Association Between Training Experience and Attitudes Toward Advance Care Planning Among Healthcare Professionals: A Cross-Sectional Study

Background: Training has been found effective in improving healthcare professionals’ knowledge, condence, and skills in conducting advance care planning (ACP). However, its association with their attitudes toward ACP, which is crucial to its implementation, remained unclear. To ll this gap, this paper examines the association between their attitudes toward ACP and relevant training experiences. Methods: An online survey about attitudes toward ACP of healthcare professionals, including physicians, nurses, social workers, and allied healthcare professionals, currently working in hospital and community care in Hong Kong was conducted. Results: Of 250 respondents, approximately half (51.6%) had received ACP-related training. Those with relevant training reported signicantly more positive in the perceived clinical relevance, willingness, and condence in conducting ACP and levels of agreement with 19 out of the 25 statements in a questionnaire about attitudes toward ACP than those without (ps ≤ 0.001–0.05). Respondents who received training only in a didactic format reported a signicantly lower level of condence in conducting ACP than did others who received a blended mode of learning (p = 0.012). Notwithstanding signicant differences between respondents with and without relevant training, respondents generally acknowledged their roles in initiating conversations and appreciated ACP in preventing decisional conict in surrogate decision-making regardless of their training experience. Conclusions: This paper revealed the association between training and positive attitudes toward ACP among healthcare professionals. The ndings showed that training is a predictor of their preparedness for ACP in terms of perceived relevancy, willingness, and condence. Those who had received training were less likely to consider commonly reported barriers such as time constraints, cultural taboos, and avoidance among patients and family members as hindrances to ACP implementation. collected questionnaire


Background
Advance care planning (ACP) is a communication process to prepare patients and their families for endof-life care.(1) Although healthcare professionals generally found ACP important for patient-centered care, many of them were reluctant to conduct ACP due to its sensitive nature and time-consuming process.(2, 3) Certain training interventions have been developed to equip healthcare professionals with the skills to facilitate ACP, and the ndings showed that training was effective in improving professionals' knowledge, con dence, and communication skills in conducting ACP. (4)(5)(6)(7)(8) However, the effects of training on their attitudes toward ACP, which is crucial to the integration of ACP into routine care practices, has rarely been studied. This paper reports the association between healthcare professionals' attitudes toward ACP and relevant training experience based on secondary analysis of the ndings from an online survey.

Study design
A cross-sectional online survey was conducted between November 2019 and April 2020 in Hong Kong.
Around this period, the Hong Kong government had launched a public consultation on legislative issues related to advance directives and dying in place, and the Hospital Authority had just formulated ACP guidelines and templates for clinicians in public hospitals. This survey primarily aimed to investigate the attitudes toward ACP of healthcare professionals, including physicians, nurses, social workers, and allied healthcare professionals currently working in hospital or community care settings in Hong Kong.

Instrument
A questionnaire was developed to investigate healthcare professionals' attitudes toward ACP based on a literature review and a team of experts in palliative care and ACP. The questionnaire included 25 statements related to recommendations for ACP, as well as bene ts and barriers of conducting ACP. The team discussed and revised the items reiteratively until consensus was reached. Respondents were asked to indicate their level of agreement with each statement on a ve-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree). Respondents were also asked to indicate their perceived relevance of ACP with their clinical work, willingness, and con dence in conducting ACP on a numeric scale, from 0 (lowest) to 10 (highest). The questionnaire also collected demographic data, including age, gender, disciplines, educational level, clinical experience, and current working setting; the questionnaire also collected experience of receiving training related to ACP and conducting ACP.

Data analysis
Statistical analysis was conducted using SPSS 25.0 (IBM Corp, Armonk, NY). Descriptive statistics was used to summarize the respondents' characteristics and their responses. The level of agreement with the 25 statements was presented in three levels: strongly disagree/disagree, unsure, and strongly agree/agree, to facilitate analysis. Chi-square test, independent t-test, Mann-Whitney U test, and ANOVA were used to examine the differences in their responses based on training experience. Univariate linear regression was used to identify the association of demographics and training experience with perceived relevancy, willingness, and con dence in conducting ACP. The variables with a p-value < 0.01 were included in multiple linear regression for identifying predictors. Variance in ation factors (VIF) were examined to rule out multicollinearity. All statistical tests were two-sided with the level of signi cance at 0.05.

Participants' characteristics
A convenience sample of 250 respondents completed the questionnaire ( Table 1). Most of them were female (66.4%) and working in public hospital settings (70.7%). Their mean age was 41.8 years (SD 10.3), ranging from 21 to 69. The respondents mainly included physicians (38.8%), nurses (48.8%), and social workers (11.2%), with an average clinical experience of 17.9 years (SD 10.3, in the range 1-42). Approximately half of the respondents (n = 129, 51.6%) had received formal training related to ACP in didactic format only (such as lectures, talks, or seminars) (n = 63, 48.5%); a combination of didactic and web-based (n = 12, 9.2%); a combination of didactic and workshop (n = 29, 22.3%); blended learning with didactic, web-based, and workshop (n = 13, 10.0%); and any format with local or overseas placement (n = 13, 10.0%). Training was associated with older age (p ≤ 0.001), increased years of clinical experience (p = 0.004), and working in internal medicine and palliative care specialties (p ≤ 0.001).
Associations between training and perceived readiness for ACP Table 2 shows the association of training with the respondents' perceived clinical relevance of, and willingness and con dence in, ACP. Respondents who had received relevant training were more likely to nd ACP related to their clinical work than the counterparts (p ≤ 0.001) and they reported signi cantly higher levels of willingness (p ≤ 0.001) and con dence (p ≤ 0.001) with conducting ACP when compared with those who did not receive such training. Univariate linear regression showed that only specialty and previous ACP training were associated with these three variables, but not age and clinical experience. Multiple linear regression indicated that respondents received relevant training perceived higher relevancy of ACP in relation to their clinical work (β = 0.23, p < 0.001), higher level of willingness to conduct ACP with their clients (β = 0.30, p < 0.001) and higher level of con dence in facilitating the ACP conversation (β = 0.35, p < 0.001). Specialty is associated with higher level of clinical relevancy (β = 0.22, p < 0.001) and higher level of con dence (β = 0.15, p < 0.05), but not for willingness. Respondents who received blended training generally reported the highest levels of relevance, willingness, and con dence when compared with other modes of learning. Those received training only in didactic format reported the lowest ratings and a signi cant difference was noted in con dence compared with their counterparts (p = 0.012). Comparisons of attitudes toward ACP between trained and non-trained As shown in Table 3, signi cant differences were noted between those with and without relevant training in the levels of agreement with 19 out of the 25 statements concerning ACP. Training was associated with perception of more facilitators and lower barriers for ACP. For example, a higher proportion of respondents who had relevant training indicated that they were comfortable with discussing end-of-life care issues with patients and their family members (ps ≤ 0.001) than their counterparts. They were more likely to disagree that "patients and their family members nd end-of-life care discussion di cult or a taboo" (ps ranged from ≤ 0.001-0.006), but they were less likely to be "hesitant to follow ACP documents for fear of legal liability" (p ≤ 0.001) and considered time a barrier to conducting ACP (p = 0.010), compared with those without training.
By contrast, more respondents who did not have relevant training were uncertain whether "the existing ACP policy and guidelines are clear" (p ≤ 0.001), whether their "seniors/supervisors or co-workers support them to conduct ACP" (ps ≤ 0.001), whether "patients nd end-of-life care discussion taboo" (p ≤ 0.001) and the di culty "for patients and their family members to reach consensus on end-of-life care" (p ≤ 0.001).

Discussion
A secondary analysis was conducted to examine the association between healthcare professionals' attitudes toward ACP and relevant training experience. The ndings echoed previous studies that healthcare professionals with relevant training felt more comfortable, willing and con dent in end-of-life care communication, although training in didactic format only appears less promising.(6, 7) Compared with those without training, the trained healthcare professionals were less likely to consider time constraints, cultural taboos, and avoidance among patients and family members as hindering factors to conducting ACP. These concerns have been widely identi ed as the major barriers to ACP implementation in the literature. (2,3,9,10) The skills gained from training might enable the respondents to approach the topic and facilitate the process tactfully and effectively. Previous studies on the effects of training interventions on attitudinal changes of healthcare professionals were only concerned about shared decision-making, psychosocial care, and end-of-life care. (6,8) This study showed that training may also be associated with positive attitudes toward ACP.
Despite the attitudinal differences in relation to training experience, the study ndings suggested that healthcare professionals largely have similar views about the merits of ACP and their duties to raise the conversation. They appreciated ACP as instrumental to clarify patients' preferences and decrease decisional con icts in surrogate decision-making. High levels of agreement were found on initiating ACP earlier in chronic illness management. The ndings were consistent with previous studies that indicate that ACP is generally agreed by healthcare professionals as necessary to prepare patients and their families for anticipated di cult decisions and that they play key roles as initiators, educators, and facilitators in ACP. (3,11) Given this consensus among healthcare professional regardless of the training experience and clinical background, training using an inclusive approach to enhance their preparedness would be the cornerstone of system-wide ACP implementation. (12) Study strengths and limitations This paper addresses the knowledge gap about the association between training and healthcare professionals' attitudes toward ACP. Although the survey included respondents with a wide range of clinical backgrounds, we acknowledged several study limitations when interpreting the study ndings.
First, the sample was recruited by convenience sampling. The ndings could not be generalized due to the potential of participation bias. Second, the causal relationship between training and attitudes toward ACP could not be concluded due to the nature of the study and confounding variables. It is hard to determine if enrolment in training was driven by preceding positive attitude toward ACP. Third, the training experience and attitudes were based on self-reports measured by a self-developed questionnaire.
Furthermore, the nature of the training varied greatly in the sample. Robust prospective studies should be conducted to examine the effects of training interventions on the attitudes and actual behaviors related to ACP of healthcare professionals.

Conclusions
The association between healthcare professionals' attitudes toward ACP and relevant training experience was examined based on secondary analysis of an online survey regarding attitudes toward ACP among healthcare professionals. The ndings showed that the trained healthcare professionals perceived higher level of readiness for ACP in terms of clinical relevancy, willingness and con dence, and they were less likely to consider time constraints, cultural taboos, and avoidance among patients and family members as hindering factors to conducting ACP, compared with those without training.