Introduction
By 2050, the global older adults population (aged 60 and above) is projected to grow to two billion, accounting for more than 20% of the global population. Due to the rise in life expectancy and the decline in birth rates, This global trend of aging is irreversible and presents significant challenges for healthcare and social systems worldwide [1‐3]. In China, the proportion of individuals aged 65 and above was 13.5% in 2020 and is expected to reach 26% (338 million) by 2050, with 8% of the population being 80 years or older [4]. Meanwhile, with the rapid development of China’s healthcare system and the continuous acceleration of urbanization, factors including rising life expectancy, a growing migrant population, and the impact of the previous one-child policy have led many older adult individuals to choose, either voluntarily or involuntarily, to live in nursing homes, resulting in a significant increase in the demand for nursing assistants (NAs) in older adults care institutions. However, the supply of qualified and skilled NAs remains insufficient to meet the needs of the aging population.
Malnutrition is a critical issue requiring urgent attention among older adult residents in nursing homes, where it is highly prevalent, strongly associated with adverse health outcomes. The prevalence of malnutrition in hospitals and long-term care facilities is reported to range between 8% and 56% [5]. Moreover, malnutrition is independently associated with prolonged hospital stays and reduced quality of life, leading to measurable adverse effects on body composition, functional status, and clinical outcomes [6, 7]. It also increases the risks of infections, falls, and fractures. Research underscores the critical role nurses play in effectively meeting patients’ nutritional needs [8]. Nurses significantly impact optimal nutritional care for malnourished patients by conducting nutritional screenings, monitoring intake and body weight, and assisting patients in achieving their targeted intake goals [7, 9]. However, care work in nursing homes globally involves more nursing assistants, who provide medical and daily living support to residents but typically have less training [10]. Bauer et al. investigated 1,152 registered nurses and nurse aides regarding malnutrition care in nursing homes and found that registered nurses possessed greater nutrition knowledge compared to nurse aides [11]. Bachrach-Lindström et al. found that registered nurses had better attitudes towards nutritional care than nurse aides [12]. The KAP model is widely used in nursing research as it helps to explore the relationship between nurses’ knowledge, attitudes, and practices, along with the factors that influence them [13‐17]. By assessing NAs’ KAP, we can identify key barriers and design targeted interventions to enhance nutritional care for older adults. The Knowledge, Attitudes, and Practices (KAP) model is widely used in nursing research as it helps to understand the relationship between nurses’ knowledge and practices, along with the influencing factors [13‐17]. By analyzing NAs’ KAP, we can identify key barriers and design targeted interventions to improve nutritional care for older adults. However, there is limited research examining the nutrition-related KAP of nursing assistants in Chinese older adults nursing homes. Consequently, the purpose of this study is to investigate the nutritional KAP of nursing assistants in nursing homes, including their knowledge, attitudes, and practices. Furthermore, we aim to analyze influencing factors to lay the foundation for developing targeted training programs.
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Materials and methods
Study design
This study used a cross-sectional design, with data collected from nursing assistants at 76 nursing homes in Shanghai using convenience sampling. Data were collected from January to September 2023. The inclusion criteria were as: (1) nursing assistants responsible for caring for older adult individuals, (2) aged ≥ 18 years, (3) who had been continuously working in nursing homes for at least three months. and (4) who voluntarily participated in this investigation. The exclusion criteria were: (1) those unable to understand the questionnaire content even after explanation, and (2) those with a history of severe mental illness.
Instruments and questionnaires
The study’s demographic questionnaire included characteristics such as age, gender, educational level, years of nursing experience, participation in nutrition training, perceptions of skill deficiencies, outdated concepts, insufficient income, and whether the leader regularly monitors and assesses the nutritional status of patients (regular supervision).
We used Sheng’s Nutrition Knowledge, Attitude, and Practice Questionnaire for Chinese nurses, which demonstrates a Cronbach’s α ranging from 0.672 to 0.764, and a test-retest reliability of 0.793. In our study, the Cronbach’s α for this scale was 0.724, indicating good internal consistency. The questionnaire includes three sections: nutrition knowledge, nutrition attitude, and nutrition practice. (1) The nutrition knowledge section consists of two parts: basic nutrition knowledge and disease-related nutrition knowledge, with 25 single-choice questions in total. The basic nutrition knowledge section includes 10 single-choice questions covering fundamental dietary principles, such as nutrient composition, daily intake recommendations et al. The disease-related nutrition knowledge section includes 15 single-choice questions cover nutrition therapy and appropriate dietary modifications for specific diseases (e.g., diabetes, hypertension, coronary heart disease, liver cirrhosis, gout, and postoperative recovery). The total score is converted to a 100-point scale, with higher scores indicating greater nutritional knowledge. (2) The nutrition attitude section includes 10 items measured on a 5-point Likert scale ranging from “ strongly agree” to “ strongly disagree”. These items evaluate nursing assistants’ interest in nutrition knowledge, perceptions of the importance of nutrition care, willingness to undertake nutrition-related clinical responsibilities, and attitudes toward participating in nutrition training. The total score is converted to a 100-point scale, with higher scores indicating more positive nutritional attitudes.(3)The nutrition practice section includes 6 items designed to evaluate self-reported practices in nutritional care during routine work. These items assess the extent to which nursing assistants pay attention to patients’ nutritional care needs, provide nutrition health education, conduct systematic nutritional assessments, establish standardized nutrition care records, report patients’ nutritional and dietary issues to physicians or dietitians, and actively accumulate nutrition knowledge in their work. Responses are measured on a 5-point Likert scale ranging from “ strongly agree” to “ strongly disagree,” and scores are converted to a 100-point scale, with higher scores indicating better nutritional care practices [17].(Supplementary 1).
Data collection
The WeChat work group utilized in this study was an existing group comprising administrators of nursing homes and community healthcare institutions. This group was originally established to support pension combined with medical service. The research team shared the questionnaire link in this group, and the administrators further distributed the link and study information to their respective nursing assistants through their internal WeChat work groups. Nursing assistants who met the inclusion criteria were invited to participate voluntarily. Participation was strictly governed by the inclusion and exclusion criteria. Besides, we set all the questions must be completed before submitted the questionnaire. Additionally, we set the same IP or WeChat account can only be filled once to prevent repeated filling. We also set a limit on the time required to fill the questionnaire. All questionnaires that taken < 1 min to answer were excluded Moreover, the same answers for consecutive questions also were excluded. Finally, a total of 61 questionnaires were excluded, resulting in 692 valid questionnaires.
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Statistical analysis
All statistical analyses were conducted using SPSS software (Version 27.0, IBM Corp, Armonk, NY, USA). Descriptive statistics were used to summarize the demographic characteristics of the participants, with continuous variables presented as mean ± standard deviation (SD) and categorical variables as frequencies and percentages. To compare nutrition knowledge, attitudes, and behaviors across different demographic groups, one-way analysis of variance (ANOVA) was employed, with post-hoc tests performed when necessary. Multiple linear regression analyses were conducted to identify factors that were independently associated with nutritional knowledge, attitudes, and behaviors. The dependent variables were the scores for nutritional knowledge, attitudes, and behaviors, while the independent variables included demographic characteristics (e.g., age, education level, years of caring experience), participation in nutrition training, regular supervision, and other relevant factors identified through univariate analyses. Only variables with a P-value < 0.05 in the univariate analyses were included in the regression models.
The assumptions of linear regression, including normality, linearity, and homoscedasticity, were assessed and found to be met. Multicollinearity was assessed using the variance inflation factor (VIF), and no significant multicollinearity was observed. A P-value of < 0.05 was considered statistically significant for all analyses. The results were reported with corresponding 95% confidence intervals (CIs) to estimate the precision of the regression coefficients. Effect sizes (β coefficients) were also presented to indicate the strength of the associations.
Results
Participant characteristics
Table 1 presents the demographic characteristics of the investigated nursing assistants. Among the 692 participants, the mean age was 50.23 ± 6.81 years, and the mean years of caring experience was 8.68 ± 6.87 years. More than half of the participants were over 50 years old and had more than 5 years of work experience. Additionally, 91.18% of the participants had an education level of senior high school or below. More than half of the participants reported that they had not participated in any nutrition training.
Table 1
Demographic characteristics of the investigated nursing assistants (N = 692)
Characteristic | Group | N | % |
|---|---|---|---|
Age | 20 ~ 29 | 18 | 2.60 |
30 ~ 39 | 15 | 2.17 | |
40 ~ 49 | 233 | 33.67 | |
50 ~ 59 | 391 | 56.50 | |
≥ 60 | 35 | 5.06 | |
Years of caring | 0 ~ 5 | 346 | 50.00 |
6 ~ 10 | 133 | 19.22 | |
11 ~ 15 | 91 | 13.15 | |
16 ~ 20 | 84 | 12.14 | |
>20 | 38 | 5.49 | |
Education | Junior High School or Below | 111 | 16.04 |
Senior High School | 520 | 75.14 | |
Vocational School | 40 | 5.78 | |
Associate Degree | 19 | 2.75 | |
Bachelor’s Degree or Above | 2 | 0.29 | |
Participated in nutrition training | Yes | 315 | 45.52 |
No | 377 | 54.48 | |
Regular supervision | Yes | 542 | 78.32 |
No | 150 | 21.68 |
Relationships between the nutritional KAP of nursing assistants
We found that the mean nutritional knowledge score was 45.07 ± 16.18, comprising 25.77 ± 10.27 in basic nutrition knowledge and 19.29 ± 8.99 in disease-related nutrition knowledge. The mean nutritional attitude score was 76.22 ± 10.03, and the mean nutritional practice score was 69.94 ± 21.46 (Supplementary 2). Pearson correlation analysis was used to assess the associations between these dimensions. The analysis revealed a significant negative association between nutritional knowledge and practice (r = -0.194, p < 0.01), indicating that higher knowledge levels did not correspond to better practices. In contrast, a positive association was observed between nutritional attitude and practice (r = 0.422, p < 0.01), suggesting that more positive attitudes were linked to better practices. No significant relationship was found between nutritional knowledge and attitude (Table 2).
Table 2
Relationships between nutritional knowledge, attitudes and practices scores of nursing assistants in nursing homes
Nutritional knowledge | Nutritional attitude | Nutritional Practice | |
|---|---|---|---|
Nutritional knowledge | 1 | ||
Nutritional attitude | -0.016 | 1 | |
Nutritional Practice | -0.194** | 0.422** | 1 |
Differences in nutritional knowledge, attitudes, and practices across demographic characteristics
In the nutritional knowledge dimension, significant differences were observed based on years of caring, education level, skill deficiency, and regular supervision. Specifically, nursing assistants with 0–5 years of caring had significantly higher nutritional knowledge scores than other groups (F = 11.275, p < 0.001). Additionally, those with a junior high school or lower educational level had significantly lower nutritional knowledge scores than those with higher educational levels (F = 4.529, p = 0.037).
Significant differences in nutritional attitude scores were also observed across various groups, particularly based on years of caring, education level, participation in nutrition training, regular supervision, and skill deficiency. Nursing assistants with higher levels of education demonstrated significantly more positive nutritional attitudes compared to those with lower levels of education (F = 5.502, p < 0.001). Furthermore, regular supervision (F = 34.89, p < 0.001) and participation in nutrition training (F = 10.22, p = 0.001) were significantly associated with higher nutritional attitude scores.
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Regarding nutritional practice, significant differences were identified across groups based on age, being a responsible nursing assistant, and skill deficiency. Age emerged as a significant factor (F = 6.061, p < 0.001), with older participants exhibiting better nutritional practices. Moreover, participation in nutrition training (F = 11.756, p < 0.001), being a responsible nursing assistant (F = 28.504, p < 0.001), and regular supervision (F = 90.321, p < 0.001) were also significant predictors of improved nutritional practice. (Supplementary 2)
Multiple regression analysis of influential factors of KAP score
Table 3 presents the influential factors of KAP scores among nursing assistants in nursing homes. Multiple linear regression analysis identified several significant predictors for nutrition knowledge, attitude, and practice scores. Specifically, years of caring (95% CI [-3.70, -1.88], p < 0.001) were negatively associated with nutritional knowledge, indicating that more years of caring were linked to lower knowledge scores. In contrast, education level (95% CI [1.94, 5.87], p < 0.001) was positively associated with higher knowledge scores, suggesting that nursing assistants with higher educational attainment had greater nutritional knowledge. Additionally, skill deficiency (95% CI [-6.37, -1.05], p = 0.006) and regular supervision (95% CI [-6.25, -0.60], p = 0.018) were negatively associated with nutritional knowledge as well.
In terms of nutritional attitudes, participation in nutrition training (95% CI [2.69, 5.58], p < 0.001), years of caring (95% CI [0.61, 1.74], p < 0.001), and education level (95% CI [1.24, 3.67], p < 0.001) were positively associated with improved nutritional attitudes. These findings indicate that nursing assistants with higher levels of education and more years of caring tend to exhibit more positive attitudes toward nutrition care. Participation in nutrition training, in particular, appears to help shape attitudes, highlighting the importance of learning opportunities in fostering a more positive nutritional attitude.
Regarding nutritional practices, age (95% CI [1.13, 5.01], p = 0.002), regular supervision (95% CI [10.94, 18.26], p < 0.001), and participation in nutrition training (95% CI [8.43, 14.52], p < 0.001) were positively associated with improved nutritional practices. These findings suggest that nursing assistants who are slightly older may possess greater experience, enabling them to implement better nutritional care practices. Additionally, regular supervision provides necessary guidance and reinforcement, while participation in nutrition training equips nursing assistants with the essential knowledge and skills to improve their nutritional care practices effectively. However, insufficient income (95% CI [-6.07, -0.31], p = 0.030) was negatively correlated with nutritional practices, indicating that individuals with insufficient income had lower scores in nutritional practices.
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Table 3
Multiple linear regression analysis of factors influencing KAP scores
Dimension | Variable | B | SE | β | t | P | 95%CI |
|---|---|---|---|---|---|---|---|
Nutritional knowledge | Years of caring | -2.789 | 0.465 | -0.219 | -6.000 | < 0.001** | [-3.70,-1.88] |
Education | 3.907 | 1.001 | 0.143 | 3.903 | < 0.001** | [1.94, 5.87] | |
skill deficiency | -3.714 | 1.355 | -0.100 | -2.741 | 0.006** | [-6.37,-1.05] | |
regular supervision | -3.422 | 1.440 | -0.087 | -2.376 | 0.018* | [-6.25,-0.60] | |
Nutritional attitude | Participated in nutrition training | 4.138 | 0.735 | 0.206 | 5.627 | < 0.001** | [2.69, 5.58] |
Years of caring | 1.177 | 0.288 | 0.149 | 4.092 | < 0.001** | [0.61, 1.74] | |
Education | 2.453 | 0.617 | 0.145 | 3.975 | < 0.001** | [1.24, 3.67] | |
Nutritional Practice | Regular supervision | 14.597 | 1.864 | 0.280 | 7.831 | < 0.001** | [10.94, 18.26] |
Participated in nutrition training | 11.474 | 1.549 | 0.266 | 7.407 | < 0.001** | [8.43, 14.52] | |
Age | 3.068 | 0.987 | 0.105 | 3.107 | 0.002* | [1.13, 5.01] | |
Insufficient income | -3.189 | 1.465 | -0.074 | -2.177 | 0.030* | [ -6.07, -0.31] |
Discussion
Our study aimed to explore the current status and influencing factors of nursing assistants’ (NAs) nutritional Knowledge, Attitudes, and Practices (KAP) to provide evidence for improving NAs’ nutritional KAP in older adult care institutions and to inform future interventions and policy development. The results revealed that 66.04% of nursing assistants scored below 50% accuracy in nutritional knowledge. Nutritional knowledge was positively correlated with education level but negatively associated with years of caring. Nutritional attitudes were positively influenced by participation in nutrition training, years of caring, and education. Meanwhile, nutritional practices were positively associated with participation in nutrition training, age, and regular supervision, whereas insufficient income negatively impacted practice scores. A comprehensive strategy targeting these areas could bridge gaps in knowledge and practice, ultimately improving the quality of nutritional care provided by nursing assistants.
According to a report by the World Health Organization (WHO), a shortage of NAs is particularly evident in various countries, including those in low- and middle-income regions. This shortage not only places additional pressure on existing healthcare systems but also raises concerns about the quality of care provided to the older adults, especially in settings where resources are already limited [14‐16, 18] In China, registered nurses make up a minority of staff in nursing homes, and NAs are the leading workforce in caring for older people [19, 20]. NAs have the most frequent contact with older adult residents and are the primary providers of healthcare in nursing homes. They play a central role in daily care and health management, being directly responsible for managing the dietary intake and nutritional care of the older adults daily [21]. Consequently, the nutritional KAP of NAs play an important role in influencing the nutritional status of the older adult residents under their care [22, 23]. However, research indicates that NAs often possess insufficient knowledge and skills related to nutrition management and may lack a clear understanding of the importance of nutritional management [5, 12, 20]. Various factors can influence the nutritional KAP of NAs, including educational background, work experience, training opportunities, institutional support, and the work environment in nursing homes. For example, due to insufficient initial education, many NAs receive minimal training in nutrition. Additionally, limited opportunities for continuing education or professional development hinder their ability to update their knowledge. The heavy workload and time constraints they face further restrict their capacity for self-directed learning and skill improvement. Most existing research focuses on nurses with very few studies specifically focusing on NAs, and there remains significant uncertainty and gaps in the existing literature regarding how these factors specifically affect the nutritional KAP of NAs [24‐28]. Furthermore, differences in scoring methods used in various studies complicate direct comparisons of nutritional KAP. These variations in scoring systems can affect how results are interpreted, highlighting the need for the development and use of standardized tools to assess nutritional KAP across diverse contexts. This would facilitate more reliable comparisons and provide clearer insights into the factors influencing nutritional KAP among NAs.
In our study, the mean nutritional knowledge score was 45.07 ± 16.18, with 78.32% of individuals scoring below 60 points. The results indicate that the nutritional knowledge level among NAs is significantly low, particularly regarding disease-related nutrition knowledge, which is consistent with previous studies [12, 28‐30]. This suggests that nutrition should receive greater emphasis in the training of NAs. Additionally, the findings revealed that in the context of Chinese nursing homes, factors such as education level, years of care, regular supervision, and skill deficiency significantly influence the nutritional knowledge of NAs. Notably, longer years of care were associated with lower knowledge scores, suggesting that without continuous professional development, knowledge may become outdated or fail to accumulate effectively, even with regular supervision. This highlights the need for ongoing training and education to keep NAs’ nutritional knowledge up to date [29, 31]. Despite ongoing efforts to improve on-the-job training for nursing assistants, as highlighted in the Civil Affairs Bureau’s guidance [32], current training programs primarily focus on basic caregiving skills with limited emphasis on clinical nutrition. While the policy framework acknowledges the importance of training, it lacks specific provisions for structured and standardized nutritional training, particularly in areas such as disease-specific dietary management and nutritional assessment techniques. To address this gap, training programs should incorporate targeted modules on clinical nutrition and provide flexible formats, such as e-learning platforms, to accommodate the busy schedules of nursing assistants, short-term intensive courses focusing on basic nutrition and disease-specific dietary management, on-site demonstrations by nutrition professionals integrated into daily caregiving tasks, and simplified guides or video tutorials for independent learning. Strengthening the focus on clinical nutrition through structured training could significantly enhance the quality of nutritional care for older adults in nursing homes.
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Interestingly, although the study identified gaps in nutritional knowledge, it also found that NAs generally exhibited positive attitudes (76.22 ± 10.03) and practices (69.94 ± 21.46) toward nutrition. This suggests that while knowledge may be lacking, the overall attitude and practice towards nutritional care remain relatively positive among NAs. This phenomenon may be explained by NAs can develop practical skills through a “learning-by-doing” approach in their daily work, even with limited theoretical knowledge. Their daily responsibilities and direct caregiving experience can significantly enhance their ability to provide nutritional care. Additionally, NAs may rely on established institutional workflows, such as meal planning and health monitoring, to implement nutritional care, which can partially compensate for their knowledge gaps. In addition, insufficient income is a negative factor influencing nutritional practices among NAs. Nutritional practices often involve complex tasks such as conducting dietary assessments, designing meal plans, and implementing therapeutic nutrition interventions. These tasks require a lot time and effort, yet they may not be directly tied to income. As a result, NAs with higher knowledge levels may exhibit lower practice engagement due to a lack of motivation or support. Improving compensation and providing structural support can significantly enhance nutritional practices.
The attitudes of NAs are considered essential for successfully translating knowledge into practice, as demonstrated in some studies [13‐15]. Our results indicate that NAs with higher educational levels and those who participated in nutrition training exhibited significantly more positive attitudes, consistent with literature that underscores the role of education and training in shaping healthcare providers’ attitudes and subsequently translates into nutritional practices [19, 20, 27‐34]. The lack of a significant relationship between knowledge and attitudes suggests that knowledge alone does not necessarily translate into a positive attitude, highlighting the need for more integrated training approaches that address both knowledge and attitudes [35‐38]. Regular supervision also demonstrated a significant positive effect on both nutritional attitudes and practices, indicating that effective supervision can further improve the nutritional attitudes and practices of NAs.
However, the inverse relationship between attitudes and practices suggests that knowledge deficiencies may undermine the ability to translate positive attitudes into effective nutritional practices. This phenomenon has also been observed in other countries [19, 29, 31, 39]. Despite the positive attitudes of NAs toward the importance of nutrition, their insufficient knowledge often hinders the adoption of best practices in nutritional care. It is further recommended that greater emphasis be placed on nutrition during the training of NAs, as the level of nutritional knowledge they possess influences their attitudes and practices in providing nutritional care to patients. Several studies have investigated the nutritional attitudes and practices of nursing staff. Mowe et al. found that a lack of interest was a significant factor influencing nurses’ attitudes toward nutritional practices. Nursing staff did not perceive nutrition as important; they lacked interest in the area and viewed it as less relevant compared to other tasks [40, 41]. Holst et al. conducted a quantitative study using questionnaires to investigate the attitudes and practices of 6,000 Scandinavian nurses toward nutrition. The study indicated that, despite nurses’ positive attitudes toward nutrition, their nutritional practices did not reflect this. Although 93% of nurses placed high importance on documenting nutritional care plans in patient records, this was rarely implemented in practice [38]. Persenius et al.‘s study showed that while nurses recorded patients’ nutritional status, little attention was given to more detailed assessments such as screening tools, BMI, and percentage weight loss [42]. These studies collectively suggest that although nursing staff may have positive attitudes toward nutrition, significant challenges remain in translating these attitudes into effective nutritional practices.
Based on the study’s findings and international research evidence, several recommendations can be proposed to enhance NAs’ KAP. First, there is a clear need for more comprehensive and continuous education and training programs focused on nutrition and malnutrition. There is also a high demand for courses aimed at improving knowledge, attitudes, and practices related to nutrition care in nursing homes, as insufficient knowledge, limited interest, and negative attitudes toward nutrition are perceived as the most common barriers to adequate nutritional practice. NAs were more likely to embrace nutrition care as part of their responsibilities after receiving training in the field [19, 21, 31, 37, 40, 43]. These programs should cover not only basic nutritional knowledge but also emphasize the practical application of this knowledge in daily care practices. In addition, regular supervision and support from experienced healthcare professionals can strengthen nutritional practices. Secondly, attention needs to be paid to addressing the lack of nutritional skills among NAs. This can be achieved through regular nutritional training and refresher courses that allow NAs to practice and improve their skills. Besides, improving the nutritional KAP of registered nurses (RNs) is essential, as they often serve as the primary mentors and supervisors for NAs, significantly influencing NAs’nutritional practices. With their advanced knowledge and professional training, RNs can play a important role in mentoring NAs. They can provide essential guidance on nutritional practices, foster positive attitudes through role modeling, and facilitate skill development in daily care practices. Furthermore, it is important to consider the deeper issues that may be contributing to gaps in knowledge and practice among NAs. This includes ensuring that NAs have access to adequate educational resources, appropriate compensation, reasonable work intensity, recognition of their critical role in geriatric care, and recognition of the importance that management places on nutrition. Finally, it is crucial to encourage an increase in the number of registered dietitians in nursing homes to improve the quality of nutritional care.
The comprehensive data collection from 76 nursing homes in Shanghai provides a broad and detailed understanding of the nutritional KAP of NAs. Previously conducted studies on knowledge and attitudes were mostly based on small sample sizes and focused mainly on registered nurses or mixed samples, with limited research specifically addressing NAs, particularly regarding their nutritional KAP, despite the critical role they play in the nutritional care of the older adults. However, several limitations of this study should be considered when interpreting the results. The cross-sectional design limits the ability to infer causality between factors and outcomes. Future research using longitudinal designs could better establish causal relationships. The use of convenience sampling may introduce selection bias, limiting the generalizability of the findings beyond the study population. Additionally, reliance on self-reported data raises the possibility of social desirability bias, where participants might overreport favorable behaviors or attitudes, potentially leading to an overestimation of actual nutritional practices. Notably, the questionnaire assessed perceptions as well as self-reported attitudes and practices of NAs, which may not accurately reflect their actual behaviors. Furthermore, although the questionnaire has demonstrated acceptable reliability and validity for Chinese nurses, it has not been specifically validated for nursing assistants. This raises potential concerns about the applicability of its psychometric properties to the study sample. Finally, the geographic limitation to Shanghai may restrict the applicability of these findings to other regions or countries with different healthcare systems and cultural contexts.
Future research should consider adopting longitudinal designs to explore the dynamic changes and causal relationships of NAs’ nutritional knowledge, attitudes, and practices. It is also recommended that similar studies be conducted on a larger scale to validate the generalizability of these findings. Furthermore, nutritional education intervention studies targeting NAs represent a promising area for further research, which have the potential not only to enhance the nutritional knowledge of nursing staff but also to improve the overall nutritional status of older adults in nursing homes.
Conclusions
Education level positively influenced knowledge and attitudes, while participation in nutrition training positively impacted attitudes and practices. In conclusion, this study revealed the current status and influencing factors of nursing assistants’ nutritional knowledge, attitudes, and practices in nursing homes in Shanghai, which provides a scientific basis for developing targeted nutritional education programs. However, effectively improving nursing assistants’ nutritional knowledge and attitudes, and facilitating their transformation into actual practices, requires further exploration and validation.
Acknowledgements
We are thankful to all the subjects who participated in this study.
Declarations
Ethics approval and consent to participate
This study was approved by the Human Ethics Research Committee of Ruijin Hospital (No. 2016143). We confirmed that all methods were performed in accordance with relevant guidelines and regulations to protect human subjects. All participants read and signed written informed consent forms.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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