between oral health-related knowledge, attitudes, practice, self-rated oral health and oral health-related quality of life among Chinese college students: a structural equation modeling approach. BMC Oral Health 21:99. 10.1186/s12903-021-01419-033676475
24. Zhou C Qu X Wang L Wu Q Zhou Y Knowledge, attitude, and practice regarding postoperative delirium among cardiac surgery nurses: a cross-sectional multi-centre study J Clin Nurs 2023 32 5046 5055 10.1111/jocn.16751 37173828
Zhou C, Qu X, Wang L, Wu Q, Zhou Y (2023) Knowledge, attitude, and practice regarding postoperative delirium among cardiac surgery nurses: a cross-sectional multi-centre study. J Clin Nurs 32:5046–5055. 10.1111/jocn.1675137173828
25. Charan J Biswas T How to calculate sample size for different study designs in medical research? Indian J Psychol Med 2013 35 121 126 10.4103/0253-7176.116232 24049221
Charan J, Biswas T (2013) How to calculate sample size for different study designs in medical research? Indian J Psychol Med 35:121–126. 10.4103/0253-7176.11623224049221
26. Yu Xingmei Zhu Yuanyuan Jiang Guichun Mediating effect of self-efficiency between adversity quotient and job burnout J Nurs(China) 2021 28 55 59 10.16460/j.issn1008-9969.2021.20.055
Yu Xm, Zhu Yy, Jiang Gc (2021) Mediating effect of self-efficiency between adversity quotient and job burnout. J Nurs(China) 28:55–59. 10.16460/j.issn1008-9969.2021.20.055
27. McCourt O Yong K Ramdharry G Fisher A Physical activity during and after haematological cancer treatment: a cross-sectional survey of haematology healthcare professionals in the United Kingdom J Multidiscip Healthc 2021 14 1659 1671 10.2147/jmdh.S295888 34234453
McCourt O, Yong K, Ramdharry G, Fisher A (2021) Physical activity during and after haematological cancer treatment: a cross-sectional survey of haematology healthcare professionals in the United Kingdom. J Multidiscip Healthc 14:1659–1671. 10.2147/jmdh.S29588834234453
28. Tay C Yuh AS Sheau Lan EL Ong CE Aloweni F Lopez V Development and validation of the incontinence associated dermatitis knowledge, attitude and practice questionnaire J Tissue Viability 2020 29 244 251 10.1016/j.jtv.2020.06.004 32773358
Tay C, Yuh AS, Sheau Lan EL, Ong CE, Aloweni F, Lopez V (2020) Development and validation of the incontinence associated dermatitis knowledge, attitude and practice questionnaire. J Tissue Viability 29:244–251. 10.1016/j.jtv.2020.06.00432773358
29. Alabdullah MN Alabdullah H Kamel S Knowledge, attitude, and practice of evidence-based medicine among resident physicians in hospitals of Syria: a cross-sectional study BMC Med Educ 2022 22 785 10.1186/s12909-022-03840-7 36376824
Alabdullah MN, Alabdullah H, Kamel S (2022) Knowledge, attitude, and practice of evidence-based medicine among resident physicians in hospitals of Syria: a cross-sectional study. BMC Med Educ 22:785. 10.1186/s12909-022-03840-736376824
30. Wu Y Chen D Wang M Tang S Ye X Chen X The effect of interprofessional education in nurses undertaking a ward rotation J Nurs Sci 2021 36 61 63 10.3870/j.issn.1001-4152.2021.22.061
Wu Y, Chen D, Wang M, Tang S, Ye X, Chen X (2021) The effect of interprofessional education in nurses undertaking a ward rotation. J Nurs Sci 36:61–63. 10.3870/j.issn.1001-4152.2021.22.061
31. Shi S Liu Z Xu B Xiang J Zhang L Current status and influencing factors of knowledge sharing behavior among specialty nurses from 12 hospitals in Jiangsu province Chin Nurs Manag 2017 17 752 758 10.3969/j.issn.1672-1756.2017.06.008
Shi S, Liu Z, Xu B, Xiang J, Zhang L (2017) Current status and influencing factors of knowledge sharing behavior among specialty nurses from 12 hospitals in Jiangsu province. Chin Nurs Manag 17:752–758. 10.3969/j.issn.1672-1756.2017.06.008
32. Jones LW Courneya KS Peddle C Mackey JR Oncologists’ opinions towards recommending exercise to patients with cancer: a Canadian national survey Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 2005 13 929 937 10.1007/s00520-005-0805-8
Jones LW, Courneya KS, Peddle C, Mackey JR (2005) Oncologists’ opinions towards recommending exercise to patients with cancer: a Canadian national survey. Support Care Cancer: Off J Multinatl Assoc Support Care Cancer 13:929–937. 10.1007/s00520-005-0805-8
33. Tsiouris A Ungar N Haussmann A Sieverding M Steindorf K Wiskemann J Health care professionals’ perception of contraindications for physical activity during cancer treatment Front Oncol 2018 8 98 10.3389/fonc.2018.00098 29670858
Tsiouris A, Ungar N, Haussmann A, Sieverding M, Steindorf K, Wiskemann J (2018) Health care professionals’ perception of contraindications for physical activity during cancer treatment. Front Oncol 8:98. 10.3389/fonc.2018.0009829670858
34. Ungar N Tsiouris A Haussmann A Herbolsheimer F Wiskemann J Steindorf K Sieverding M To rest or not to rest-health care professionals’ attitude toward recommending physical activity to their cancer patients Psychooncology 2019 28 784 791 10.1002/pon.5020 30716190
Ungar N, Tsiouris A, Haussmann A, Herbolsheimer F, Wiskemann J, Steindorf K, Sieverding M (2019) To rest or not to rest-health care professionals’ attitude toward recommending physical activity to their cancer patients. Psychooncology 28:784–791. 10.1002/pon.502030716190
35. Wang Z Liu L Yu K Wang J Zhang R Tang Y Yue S Best-practice evidence on physical activity for cancer survivors Chin Nurs Manag 2020 20 717 723 10.3969/j.issn.1672-1756.2020.05.016
Wang Z, Liu L, Yu K, Wang J, Zhang R, Tang Y, Yue S (2020) Best-practice evidence on physical activity for cancer survivors. Chin Nurs Manag 20:717–723. 10.3969/j.issn.1672-1756.2020.05.016
36. Zhang Q Li F Zhang H Yu X Cong Y Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: a randomized controlled trial Int J Nurs Stud 2018 78 52 60 10.1016/j.ijnurstu.2017.08.010 28939343
Zhang Q, Li F, Zhang H, Yu X, Cong Y (2018) Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: a randomized controlled trial. Int J Nurs Stud 78:52–60. 10.1016/j.ijnurstu.2017.08.01028939343
37. Liu Ty (2021) Construction of physical activity intervention program for breast cancer survivors based on the behavior change wheel theory. Huazhong University of Science and Technology, Wuhan.
38. Roberts AL Potts HWW Stevens C Lally P Smith L Fisher A Cancer specialist nurses’ perspectives of physical activity promotion and the potential role of physical activity apps in cancer care J Cancer Survivorship: Res Pract 2019 13 815 828 10.1007/s11764-019-00801-w
Roberts AL, Potts HWW, Stevens C, Lally P, Smith L, Fisher A (2019) Cancer specialist nurses’ perspectives of physical activity promotion and the potential role of physical activity apps in cancer care. J Cancer Survivorship: Res Pract 13:815–828. 10.1007/s11764-019-00801-w
39. Tan X Zhang Y Shao H Healthy China 2030, a breakthrough for improving health Glob Health Promot 2019 26 96 99 10.1177/1757975917743533 29297762
Tan X, Zhang Y, Shao H (2019) Healthy China 2030, a breakthrough for improving health. Glob Health Promot 26:96–99. 10.1177/175797591774353329297762
40. Zhong Y McKenna L Copnell B Zhao W Moss C Professional adaptation experiences of Chinese migrant nurses in Australia: a qualitative study West J Nurs Res 2023 45 626 633 10.1177/01939459231167711 37021833
Zhong Y, McKenna L, Copnell B, Zhao W, Moss C (2023) Professional adaptation experiences of Chinese migrant nurses in Australia: a qualitative study. West J Nurs Res 45:626–633. 10.1177/0193945923116771137021833
41. Lu J Deng Q Liu W Effects of organizational atmosphere and organizational practice on knowledge, attitude, and practice toward diffusion and utilization of hepatic contrast-enhanced ultrasound among physicians Front Public Health 2022 10 778253 10.3389/fpubh.2022.778253 35372238
Lu J, Deng Q, Liu W (2022) Effects of organizational atmosphere and organizational practice on knowledge, attitude, and practice toward diffusion and utilization of hepatic contrast-enhanced ultrasound among physicians. Front Public Health 10:778253. 10.3389/fpubh.2022.77825335372238
42. Huang M Liu Y Jiang Y Huang Y Study of prediction model of nursing human resources based on human factors engineering theory Chin Nurs Res 2023 37 52 61 10.12102/j.issn.1009-6493.2023.01.009
Huang M, Liu Y, Jiang Y, Huang Y (2023) Study of prediction model of nursing human resources based on human factors engineering theory. Chin Nurs Res 37:52–61. 10.12102/j.issn.1009-6493.2023.01.009
43. Mina DS Langelier D Adams SC Alibhai SMH Chasen M Campbell KL Oh P Jones JM Chang E Exercise as part of routine cancer care Lancet Oncol 2018 19 e433 e436 10.1016/s1470-2045(18)30599-0 30191843
Mina DS, Langelier D, Adams SC, Alibhai SMH, Chasen M, Campbell KL, Oh P, Jones JM, Chang E (2018) Exercise as part of routine cancer care. Lancet Oncol 19:e433–e436. 10.1016/s1470-2045(18)30599-030191843
44. The Lancet O Exercise and cancer treatment: balancing patient needs Lancet Oncol 2018 19 715 10.1016/s1470-2045(18)30376-0 29893247
The Lancet O (2018) Exercise and cancer treatment: balancing patient needs. Lancet Oncol 19:715. 10.1016/s1470-2045(18)30376-029893247
