Background
The anthrax email incident in the United States in 2001 indicated that the mass threat of bioterrorism has become a reality [1]. The spread of infectious diseases such as SARS, H1N1, Ebola, MERS, COVID-19, and Monkey Pox in human societies has increased concerns about bioterrorist attacks [2]. Bioterrorism has become one of the greatest terrorist threats in the world. Bioterrorism is defined as the intentional release of biological agents or toxins to affect human, animal, or plant health as a means of achieving panic, mass casualties, or economic loss [3]. It is contagious, latent, hidden, inexpensive, easy to produce, catastrophic, and prone to panic [4‐6]. Bioterrorism is a typical “black swan” event with a low probability of occurrence, high hazard, and unpredictability [7]. According to the open-source Global Terrorism Database, 41 terrorist attacks involving biological agents have been recorded worldwide [8]. Although the use of biological agents as weapons in terrorist attacks is relatively rare, accounting for only approximately 8% of the total number of chemical, biological, radiation, and nuclear (CBRN) incidents worldwide [9], bioterrorism has great potential to cause mass casualties [10]. When a disease spreads uncontrollably, it may lead to a large-scale, catastrophic epidemic and even cause social panic and a national crisis [11]. Biosecurity affects people’s lives and health, as well as economic and social development. It is a major event involving the survival and development of a country. It is also a significant force that influences and even reshapes the global pattern. Working cooperatively to prevent bioterrorism threats is an urgent task facing the international community.
Healthcare workers are the first group to detect potential bioterrorism activities, contact bioterrorism victims, and take treatment measures, playing a critical role in preventing bioterrorism [12‐15]. Nurses, the largest group of healthcare workers [15‐17], are an indispensable part of bioterrorism prevention, with tasks including surveillance and early warning, symptom assessment, and medical treatment [18]. Simulations from the Center for Nonproliferation Studies demonstrated that preparing for bioterrorism can effectively lower the number of casualties by 75% [19]. Therefore, nurses, regardless of their education level, area of specialization, or practice setting, should complete bioterrorism preparedness as a compulsory course [20]. Nurses have the responsibility and obligation to be adequately prepared for bioterrorism and to have good knowledge, attitudes, and practices to protect themselves, their patients, and their families from infection [21].
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The knowledge, attitude, and practice model (KAP model) divides the change of human practices into three continuous processes: acquiring knowledge, generating attitudes and forming practices [22]. Bioterrorism knowledge, attitudes, and practices among nurses have been studied in the past. Studies on the United States nurses reported that the level of bioterrorism knowledge was not at the desired level [23, 24]. A study on Iranian nurses found that more than 90% of the participants had low levels of knowledge and attitudes towards bioterrorism [25]. China investigated nurses’ and core emergency response competencies regarding major infectious disease outbreaks, which addressed bioterrorism preparedness [26]. Although China is currently paying attention to bioterrorism, research on this topic is insufficient, and there is a lack of bioterrorism-specific research. Thus, this study integrated three dimensions of bioterrorism knowledge, attitudes and practices with the aim of examining the present level of bioterrorism knowledge, attitudes, and practices among nurses at Tianjin’s medical institutions. It also explored the relationships between bioterrorism knowledge, attitudes, and practices, as well as demographic variables that influence the scores of each dimension. The findings of this study can provide beneficial information for relevant institutions to formulate educational policies, and also have great significance in improving nurses’ attention and coping ability with bioterrorism.
Methods
Study design
This study utilized a descriptive correlational research design. The convenience sampling approach was applied and conducted a survey of nurses in five tertiary general hospitals in Tianjin to assess their knowledge, attitudes, and practices regarding bioterrorism. When selecting the sample hospitals, geographic accessibility and the existence of partnerships were prioritized to improve sample compliance (Table 1). When identifying the sample units, the focus was on the degree of correlation with bioterrorism events. Nurses in high-risk environments and those who are often on the front lines of rescue will be given special consideration. The five selected tertiary general hospitals all provide medical and health services, as well as higher education and scientific research, and each has at least 500 beds. This study conformed to the STROBE guidelines [27] (Supplementary material).
Table 1
Basic information about the sample hospitals and reasons for inclusion
No. | Name of hospital | location | Reasons for inclusion |
|---|---|---|---|
1 | Tianjin Medical University General Hospital | Heping district | It is a large, comprehensive tertiary hospital in Tianjin, boasting rich medical resources and strong technical strength. It holds an important position and has rich experience responding to various public health emergencies. In addition, the hospital has a close partnership with Tianjin University and is conveniently located in one of the city’s six districts. |
2 | Tianjin Nankai Hospital | Nankai district | It is primarily characterized by the integration of traditional Chinese and Western medicine and possesses national key disciplines. The hospital is large and has ample space and resources to conduct bioterrorism-related research and scenario simulations. Moreover, it is conveniently located in one of the city’s six districts. |
3 | Tianjin Children’s Hospital | Beichen district | It focuses on the field of children’s medical care and holds an important position in the regional medical system. In bioterrorism events, children are susceptible groups. Their physiological and psychological reactions are different from those of adults, and they are more likely to suffer greater harm. |
4 | Tianjin First Center Hospital | Xiqing district | As a large comprehensive tertiary hospital in Tianjin, it has strong strength. A professional nursing team, it excels in handling complex diseases and emergencies, representing central hospitals. Located in one of the four districts around the city, it has convenient transportation and close cooperation with Tianjin University. |
5 | Tianjin Beichen Hospital | Beichen district | It has rich experience in infectious disease prevention and control, with an emergency response mechanism. As a major medical institution in the region, it represents hospitals in surrounding urban areas of Tianjin. |
Participants
This study’s intended demographic information was collected from nurses working in relevant roles in the selected institutions. The inclusion and exclusion criteria are shown in Table 2 The sample size was calculated using the formula \(\:n=\frac{{Z}^{2}p\left(1-p\right)}{{d}^{2}}\), where Z is the standard normal distribution value of 1.96, corresponding to α = 0.05; d is the error of tolerance for deviation, also referred to as precision (0.05); and p represents the proportion of nurses prepared for bioterrorism. Due to the lack of previous relevant research, the p value was 50%. The minimum sample size was 384. Considering a 20% nonresponse rate, at least 480 questionnaires should be distributed.
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Table 2
Inclusion and exclusion criteria
Inclusion criteria | Exclusion criteria |
|---|---|
1. Registered nurse with nurse practitioner qualification of the People’s Republic of China. | 1. Non-registered nurses with less than six months’ experience. |
2. Have six months or more work experience. | |
3. Still working in the hospital. | 2. May leave the job within a year. |
4. Voluntarily participate in this study and sign the informed consent form. | 3. Unwilling to participate in this study. |
Measures
Sociodemographic characteristics
The demographic section comprised 7 items: the participant’s gender, age, marital status, work unit, educational level, years of experience, and previous bioterrorism education.
Knowledge of bioterrorism
A. R. Katz et al. [28] developed a survey instrument in 2006 to measure bioterrorism preparedness among physicians and nurses in Hawaii. The instrument consists of 12 multiple-choice questions based on bioterrorism knowledge, with questions focusing on bioterrorism agents, early identification, symptom monitoring, clinical features and treatment measures for diseases caused by Class A biological agents. A.Nofal et al. [29] added 38 true or false questions on bioterrorism knowledge based on 12 multiple-choice questions to assess the knowledge and preparedness of Saudi healthcare workers. This study utilized the above survey instrument to measure nurses’ knowledge of bioterrorism, with permission from the relevant authors. The knowledge dimension comprises 12 multiple-choice questions and 38 true/false questions. One point is assigned for each correct answer, and no point is assigned for the wrong answer, with a total possible score of 50 points. The higher the score is, the greater the level of bioterrorism knowledge of nurses. The Cronbach’s alpha for the tool was 0.88 in a previous study and 0.73 in this study.
Attitudes toward bioterrorism
S.A. Bahreini Moghadam et al. [30] developed a survey tool to measure Iranian volunteers’ knowledge and attitudes toward bioterrorism, which included 6 questions to measure volunteers’ attitudes toward participating in rescue operations in the event of a bioterrorism attack. This survey instrument was used in this study to measure nurses’ attitudes toward responding during a bioterrorism attack. The attitude dimension comprises 6 questions. Every question is scored on a five-point Likert scale ranging from 1 “strongly disagree” to 5 “strongly agree”. The Cronbach’s alpha for the scale was 0.78 in a previous study and 0.96 in the present study.
Practices related to bioterrorism
C. Stankovic et al. [31] developed a survey tool for assessing bioterrorism preparedness among Michigan pediatricians, focusing on participation in bioterrorism training and drills, as well as the development of office/workplace, patient, family, and personal bioterrorism response plans. This study used this instrument to measure nurses’ bioterrorism practices with the author’s permission and made appropriate adjustments based on the actual situation. The practice dimension includes six questions, each of which is scored on a five-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The Cronbach’s alpha for the scale was 0.94 in the present study.
Data collection and quality assessment
The data were collected from August 15 to September 15, 2023. The electronic questionnaire was distributed to eligible participants online through the platform Wenjuanxing (SoJump). The purpose of the survey and how to answer the questions were explained by the head nurse of each unit, which took approximately 15–20 min to complete. Each nurse completed the questionnaire individually and anonymously to ensure the security of the identification information, as well as the anonymity and confidentiality of the data.
The questionnaire used in the study has been submitted to experts for critical review and translated into Chinese to ensure its applicability and consistency. Before the formal survey, a small pre-survey was conducted on 5% of the sample size. Then, the questionnaire was modified based on the feedback information and questions to prepare for the formal survey. These 5% of participants were excluded from the main study sample. After the official survey begins, the participants need to improve their information when entering the Questionnaire Star system and complete verification through email, mobile phones, or other means. The same IP address, device, and user name can only be entered once to ensure that the collected data are authentic and reliable. Respondents received an electronic copy of the informed consent form before completing the questionnaire and were automatically positioned on the questionnaire screen if they agreed to participate. Otherwise, they were automatically logged out of the questionnaire platform.
Ethical considerations
This study was approved by the Tianjin University Health Research Ethics Committee (TJUE-2024-002). Participation in this study was voluntary, and participants had the right to refuse or withdraw at any time without consequence.
Data analysis
This study used IBM SPSS Statistics 26.0 software to analyze the collected data. The participants’ sociodemographic characteristics were analyzed descriptively using frequencies and percentages. Maximum, minimum, median, and interquartile spacing were used to describe participants’ levels of knowledge, attitudes, and practices regarding bioterrorism. A final score on each dimension of less than 50% of the total score is considered low, a score between 50% and 75% is considered satisfactory, and a score greater than 75% is considered good. The data in this study did not correspond to a normal distribution, so Mann‒Whitney and Kruskal‒Wallis tests were used to analyze the differences between knowledge, attitudes, and practice scores and sociodemographic characteristics, and p < 0.05 was considered to indicate statistical significance. Spearman correlation analysis was utilized to determine correlations between bioterrorism knowledge, attitudes, and practices. Multiple linear regression analysis was used to determine the factors influencing Tianjin nurses’ knowledge, attitudes, and practices regarding bioterrorism, and p < 0.05 was considered to indicate statistical significance.
Results
Participants’ sociodemographic characteristics
A total of 480 questionnaires were distributed in this study, and 442 questionnaires were recovered. After excluding invalid questionnaires with incomplete answers and excessively short response times, 429 valid questionnaires were ultimately included. Among the 429 respondents, the majority of nurses were female (86.9%), with the largest number in the 31–40 age group (35.7%), followed by the ≤ 30 age group (28.2%). Most respondents were married (70.9%), 51.0% of the nurses had a bachelor’s degree, 32.2% had a master’s degree, 4.7% had a doctoral degree, and 12.1% had an associate degree or below. A total of 33.1% and 24.2% of the respondents worked in the internal medicine and infectious disease units, respectively, and 13.3% of the respondents worked in the emergency unit. Approximately half of the respondents had more than 10 years of experience (49.0%), and 59.4% had no previous bioterrorism-related education (Table 3).
Table 3
Socio-demographics characteristics of the nurse respondents in Tianjin (n = 429)
Variables | Categories | Frequency (N) | Percentage (%) |
|---|---|---|---|
Gender | Male | 56 | 13.1% |
Female | 373 | 86.9% | |
Age (year) | ≤ 30 | 121 | 28.2% |
31–40 | 153 | 35.7% | |
41–50 | 104 | 24.2% | |
>50 | 51 | 11.9% | |
Marital status | Married | 304 | 70.9% |
Single | 115 | 26.8% | |
Divorced/widowed | 10 | 2.3% | |
Work unit | Infectious diseases | 104 | 24.2% |
Internal medicine | 142 | 33.1% | |
Surgery | 41 | 9.6% | |
Emergency | 57 | 13.3% | |
Critical care medicine | 10 | 2.3% | |
Nursing | 28 | 6.5% | |
Other | 47 | 11.0% | |
Educational level | Associate degree or below | 52 | 12.1% |
Bachelor’s degree | 219 | 51.0% | |
Master’s degree | 138 | 32.2% | |
Doctoral degree | 20 | 4.7% | |
Years of experience | <5 years | 90 | 21.0% |
5–10 years | 129 | 30.1% | |
>10 years | 210 | 49.0% | |
Previous bioterrorism education | No | 255 | 59.4% |
Yes | 174 | 40.6% |
Evaluation of knowledge, attitudes, and practices toward bioterrorism
Table 4 shows the nurses’ knowledge, attitudes, and practices regarding bioterrorism. Overall, the knowledge score was satisfactory (74.83%). The knowledge score ranged from 0 to 50, with a minimum of 20 and a maximum of 43. The mean score was 33.06 ± 4.872, the median was 34, and the interquartile range was 30–37. Overall, the attitude score was good (68.06%). The attitude score varied from 6 to 30, with a minimum of 6 and a maximum of 30. The mean score was 23.83 ± 5.228, with a median of 24 and an interquartile range of 20–30. Overall, the practice score was poor (78.56%). The practice score ranged from 6 to 30, with a minimum of 6 and a maximum of 30. The mean score was 10.94 ± 6.505, the median was 8, and the interquartile range was 6–14.
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Table 4
Levels of the main study variables
Variables | Range | Min | Max | M ± SD | Md.(IQR) | Poor (<50th percentile) | Satisfactory (50th ≤ 75th percentile) | good (>75th percentile) |
|---|---|---|---|---|---|---|---|---|
Knowledge | 0–50 | 20 | 43 | 33.06 ± 4.872 | 34(30–37) | 27(6.29%) | 321(74.83%) | 81(18.88%) |
Attitudes | 6–30 | 6 | 30 | 23.83 ± 5.228 | 24(20–30) | 16(3.73%) | 121(28.21%) | 292(68.06%) |
Practices | 6–30 | 6 | 30 | 10.94 ± 6.505 | 8(6–14) | 337(78.56%) | 62(14.45%) | 30(6.99%) |
Association of sociodemographic characteristics and knowledge, attitudes, and practices score
In this study, work unit, educational level, years of experience, previous bioterrorism education all had impacts on the bioterrorism knowledge scores, and the differences were statistically significant. Gender, educational level, and previous bioterrorism education all had impacts on the bioterrorism attitude scores, and the differences were statistically significant. Marital status, years of experience, and previous bioterrorism education all had impacts on the bioterrorism practice scores, and the differences were statistically significant (Table 5).
Table 5
Effects of sociodemographic variables on knowledge, attitudes, and practices related to bioterrorism
Variables | Categories | Knowledge score | Attitude score | Practice score | |||
|---|---|---|---|---|---|---|---|
Md.(IQR) | Z/H | Md.(IQR) | Z/H | Md.(IQR) | Z/H | ||
Gender | Male | 32(28.25-36) | -1.21 | 28(24–30) | -4.66*** | 10(6–14) | -0.97 |
Female | 34(30.5–37) | 24(20–28) | 8(6–14) | ||||
Age (year) | ≤ 30 | 33(29–36) | 4.09 | 24(20–30) | 2.31 | 9(6-14.5) | 4.48 |
31–40 | 34(31–37) | 24(22–30) | 8(6–14) | ||||
41–50 | 33(31–36) | 24(19–28) | 8(6–14) | ||||
>50 | 33(30–36) | 24(22–30) | 6(6–14) | ||||
Marital status | Married | 34(30–37) | 0.21 | 24(21.25-29) | 2.12 | 8(6–14) | 13.63** |
Single | 33(30–37) | 24(18–30) | 10(6–17) | ||||
Divorced/widowed | 35(30.75–36.25) | 22(20–25) | 6(6-11.75) | ||||
Work unit | Infectious diseases | 34(30.25-36) | 13.34* | 24(20–30) | 7.31 | 8(6–14) | 2.77 |
Internal medicine | 33(30.75-36) | 24(19.75–27.25) | 8(6–14) | ||||
Surgery | 34(29.5–36) | 24(18-27.5) | 8(6–14) | ||||
Emergency | 37(31–40) | 24(23–30) | 10(6–14) | ||||
Critical care medicine | 33(30-37.75) | 26(22.75-30) | 8(6–15) | ||||
Nursing | 34(30.25-36) | 24(21-26.75) | 8(6–10) | ||||
Other | 32(29–35) | 24(22–30) | 8(6–14) | ||||
Educational level | Associate degree or below | 32(27.25-34) | 22.30*** | 22(18–24) | 10.93* | 6(6-15.65) | 5.60 |
Bachelor’s degree | 34(30–36) | 24(20–29) | 9(6–15) | ||||
Master’s degree | 34(31–37) | 24(23–30) | 8(6–12) | ||||
Doctoral degree | 37(34.25-38) | 25(22.25–29.5) | 7(6–13) | ||||
Years of experience | <5 years | 32(27–34) | 25.53*** | 24(22–30) | 3.37 | 12(6–20) | 33.25*** |
5–10 years | 34(30–37) | 24(21–30) | 10(6–16) | ||||
>10 years | 35(31.75-37) | 24(19–28) | 6(6–10) | ||||
Previous bioterrorism education | No | 32(29–36) | -4.69*** | 24(18–27) | -5.30*** | 8(6–14) | -2.87** |
Yes | 35(32–37) | 24(23–30) | 9(6–15) | ||||
Correlations between knowledge, attitudes and practices
Spearman’s correlation analysis revealed a significant negative correlation between nurses’ bioterrorism knowledge and attitudes (r = -0.38, p < 0.01) and between their knowledge and practices (r = -0.42, p < 0.01), and a significant positive correlation between attitudes and practices (r = 0.21, p < 0.01). The relevant results are shown in Table 6.
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Table 6
Correlations among study variables
Variables | Knowledge | Attitudes | Practices |
|---|---|---|---|
Knowledge | 1 | ||
Attitudes | -0.38** | 1 | |
Practices | -0.42** | 0.21** | 1 |
Multiple linear regression of knowledge, attitudes, and practices toward bioterrorism
The statistically significant indicators of bioterrorism knowledge, attitudes, and practices from the results of the single-factor analysis were entered into the multifactor model. In Model 1, educational level, years of experience, and previous bioterrorism education significantly predicted bioterrorism knowledge. The regression equation was Y1 = 24.71 + 1.15 (educational level) + 1.57 (years of experience) + 1.85 (previous bioterrorism education). In Model 2, gender, educational level, and previous bioterrorism education significantly predicted bioterrorism attitudes. The regression equation was Y2 = 24.82–3.21 (gender) + 0.72 (educational level) + 2.38 (previous bioterrorism education). In Model 3, years of experience and previous bioterrorism education significantly predicted bioterrorism practices. The regression equation was Y3 = 13.92–2.3 (years of experience) + 1.65 (previous bioterrorism education). The relevant results are shown in Table 7.
The Durbin–Watson statistics for Model 1, Model 2, and Model 3 were 1.75, 2.10, and 1.74, indicating that there was no autocorrelation between the variables. The variation inflation factor (VIF) ranged from 1.0 to 1.22, indicating that there was no multicollinearity between variables.
Table 7
Multiple linear regression for variables contributing to knowledge, attitudes, and practices related to bioterrorism
Variables | Knowledge(Model 1) | Attitudes(Model 2) | Practices(Model 3) | ||||||
|---|---|---|---|---|---|---|---|---|---|
B | β | t | B | β | t | B | β | t | |
(Constant) | 24.71 | 21.53*** | 24.82 | 14.94*** | 13.92 | 7.74*** | |||
Gender | -3.21 | -0.21 | -4.52*** | ||||||
Age | |||||||||
Marital status | -0.05 | -0.01 | -0.07 | ||||||
Work unit | -0.16 | -0.06 | -1.41 | ||||||
Educational level | 1.15 | 0.17 | 3.82*** | 0.72 | 0.10 | 2.20* | |||
Years of experience | 1.57 | 0.26 | 5.62*** | -2.30 | -0.28 | -5.48*** | |||
Previous bioterrorism education | 1.85 | 0.19 | 4.09*** | 2.38 | 0.22 | 4.84*** | 1.65 | 0.13 | 2.70** |
Model F | F = 17.15(p<0.001) | F = 17.75(p<0.001) | F = 14.59(p<0.001) | ||||||
Adjusted R-square | 0.131 | 0.105 | 0.087 | ||||||
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Discussion
This study was a cross-sectional survey of nurses in five tertiary general hospitals in Tianjin, China. In this study, we assessed the current state of bioterrorism knowledge, attitudes, and practices among nurses in Tianjin, and analyzed the correlations and potential influencing factors among bioterrorism knowledge, attitudes, and practices.
Knowledge of bioterrorism
In this study, nurses’ knowledge of bioterrorism reached an acceptable level of satisfaction, but there was a gap between it and a good level.
Bioterrorism knowledge scores significantly differed according to work unit, educational level, years of experience, and previous bioterrorism education. Emergency unit nurses had higher bioterrorism knowledge scores than nurses in other groups. This may be because the emergency unit is the frontline for responding to public health emergencies. Emergency nurses play important roles in pre-examination and triage, emergency rescue, and batch casualty care. They usually receive relatively rich education and practical experience in emergencies [32‐34]. Regarding educational level, nurses with master’s and doctoral degrees had higher scores for bioterrorism knowledge. Nurses with higher degrees have more learning and training opportunities, and have developed better understanding and thinking skills in the process of continuing their education. Nurses with more than ten years of experience had higher scores. This may be because as working years increase, nurses’ work experience also gradually increases, and their knowledge of bioterrorism is more comprehensive [35]. Nurses who had received relevant education had higher scores for bioterrorism knowledge. Nurses who participate in bioterrorism education can acquire more professional knowledge and further enhance their willingness and confidence in bioterrorism prevention work.
In Model 1, educational level, years of experience, and previous bioterrorism education significantly predicted bioterrorism knowledge scores. The most important way to prevent bioterrorism is to enhance the knowledge of healthcare workers. Bioterrorism education will play a positive role. One study showed that by using virtual social network education to intervene with respondents, emergency nurses in the intervention group had significantly greater knowledge scores about disaster preparedness than nurses in the control group [36]. Therefore, relevant health institutions and medical institutions should strengthen bioterrorism education for nurses, including in-service education and continuing medical education [37]. We should also pay attention to the differences between nurses with different academic levels and working years, provide as many training opportunities related to bioterrorism as possible, and enhance nurses’ awareness of self-renewal and active learning.
Attitudes toward bioterrorism
In this study, nurses’ attitude scores regarding bioterrorism were good overall.
Bioterrorism attitude scores significantly differed according to gender, educational level, and previous bioterrorism education. Male nurses are more willing to proactively respond to bioterrorism. They are more likely to perceive the benefits of bioterrorism preparedness [29] and have a higher degree of bioterrorism preparedness [38]. This may be because male nurses have a stronger perception of professional responsibilities and are more aware of their roles and functions at disaster work sites [39]. Female nurses are more thoughtful and will show more patience in dealing with emergencies. Therefore, relevant institutions need to pay more attention to the attitude education of female nurses and give full play to the unique advantages of men and women. However, it should be noted that among the survey respondents in this study, male nurses accounted for only 13.1%, which may lead to biased results. More scientific and rigorous in-depth investigations are needed on the impact of gender on bioterrorism attitudes. In terms of educational level, nurses with master’s and doctoral degrees had higher attitude scores about bioterrorism than other groups. Participants with higher degrees are more likely to assist during natural and man-made disasters. Nurses who received bioterrorism education showed more positive attitudes. Bioterrorism education will improve nurses’ perceived benefits of bioterrorism prevention to a certain extent, resulting in a positive coping attitude [29].
In Model 2, gender, educational level, and previous bioterrorism education significantly predicted attitude scores regarding bioterrorism. Nurses without bioterrorism education (96.9%) had an indifferent attitude towards bioterrorism prevention. After receiving such education, nearly all nurses (98.5%) had a positive attitude [13]. Therefore, educational and medical institutions should provide bioterrorism-related courses and policies to change how nurses think about bioterrorism prevention [40]. At the same time, among China’s nurses, women and nurses with a bachelor’s degree account for a high proportion. To further improve nurses’ willingness to respond to bioterrorism, attitude education should focus more on women and nurses with a graduate degree or below.
Practices related to bioterrorism
In this study, nurses scored poorly regarding bioterrorism practices.
Bioterrorism practice scores significantly differed according to marital status, years of experience, and previous bioterrorism education. Single nurses had higher bioterrorism practice scores than nurses in other groups. The reason may be that marriage causes a huge change in the family role of nurses, shifts the focus of life, and takes on greater family responsibilities. Married, divorced, or widowed nurses devote more time and energy to their families, which affects their learning and work. In terms of working years, nurses with shorter working experience scored better. This may be related to the gradual strengthening of systematic education related to bioterrorism in China in recent years. Nurses with bioterrorism education had higher practice scores. This may be because the first step in changing practice is to increase awareness of the incident [41], and bioterrorism education can improve nurses’ awareness of bioterrorism preparedness [42].
In Model 3, years of experience and previous bioterrorism education significantly predicted bioterrorism practice scores. Continuing medical education can improve the emergency response capabilities of health workers and increase the effectiveness of teamwork [43]. Therefore, hospitals and other relevant institutions should do a good job of continuing medical education on bioterrorism for nurses and provide more educational opportunities and platforms for nurses. The forms may include conferences, lectures, seminars, self-study papers, and online training scenario simulations [37]. Young nurses are highly motivated to learn and should make good use of this characteristic to carry out bioterrorism education and training. At the same time, attention should also be paid to nurses with longer working years, and bioterrorism scenario simulations, desktop exercises, and other forms should be used to increase interest and fully mobilize enthusiasm.
Correlations between knowledge, attitudes, and practices related to bioterrorism
The conflicting results remain on the relationship between bioterrorism knowledge and attitude, knowledge and practice. In this study, there was a significant negative correlation between bioterrorism knowledge and attitude, knowledge and practice, and a significant positive correlation between bioterrorism attitude and practice. This finding was consistent with previous research results showing that respondents with more knowledge are less willing to participate in bioterrorism prevention work [44, 45]. There are also studies showing the opposite view. For example, healthcare workers with the most about anthrax had the highest willingness to go to work [46], respondents’ disaster management knowledge was positively correlated with attitudes and practices [47]. From this point of view, this is a conflicting result in the progressive relationship between knowledge, attitudes, and practices in the theory of KAP. This may be because bioterrorism is inherently unique. On the one hand, it is rare compared to natural disasters with low occurrence probability. On the other hand, once bioterrorism occurs, it may lead to large-scale infectious diseases and social unrest. Nurses with higher bioterrorism knowledge generally have a deeper understanding of the dangers, and may be unwilling to actively participate in bioterrorism response work. Nevertheless, combined with the theory of KAP, more disease knowledge affects health and prevention practices [48]. Relevant institutions should also strengthen bioterrorism education and training for nurses, the largest health care group so that the mastery of bioterrorism knowledge reaches a good level.
Strengths and limitations
While most of the existing studies on knowledge, attitudes, and practices toward bioterrorism preparedness included only one or two of these dimensions. The uniqueness of this study lies in integrating measurement tools for all three dimensions and researching knowledge, attitudes, and practices toward bioterrorism preparedness. Moreover, findings can be applied clinically, like providing targeted training and formulating differentiated plans for nurses with different educational levels and years of experience. Make full use of the positive attitude of nurses with high educational levels and give them leadership roles in knowledge dissemination and training. Optimize hospital human resource management by reasonably matching nurses with different years of experience to play the role of complementing experiences and practices. However, this study also has some limitations. First, the respondents who participated in this study were conveniently sampled, and there are few domestic studies on bioterrorism knowledge, attitudes, and practices. As a result, the results of this study lack other studies as a reference and cannot be generalized to other nurse groups. Second, the data in this study were collected through self-reported questionnaires, which may lead to some bias in the results and cannot accurately reflect the knowledge, attitudes, and practices levels of nurses in Tianjin regarding bioterrorism. Finally, in the three multiple linear regression models, the variables explained 13.1%, 10.5%, and 8.7% of the variance respectively, which indicates that many factors affecting bioterrorism knowledge, attitudes, and practices have not been examined in this study. In future research, more scientific research methods are needed to further explore more related influencing factors of nurses’ bioterrorism knowledge, attitudes, and practices.
Conclusions
This study adopted a descriptive correlational research design and selected nurses from five tertiary general hospitals in Tianjin as the research subjects. This study analyzed the current status of nurses’ knowledge, attitudes, and practices regarding bioterrorism. Spearman correlation analysis and multiple linear regression were used to explore the correlation between nurses’ bioterrorism knowledge, attitudes, and practices, as well as the demographic characteristics variables that affect the scores of each dimension. This study found that nurses’ bioterrorism knowledge scores were satisfactory, attitude scores were good, and practice scores were poor. Educational level, years of experience, and previous bioterrorism education are influencing factors of the knowledge dimension. Gender, educational level, and previous bioterrorism education are influencing factors on the attitude dimension. Years of experience and previous bioterrorism education are influencing factors in the practice dimension. There is a significant negative correlation between bioterrorism knowledge and attitudes, knowledge and practices, and a significant positive correlation between attitudes and practices. This result may be caused by the particularity of bioterrorism itself. To improve nurses’ bioterrorism prevention capabilities, it is also necessary to strengthen the development of continuing medical education and provide regular bioterrorism special training and drills.
Acknowledgements
We would like to acknowledge the National Key Research and Development Program and the Foundation of Social Science and Humanity of China, all the members of the Institute of Disaster and Emergency Medicine of Tianjin University for their support.
Declarations
Ethics approval and consent to participate
This study was approved by the Tianjin University Health Research Ethics Committee (TJUE-2024-002). Written informed consent was taken from the study participants after assuring the anonymity and confidentiality of their data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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