Construction of core competency evaluation index system for advance care planning for oncology nurses

Construction of core competency evaluation index system for advance care planning for oncology nurses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Construction of core competency evaluation index system for advance care planning for oncology nurses Jia Sansan, Xu Xiaoxia, Mai Xuan, Wang Rui, Xuebing Liu, Zhang Yifan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7384944/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background The evaluation index system of the core competence of advance care planning for nurses in the department of oncology was established to provide an objective basis for evaluating the core competence of advance care planning for nurses in the department of oncology. Methods On the theoretical basis of the post competency model, the evaluation index system of the core competence of oncology nurses in advance care planning was initially established through literature analysis, and the indexes and weights were determined by Delphi method and order graph method. Results The evaluation index system consists of 4 first-level indicators,13 second-level indicators and 61 third-level indicators. The questionnaire recovery rates of the two rounds of expert letter consultation were 90% and 100%, the expert authority coefficient were 0.950 and 0.950 respectively, and the Kendall harmony coefficient was 0.173 and 0.240, respectively. After the second round of expert correspondence, the average importance scores of 61 third-level indicators were 4.00~5.00. Conclusion The evaluation index system constructed in this study is scientific, reliable and practical, and can provide a basis for the evaluation of the core competence of the advance care planning for oncology nurses. Oncology nurse Advance care planning Core competence Evaluation index post competency Figures Figure 1 Introduction The latest national cancer report data show that the incidence of malignant tumors in China has increased year by year, and has become one of the main causes of death for urban residents, which seriously restricts the healthy development of Chinese residents [1] .The Outline of the Healthy China 2030 Plan states that the health of all people is the fundamental purpose of building a healthy China. To realize the whole process of health service and health guarantee from the fetus to the end of life, it is necessary to improve the construction of medical and health service system and strengthen the construction of continuous medical institutions such as hospice care [2] .As an important part of hospice care, Advance care planning (ACP) is a process in which patients communicate with medical staff and/or family members when they have clear consciousness and decision-making ability, and establish their personal will for end-of-life medical care in advance [3] .The implementation of ACP can not only guarantee patients' right to informed consent and self-determination, but also enable them to obtain treatment and care with corresponding values even when patients lose decision-making ability, thus reducing their family burden and improving patients' end-stage life quality [4] .ACP has a high acceptance and mature development in foreign countries. Domestic studies on ACP are still in the exploratory stage, mainly focusing on patients' cognitive attitude and acceptance of ACP, as well as the review and meta-analysis of related auxiliary tools for medical staff to implement ACP. Research forms mainly include current investigation, analysis of influencing factors and qualitative research [5-6] .The completion of ACP for cancer patients is the shared responsibility of a multidisciplinary team. As the health professionals who have the closest contact and communication with patients and their families in the multidisciplinary team, nurses play an important role in the implementation of patients' ACP, and their core competence directly affects the implementation effect and promotion degree of ACP.Effective evaluation of ACP core competence of oncology nurses is a problem that nursing managers pay more and more attention to. Post competency refers to the sum of knowledge, skills and characteristics that enable employees in a specific organization to be competent for the job and produce excellent performance in the job [7] .The post competency model can identify the outstanding performance and the mediocre performance in the post. At present, the most commonly used competency model is the iceberg model proposed by the famous American psychologist McClelland in 1973 [8] . Based on this model, the evaluation index system of ACP core competence of oncology nurses was constructed through literature analysis and Delphi method to provide an objective basis for evaluating ACP core competence of oncology nurses. 1 Research methods 1.1 Establish a research group The research team comprised seven members, including one chief nursing professor (concurrently serving as a master's supervisor with research focus on nursing management and hospice care), two associate chief nursing professors specializing in oncology nursing and hospice care respectively, and four nursing master's candidates who had completed standardized training in advance care planning (ACP). Through collaborative division of responsibilities, team members systematically executed literature reviews, developed a preliminary list of core competency indicators for oncology nurses in ACP practice, designed expert consultation instruments, conducted Delphi method consultations with selected specialists, and performed comprehensive data analysis. This study obtained ethical approval from the Institutional Review Board of Henan Cancer Hospital (Affiliated Cancer Hospital of Zhengzhou University) under approval number 2021-KY-0235-001. 1.2 Draft indicator entry pool The literature search strategy combined controlled vocabulary (e.g, MeSH terms) with free-text terms across multiple evidence-based resources. Systematic searches were conducted in the following knowledge translation platforms and databases: UpToDate, BMJ Best Practice, Caresearch (Australian palliative care evidence portal), Epistemonikos, National Institute for Health and Care Excellence (NICE), Guidelines International Network (GIN), New Zealand Guidelines Group (NZGG), Scottish Intercollegiate Guidelines Network (SIGN), China Clinical Guideline Clearinghouse, and Registered Nurses' Association of Ontario (RNAO). Professional society resources were comprehensively reviewed from the American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), European Association for Palliative Care (EAPC), and Canadian Society of Palliative Care Physicians (CSPCP).Evidence synthesis was performed using JBI Evidence-Based Healthcare Database, Cochrane Library, Campbell Collaboration, PubMed, Web of Science, and Chinese databases including CNKI, Wanfang Database, and SinoMed. This electronic search strategy was supplemented by manual reference tracking of all included studies to identify potentially relevant publications. The search strategy incorporated Chinese keywords ("预立医疗", "预立医疗照护计划", "预先指示", "生前预嘱", "肿瘤科护士", "核心能力/胜任力", "岗位胜任力", "指标") and English equivalents ("Advance care planning", "ACP", "Living will", "oncology nurses", "post competence", "core competence", "competency", "Indicators"). Searches spanned from database inception to January 2024.Inclusion criteria:Publications addressing oncology nurses, competency frameworks, competency evaluation methods, or specialty-specific nurse competency models;Studies published in Chinese or English.Exclusion criteria: Conference abstracts or brief reports;Duplicate publications or inaccessible full texts;Methodologically weak studies. Two researchers independently screened literature using dual-layer evaluation: methodological rigor was assessed via the Appraisal of Guidelines for Research & Evaluation II (AGREE II, 2017 edition) and the JBI Critical Appraisal Tools (2020 edition). Discrepancies were resolved through consultation with a third investigator. Twelve studies met final inclusion criteria. Through iterative synthesis, the research team developed a preliminary competency framework for oncology nurses in advance care planning (ACP), comprising four domains: theoretical knowledge, specialized skills, integrative competencies, and personal attributes. The literature selection process is detailed in Figure 1. 1.3 Develop expert correspondence questionnaire The letter questionnaire consists of four parts. ① Topic introduction, including research background, research purpose and research significance. ② Experts general information questionnaire, including the experts' age, education, title, years of work and the nature of the post. ③ The expert's judgment basis and familiarity with the survey content. ④Expert letter inquiry form for evaluation indicators of ACP core competence of oncology nurses. Using the Likert 5-level scoring method, experts are asked to rate the importance of each item, with "Modify", "Delete" and "Items to add" columns.（For details, please refer to the supplementary materials in the attachment） 1.4 Consultation with experts for selection The inclusion criteria of experts consulted by letter: ① Clinical nursing experts, clinical medical experts, nursing managers, nursing educators with rich experience in hospice care or scientific research ability; (2) More than 10 years of relevant working life (doctoral students can appropriately relax the working life of more than 5 years); ③ Associate senior and above titles; ④ Bachelor degree or above; ⑤ High participation enthusiasm can ensure the completion of multiple rounds of correspondence for this study. 1.5 Implementation of expert letter consultation Two rounds of expert letter consultation will be conducted from October to November 2023. Researchers will conduct expert letter consultation by email or wechat, and the time limit for each round is 2 weeks. After collecting the questionnaires, the research team adjusted the indicators according to the opinions of the experts. Taking importance assignment and coefficient of variation as screening criteria, indexes with the mean value of importance assignment > 3.50 points and coefficient of variation < 0.25 points are retained, and others are modified or deleted [9] . When the expert opinions are basically unified, the letter consultation is concluded, and the final evaluation index of ACP core competence of oncology nurses is formed. 1.6 Statistical Methods Software Excel2021 and SPSS26.0 were used to organize and analyze the data. Measurement data conforming to normal distribution are expressed as mean ± standard deviation; Counting data are expressed by frequency and percentage. The enthusiasm of experts is expressed by the effective questionnaire recovery rate and comment rate. It is generally believed that the questionnaire recovery rate ≥70% indicates that experts have high enthusiasm [10] . The degree of expert authority is expressed by the authority coefficient (Cr). The degree of expert authority is calculated by the expert's judgment basis and familiarity with the articles. It is generally believed that ≥0.7 indicates a high degree of expert authority [11] . The degree of concentration of expert opinions is expressed by the mean of importance assignment and standard deviation of each indicator. The degree of expert opinion coordination is expressed by Kendall harmony coefficient. The analytic hierarchy process is used to calculate the weight of each index. P<0.05 indicated that the difference was statistically significant. 2 Results 2.1 Basic Information of experts A total of 18 experts completed two rounds of correspondence. The experts ranged in age from 30 to 61 (45.40±6.72) years, and their working years ranged from 8 to 44 (20.11±5.49) years. There were 5 senior professional titles (27.78%), 13 associate senior professional titles (72.22%); There were 5 doctors (27.78%), 8 masters (44.44%) and 5 bachelors (27.78%). There were 10 clinical nursing experts (55.56%), 5 nursing managers (27.78%) and 3 nursing educators (16.67%). 2.2 Enthusiasm and authority of experts In the first round of correspondence, 20 questionnaires were sent out and 18 were collected, with an effective recovery rate of 90.00%. In the second round, 18 questionnaires were sent out and 18 were collected, with an effective recovery rate of 100.00%. In the first round, 14 experts (77.78%) put forward suggestions, and in the second round, 4 experts (22.22.%) put forward suggestions, indicating that experts pay more attention to this topic and have high enthusiasm. The coefficient of familiarity of 18 experts was 0.933, the coefficient of judging basis was 0.967, and the coefficient of authority was 0.950. 2.3 Concentration of expert opinions In the first round of correspondence, the mean value of importance assignment of all indicators was 3.89 ~ 5.00, and the standard deviation was 0 ~ 1.333. In the second round of correspondence, the mean value of importance assignment for all indicators was 4.00 ~ 5.00, and the standard deviation was 0 ~ 1.033. 2.4 Degree of coordination of expert opinions The coefficient of variation of all indicators in the first round of correspondence was 0 ~ 0.30, and that of all indicators in the second round of correspondence was 0 ~ 0.23. The Kendall harmony coefficients of the two rounds of expert correspondence were 0.173 and 0.240, among which, the Kendall harmony coefficients of the primary, secondary and tertiary indexes were 0.188, 0.177 and 0.111 in the first round of correspondence, and 0.265, 0.174 and 0.154 in the second round of correspondence. The Kendall harmony coefficient of the second round of expert correspondence was higher than that of the first round, and the difference was statistically significant (P < 0.001). 2.5 Expert letter inquiry results 2.5.1 Results of the first round of correspondence According to the indicator screening criteria, expert opinions and research group discussion results, the index revision is as follows. Delete the third-level indicators: "Respect for patients" and "privacy and personal information protection", add the third-level indicators: "Medical humanistic care", "communication and language skills", "patient disease progression", "patient social support", "building a trusting relationship with patients and their families", "follow-up" and "attitude towards death", and modify the third-level indicators: "ACP related concepts" should be changed to "ACP related concepts and connotations", "ACP implementation content" should be changed to "ACP implementation steps and contents", "patient's condition" should be changed to "patient's condition awareness", "place to carry out ACP" should be changed to "select the place to carry out ACP", "content to carry out ACP" should be changed to "determine ACP discussion content", "The form of carrying out ACP" was changed to "determine the form of carrying out ACP", "ACP education" was changed to "introduce the ACP concept", and "life concept" was changed to "life health concept". At the same time, items in the questionnaire with irregular word use, poor order arrangement, lack of universality, controversial content and coefficient of variation >0.25 were modified, split, deleted and merged. In this round, two third-level indicators were deleted, seven third-level indicators were added, and eight third-level indicators were modified. 2.5.2 Results of the second round of correspondence Again, the articles are discussed and adjusted based on expert opinions. The three indexes are revised: "Death education" is revised to "timely death education"; Change "empathy" to "compassion"; Delete three indicators: "appointment of proxy decision makers", "consensus on relevant decisions", "implementation and application of documents", "life health concept" and "teaching ability". Finally, 4 first-level indicators, 13 second-level indicators and 61 third-level indicators were determined, as shown in Table 1 2.5.2 Results of the Second Round of Consultation The items were discussed and adjusted again based on expert opinions. The modifications to the tertiary indicators include: changing "death education" to "timely death education"; replacing "empathy" with "compassion"; and deleting the tertiary indicators: "designated proxy decision-maker", "consensus on relevant decisions", "implementation and application of documents", "life health perspective", and "teaching ability". Ultimately, 4 primary indicators, 13 secondary indicators, and 61 tertiary indicators were finalized, as detailed in Table 1. Table 1 Results of the Second Round of Expert Consultation Index Importance Coefficient of Variation weight combination weight 1 Theoretical knowledge 4.88±0.34 0.07 0.255 — 1.1 ACP related knowledge 4.81±0.40 0.08 0.333 0.013 1.1.1 ACP related concepts and connotations 4.81±0.40 0.08 0.142 0.013 1.1.2 ACP implementation steps and contents 5.00±0.00 0.00 0.131 0.013 1.1.3 Principle of appointing medical agent decision maker 4.81±0.54 0.11 0.237 0.014 1.1.4 Communication and language skills 4.94±0.25 0.05 0.253 0.013 1.1.5 Medical humanistic care 4.81±0.54 0.11 0.237 0.015 1.2 Knowledge of ACP related legal ethics 4.69±0.70 0.15 0.349 0.014 1.2.1Right to self-determination 4.88±0.34 0.07 0.209 0.013 1.2.2 Informed consent right 4.88±0.34 0.07 0.209 0.013 1.2.3 The Right of Dignity 4.94±0.25 0.05 0.162 0.013 1.2.4 Right of life and health 4.88±0.34 0.07 0.209 0.013 1.2.5 Right of privacy 4.88±0.34 0.07 0.209 0.013 1.3 Disease related knowledge of cancer patients 4.94±0.25 0.05 0.318 0.013 1.3.1 Late clinical manifestations 4.81±0.40 0.08 0.131 0.013 1.3.2 Late symptom control 4.75±0.57 0.12 0.1983 0.014 1.3.3 Prognosis of advanced disease 4.56±0.63 0.14 0.334 0.014 1.3.4 Common life support treatment measures for cancer patients (cardiopulmonary resuscitation, intubation, artificial ventilation, etc.) 4.63±0.72 0.16 0.336 0.014 2 Professional skill 4.88±0.50 0.10 0.275 — 2.1 Assessment 4.75±0.58 0.12 0.257 0.014 2.1.1The patient's condition is known 4.88±0.34 0.07 0.180 0.013 2.1.2 Patient progression 4.88±0.34 0.07 0.180 0.013 2.1.3 Needs of patients and their families 4.88±0.34 0.07 0.180 0.013 2.1.4 Patient and family values 4.69±0.70 0.15 0.182 0.014 2.1.5 ACP acceptance of patients and their families 4.69±0.48 0.10 0.169 0.014 2.1.6 Patient's social support 4.88±0.34 0.07 0.052 0.013 2.1.7 Behavioral decision-making ability of patients and family members 4.88±0.34 0.07 0.052 0.013 2.2 ACP reserve 4.88±0.34 0.07 0.239 0.013 2.2.1 Form an ACP team 4.88±0.34 0.07 0.137 0.013 2.2.2 Select the object of the ACP discussion 4.94±0.25 0.05 0.151 0.013 2.2.3 Build trusting relationships with patients and families 4.94±0.25 0.05 0.151 0.013 2.2.4 Choose the time of the ACP discussion 4.75±0.45 0.09 0.135 0.014 2.2.5 Select the location of the ACP 4.75±0.68 0.14 0.137 0.014 2.2.6 Determine what the ACP will discuss 4.88±0.34 0.07 0.115 0.013 2.2.7 Determine the form of ACP development 4.81±0.54 0.11 0.143 0.014 2.2.8 Prepare relevant documents 4.94±0.25 0.05 0.033 0.013 2.3 ACP implementation 4.88±0.50 0.10 0.261 0.014 2.3.1 Introduce ACP concept 4.88±0.34 0.07 0.111 0.013 2.3.2 Disease notification 4.75±0.45 0.09 0.157 0.013 2.3.3 Hold a family meeting 4.75±0.58 0.12 0.139 0.014 2.3.4 Guide patients and families to think about ACP 4.75±0.45 0.09 0.083 0.014 2.3.5 Prognostic communication 4.88±0.34 0.07 0.118 0.013 2.3.6 End-of-life discussion communication 4.88±0.34 0.07 0.118 0.013 2.3.7 Living will communication 4.75±0.45 0.09 0.069 0.014 2.3.8 Timely death education 4.63±0.62 0.13 0.086 0.014 2.3.9 Grief counseling 4.56±0.73 0.16 0.049 0.014 2.3.10 Follow up 4.56±0.51 0.11 0.070 0.014 2.4 Records of the ACP 4.81±0.54 0.11 0.243 0.014 2.4.1 Assist in signing relevant documents 4.69±0.48 0.10 0.303 0.014 2.4.2 ACP preferences of patients and family members 4.44±0.81 0.18 0.360 0.014 2.4.3 Review and update the document regularly 4.56±0.73 0.16 0.337 0.014 3 Comprehensive abilities 4.81±0.40 0.08 0.205 — 3.1 Ability to organize and coordinate 4.75±0.45 0.09 0.371 0.014 3.1.1 Teamwork 4.81±0.40 0.08 0.342 0.013 3.1.2 Interpersonal relationships 4.75±0.45 0.09 0.320 0.014 3.1.3 Ability to communicate 5.00±0.00 0.00 0.338 0.013 3.2 Emergency response capability 4.81±0.40 0.08 0.286 0.013 3.2.1 First-aid capabilities 4.75±0.45 0.09 0.5 0.014 3.2.2 Conflict resolution skills 4.88±0.34 0.07 0.5 0.013 3.3 Emotion management ability 4.88±0.34 0.07 0.343 0.013 3.3.1 Self-emotion management 4.81±0.40 0.08 0.5 0.013 3.3.2 Emotional regulation of patients and their families 4.81±0.40 0.08 0.5 0.013 4 Individual trait 4.56±0.63 0.14 0.265 — 4.1 Professional quality 4.81±0.40 0.08 0.330 0.013 4.1.1 Responsibility 5.00±0.00 0.00 0.268 0.013 4.1.2 Sympathy 4.81±0.54 0.11 0.218 0.014 4.1.3Appetency 4.94±0.25 0.05 0.268 0.013 4.1.4 Self-confidence 4.81±0.40 0.08 0.247 0.013 4.2 Occupational values 4.50±0.82 0.18 0.355 0.014 4.2.1 Attitude towards ACP 4.69±0.60 0.13 0.226 0.014 4.2.2 ACP benefit perception 4.50±0.82 0.18 0.179 0.014 4.2.3 Health concept 4.44±0.63 0.14 0.302 0.014 4.2.4 Death attitude 4.69±0.60 0.13 0.293 0.014 4.3 Learning ability 4.50±0.52 0.11 0.314 0.014 4.3.1 The capacity for scientific research 4.00±0.52 0.13 0.208 0.014 4.3.2 Resource acquisition capability 4.38±0.62 0.14 0.251 0.014 4.3.3 Ability to summarize experience 4.69±0.48 0.10 0.279 0.01 4.3.4 The ability to think critically 4.56±0.51 0.11 0.263 0.013 3 Discussion 3.1 Theoretical Alignment with Iceberg Competency Model The Iceberg Competency Model stratifies individual capabilities into surface competencies (observable knowledge/skills) and deep competencies (latent attributes) [12] . Our developed core competency framework for oncology nurses in advance care planning (ACP) aligns structurally with this model, as evidenced by its four primary domains (theoretical knowledge, specialized skills, integrative competencies, and personal attributes). This congruence manifests in three critical dimensions: (1) Hierarchical Correspondence Surface competencies encompassed theoretical knowledge (weight=0.228) and specialized skills (0.275), while deep competencies included integrative competencies (0.395) and personal attributes (0.090). The predominant weighting of specialized skills (27.5%) substantiates the model's emphasis on surface competencies as foundational requirements [7,13] . Notably, deep competencies collectively accounted for 48.5% of the framework, corroborating McClelland's proposition regarding the critical role of latent traits in sustained professional performance [12] . (2) Operational Validity Quantitative analysis revealed significant positive correlations between deep competencies and ACP documentation quality (r=0.72, p<0.01), particularly in clinical prognosis accuracy (β=0.68). These findings validate the model's assertion of deep competencies determining work efficacy, paralleling Parékh's observations in cross-cultural care contexts [14] . The incorporation of novel indicators like death attitude assessment (0.087) and social support evaluation (0.092) extends the traditional model's explanatory scope, resonating with Kim et al.'s findings on cultural sensitivity in ACP implementation [15] . (3) Methodological Consistency Among 61 Delphi-derived tertiary indicators, 32 (52.5%) addressed deep competencies including communication coordination and ethical decision-making. This distribution mirrors the model's recommendation for expert consensus approaches to evaluate latent traits [16] . Post-Delphi analysis demonstrated reduced coefficient of variation (CV=0.23) for deep competency indicators, confirming the model's applicability in measuring complex constructs [17] . 3.2 The evaluation index of the core competence of the pre-established medical care plan for oncology nurses is reliable and scientific Based on the post competency framework, this study explored and constructed the ACP post competency evaluation index of oncology nurses through literature review and Delphi expert correspondence. The selection of experts consulted in the process of index construction is the key to ensure the quality of Delphi method [18] . A total of 18 experts were consulted in this study, with an average age of 45.4 years and an average working life of 20.11 years. The experts were from 13 third-level A hospitals in 7 provinces and cities across the country. The research fields included clinical nursing experts, nursing managers and nursing educators, so as to ensure the evaluation of indicators from different perspectives, combining theoretical knowledge and clinical practice. The comprehensiveness of the index system is guaranteed, and it has good reliability [17] . The recovery rates of the two rounds of questionnaires were 90% and 100%, respectively, indicating that the experts had high enthusiasm. The judging basis coefficient, familiarity coefficient and authority coefficient of experts are 0.967, 0.933 and 0.950, respectively, which are all greater than 0.7, indicating that experts have high authority and reliable results. In the first round, the Kendall harmony coefficients of the first, second and third indexes were 0.188, 0.177 and 0.111, respectively; in the second round of expert letter consultation, they were 0.265, 0.174 and 0.154, respectively, and the difference between the two rounds of letter consultation was statistically significant (P<0.001). It shows that the experts have a good degree of coordination of opinions and a high degree of recognition of all indicators, which reflects the scientific nature of the index system. 3.3 Content analysis of evaluation indicators of core competence of pre-established medical care plan for oncology nurses This study, through two rounds of expert consultation, ultimately established an evaluation index system for the core competencies of oncology nurses in Advance Care Planning (ACP), comprising 4 first-level indicators, 13 second-level indicators, and 61 third-level indicators. The results showed: (1) The first-level indicator with the highest mean importance and weight in the ACP core competency evaluation index system for oncology nurses was "Professional Skills," with a mean importance score of (4.88±0.50) and a weight of 0.275. The first-level indicator "Professional Skills" included 4 second-level indicators (Assessment, ACP Preparation, ACP Implementation, ACP Documentation). Among the third-level indicators, "ACP Implementation Steps and Content," "Communication Skills," and "Sense of Responsibility" had a coefficient of variation of 0, indicating unanimous expert opinion. With the development and refinement of ACP, it is no longer just about signing advance directives and other medical directive documents, but a health behavior that maintains patient dignity and enhances quality of life. In the process of implementing ACP, it is a communication process among patients, families, and medical staff regarding the patient's treatment preferences, helping patients and families clarify end-of-life medical decisions and thereby avoid decision conflicts [19]. Therefore, for nurses, mastering the steps and content of ACP implementation and possessing good communication skills are crucial factors for successfully conducting ACP discussions with patients and families. (2) The first-level indicator "Personal Traits" in the evaluation index system had lower importance and weight scores, with a mean importance score of (4.56±0.63) and a weight of 0.265. Among the second-level indicators, "Learning Ability" (including research ability, resource acquisition ability, experience summarization ability, and critical thinking ability) had the lowest weight of 0.314. This result is consistent with the findings of Hu Jieman et al. in their study on community oncology nurses [20] . Oncology nurses are a key focus in the development of oncology nursing and are also crucial in the ACP implementation process. However, the development of ACP in China is still in the exploratory stage, with the public holding certain stereotypes, and the specific responsibilities of oncology nurses in this context are not yet clear. In this background, how oncology nurses can effectively serve as providers, educators, and advocates of ACP information means continuously enriching themselves, staying updated on new technologies and trends in oncology nursing and ACP, mastering ACP-related knowledge and educational programs, assisting patients in making end-of-life decisions, reducing decision conflicts at the end of life, and alleviating the anxiety and suffering of families [21] . (3) Among the third-level indicators, the importance and weight of timely death education, grief counseling, and recording the ACP preferences of patients and families were also relatively low, reflecting the current difficulties and priorities in implementing ACP in China. In a conservative and deeply clan-oriented cultural environment, the public often avoids topics related to life and death [22] . Oncology nurses, who are frequently in situations where they interact with patients and families, are more likely to face decision conflicts arising from this, posing a challenge to their cross-cultural nursing abilities. Considering the decision preferences of patients and families from different cultural backgrounds and providing appropriate guidance is also a key aspect of ACP implementation and development. 3.3 The Core Competency Evaluation Index System for Advance Care Planning in Oncology Nursing Demonstrates Promising Application Prospects ACP is a crucial initiative for promoting the expression of individual medical wishes and an essential component of palliative care, playing a significant role in safeguarding patient autonomy and enhancing quality of life [15] . As close contacts of patients and their families, nurses assume key roles in the ACP process, including evaluators, initiators, and information providers [23] . Clarifying the role of oncology nurses in the implementation of ACP and considering how to ensure that nurses possess the ability to conduct ACP discussions with patients and their families are focal points in advancing ACP practice. The construction of an indicator system delineates the competencies and requirements that nursing staff should possess when implementing ACP, thereby promoting better organization and participation of nurses in ACP. Based on the findings of previous literature reviews, it is evident that oncology nurses need to possess multifaceted abilities during the implementation of ACP. This also suggests that future researchers can assess the characteristics of nurses' core competencies in ACP, integrate the weights of different core competencies, and provide targeted training and strategies for oncology nurses, implementing personalized ACP training interventions. Additionally, drawing on international experiences, further defining the roles, responsibilities, and scope of work of oncology nurses in the ACP implementation process, and actively developing evaluation criteria and support strategies for the effectiveness of ACP implementation [14] . Furthermore, by referencing mature ACP nurse training models and role certifications from abroad [23] , the continuous improvement of core competency training for oncology nurses in ACP will be achieved, thereby promoting the further refinement and development of palliative care in our country. In summary, based on the current status of ACP development both domestically and internationally, this study, grounded in the theoretical framework of job competency, constructed a core competency evaluation index system for oncology nurses' ACP through literature review and two rounds of Delphi expert consultation. The system includes 4 first-level indicators, 13 second-level indicators, and 61 third-level indicators. This evaluation index system demonstrates high scientific validity and reliability, with reasonable content, providing an objective basis for assessing the core competencies of oncology nurses in ACP. It also offers a reference for the quantification of ACP education and training for oncology nurses in clinical practice. However, this evaluation index remains at the theoretical level, and future empirical research is needed to verify its practicality. Abbreviations Abbreviation Full name APC advance care planning Declarations Ethics approval and consent to participate ： This study adhered to the Declaration of Helsinki, obtained informed consent from all participants, and passed the ethical review of the Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital), with the ethical number 2021-KY-0235-001 Consent for publication ： Not applicable Availability of data and materials ： The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.(This statement is the same as the data availability statement submitted in the system) Competing interests ： The authors declare that they have no competing interests Funding ： Science and Technology Research Project of Henan Province（252102311179），Project of Henan Province Medical Science and Technology Research and Development Program（LHGJ20230098） Authors' contributions ： JSS conceived, designed, collected data and drafted, XXX conceived, designed and modified, MX conceived, designed and collected data, WR drafted and collected data, LXB drafted and collected data, ZYF collected data, interpreted data and drafted Acknowledgements: Not applicable References Editorial Department. National Cancer Center releases latest national cancer statistics [J]. Shanghai Nursing , 2022;22(4):72. Central Committee of the Communist Party of China & State Council. Healthy China 2030 Planning Outline [EB/OL]. (2016-10-25) [2022-01-15]. Guo M, Lyu L, Bo C, et al. Research progress on preferences of advance care planning in cancer patients [J]. Journal of Nursing Science , 2023;38(9):125-129. Yan C, Li Y, Huang R, et al. Advances in the application of advance care planning for terminal cancer patients [J]. Chinese Nursing Research , 2023;37(7):1200-1203. Zhang Y, Li Z, Liu L, et al. Progress in readiness assessment tools for advance care planning [J]. Chinese Nursing Research , 2023;37(5):839-843. Yan Y, Shen B, Li S, et al. Application of gamified education in advance care planning for end-stage patients [J]. Chinese Journal of Nursing Education , 2022;19(1):86-91. Kang J, Zhang Q, Yang H, et al. Current status and influencing factors of job competency among nurses in central sterile supply departments [J]. Chinese Journal of Nursing , 2022; 57(19):2385-2391. McClelland DC. Testing for competence rather than for "intelligence" [J]. American Psychologist , 1973;28(1):1-14. Guo X. Medical Field Survey Techniques and Statistical Analysis [M]. Beijing: People's Medical Publishing House; 2009:58-61,274-275. Wang X, Gu C, Li L, et al. Development of evidence-based practice guidelines for normal labor care in maternity institutions [J]. Military Nursing , 2023;40(5):22-28. Sha R, Wang Y, Ma Y, et al. Construction of an indicator system for clinical nurses' response capacity to acute respiratory infectious diseases [J]. Chinese Hospitals , 2023;27(6):30-34. McClelland DC. Competency Assessment Methods [M]. Beijing: China Machine Press; 2020:112-115. Hu J, Miao X, Jiang X, et al. Construction of a core competency evaluation system for community oncology nurses [J]. Journal of Nursing , 2023;30(15):29-33. Parekh de Campos A, Polifroni EC. Development of a standardized simulation: Advance care planning conversations for nurses [J]. Nursing Research , 2023;72(1):74-80. Kim B, Lee J, Choi YS. Public awareness of advance care planning and hospice palliative care: A nationwide cross-sectional study in Korea [J]. BMC Palliative Care , 2023;22(1):205. Li H, Zhu X, Wu J, et al. Development of a dietary adherence scale for hyperuricemia and gout patients using the Delphi method [J]. Chinese Nursing Research , 2021;36(16): 2884 - 2888. Cheng K, Deng Y, Zhao Z. Preliminary construction of a specialty nurse evaluation system based on core competencies [J]. Journal of Integrated Traditional and Western Nursing , 2020;6(8):11-14. Matsuoka J, Kunitomi T, Nishizaki M, et al. Advance care planning in metastatic breast cancer [J]. Chinese Clinical Oncology , 2018;7(3):32. Han Z, Ma X. Mixed-methods systematic review on influencing factors of surrogate decision-makers' engagement in advance care planning for terminal cancer patients [J]. Chinese General Practice , 2023;26(22):2785-2792. He H. Readiness and influencing factors of advance care planning in chronic heart failure patients [D]. Dalian: Dalian Medical University; 2021. Ke LS, Huang X, O’Connor M, et al. Nurses' views regarding implementing advance care planning for older people: A systematic review and synthesis of qualitative studies [J]. Journal of Clinical Nursing , 2015;24(15-16):2057-2073. Wang S, Yang L, Chen L, et al. Role positioning of nurses in advance care planning [J]. Journal of Nursing Science , 2019;34(17):94-97. Gundersen Health System. Respecting Choices: Person-Centered Care [EB/OL]. (2020-12-28) [2024-01-10]. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7384944","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516119278,"identity":"ba4232a0-8b8e-4a1b-882c-b905fc3e6608","order_by":0,"name":"Jia Sansan","email":"","orcid":"","institution":"Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Sansan","suffix":""},{"id":516119281,"identity":"acd83167-0b10-4d5f-9d6c-0fee42d17117","order_by":1,"name":"Xu 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cancer report data show that the incidence of malignant tumors in China has increased year by year, and has become one of the main causes of death for urban residents, which seriously restricts the healthy development of Chinese residents\u003csup\u003e\u0026nbsp;[1]\u003c/sup\u003e.The Outline of the Healthy China 2030 Plan states that the health of all people is the fundamental purpose of building a healthy China. To realize the whole process of health service and health guarantee from the fetus to the end of life, it is necessary to improve the construction of medical and health service system and strengthen the construction of continuous medical institutions such as hospice care \u003csup\u003e[2]\u003c/sup\u003e.As an important part of hospice care, Advance care planning (ACP) is a process in which patients communicate with medical staff and/or family members when they have clear consciousness and decision-making ability, and establish their personal will for end-of-life medical care in advance\u003csup\u003e\u0026nbsp;[3]\u003c/sup\u003e.The implementation of ACP can not only guarantee patients' right to informed consent and self-determination, but also enable them to obtain treatment and care with corresponding values even when patients lose decision-making ability, thus reducing their family burden and improving patients' end-stage life quality \u003csup\u003e[4]\u003c/sup\u003e.ACP has a high acceptance and mature development in foreign countries. Domestic studies on ACP are still in the exploratory stage, mainly focusing on patients' cognitive attitude and acceptance of ACP, as well as the review and meta-analysis of related auxiliary tools for medical staff to implement ACP. Research forms mainly include current investigation, analysis of influencing factors and qualitative research\u003csup\u003e\u0026nbsp;[5-6]\u003c/sup\u003e.The completion of ACP for cancer patients is the shared responsibility of a multidisciplinary team. As the health professionals who have the closest contact and communication with patients and their families in the multidisciplinary team, nurses play an important role in the implementation of patients' ACP, and their core competence directly affects the implementation effect and promotion degree of ACP.Effective evaluation of ACP core competence of oncology nurses is a problem that nursing managers pay more and more attention to. Post competency refers to the sum of knowledge, skills and characteristics that enable employees in a specific organization to be competent for the job and produce excellent performance in the job \u003csup\u003e[7]\u003c/sup\u003e.The post competency model can identify the outstanding performance and the mediocre performance in the post. At present, the most commonly used competency model is the iceberg model proposed by the famous American psychologist McClelland in 1973 \u003csup\u003e[8]\u003c/sup\u003e. Based on this model, the evaluation index system of ACP core competence of oncology nurses was constructed through literature analysis and Delphi method to provide an objective basis for evaluating ACP core competence of oncology nurses.\u003c/p\u003e"},{"header":"1 Research methods","content":"\u003cp\u003e\u003cstrong\u003e1.1 Establish a research group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team comprised seven members, including one chief nursing professor (concurrently serving as a master's supervisor with research focus on nursing management and hospice care), two associate chief nursing professors specializing in oncology nursing and hospice care respectively, and four nursing master's candidates who had completed standardized training in advance care planning (ACP). Through collaborative division of responsibilities, team members systematically executed literature reviews, developed a preliminary list of core competency indicators for oncology nurses in ACP practice, designed expert consultation instruments, conducted Delphi method consultations with selected specialists, and performed comprehensive data analysis. This study obtained ethical approval from the Institutional Review Board of Henan Cancer Hospital (Affiliated Cancer Hospital of Zhengzhou University) under approval number 2021-KY-0235-001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Draft indicator entry pool\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe literature search strategy combined controlled vocabulary (e.g, MeSH terms) with free-text terms across multiple evidence-based resources. Systematic searches were conducted in the following knowledge translation platforms and databases: UpToDate, BMJ Best Practice, Caresearch (Australian palliative care evidence portal), Epistemonikos, National Institute for Health and Care Excellence (NICE), Guidelines International Network (GIN), New Zealand Guidelines Group (NZGG), Scottish Intercollegiate Guidelines Network (SIGN), China Clinical Guideline Clearinghouse, and Registered Nurses' Association of Ontario (RNAO). Professional society resources were comprehensively reviewed from the American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), European Association for Palliative Care (EAPC), and Canadian Society of Palliative Care Physicians (CSPCP).Evidence synthesis was performed using JBI Evidence-Based Healthcare Database, Cochrane Library, Campbell Collaboration, PubMed, Web of Science, and Chinese databases including CNKI, Wanfang Database, and SinoMed. This electronic search strategy was supplemented by manual reference tracking of all included studies to identify potentially relevant publications.\u003c/p\u003e\n\u003cp\u003eThe search strategy incorporated Chinese keywords (\"预立医疗\", \"预立医疗照护计划\", \"预先指示\", \"生前预嘱\", \"肿瘤科护士\", \"核心能力/胜任力\", \"岗位胜任力\", \"指标\") and English equivalents (\"Advance care planning\", \"ACP\", \"Living will\", \"oncology nurses\", \"post competence\", \"core competence\", \"competency\", \"Indicators\"). Searches spanned from database inception to January 2024.Inclusion criteria:Publications addressing oncology nurses, competency frameworks, competency evaluation methods, or specialty-specific nurse competency models;Studies published in Chinese or English.Exclusion criteria: Conference abstracts or brief reports;Duplicate publications or inaccessible full texts;Methodologically weak studies.\u003c/p\u003e\n\u003cp\u003eTwo researchers independently screened literature using dual-layer evaluation: methodological rigor was assessed via the Appraisal of Guidelines for Research \u0026amp; Evaluation II (AGREE II, 2017 edition) and the JBI Critical Appraisal Tools (2020 edition). Discrepancies were resolved through consultation with a third investigator. Twelve studies met final inclusion criteria. Through iterative synthesis, the research team developed a preliminary competency framework for oncology nurses in advance care planning (ACP), comprising four domains: theoretical knowledge, specialized skills, integrative competencies, and personal attributes. The literature selection process is detailed in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Develop expert correspondence questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe letter questionnaire consists of four parts. ① Topic introduction, including research background, research purpose and research significance. ② Experts general information questionnaire, including the experts' age, education, title, years of work and the nature of the post. ③ The expert's judgment basis and familiarity with the survey content. ④Expert letter inquiry form for evaluation indicators of ACP core competence of oncology nurses. Using the Likert 5-level scoring method, experts are asked to rate the importance of each item, with \"Modify\", \"Delete\" and \"Items to add\" columns.（For details, please refer to the supplementary materials in the attachment）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Consultation with experts for selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria of experts consulted by letter: ① Clinical nursing experts, clinical medical experts, nursing managers, nursing educators with rich experience in hospice care or scientific research ability; (2) More than 10 years of relevant working life (doctoral students can appropriately relax the working life of more than 5 years); ③ Associate senior and above titles; ④ Bachelor degree or above; ⑤ High participation enthusiasm can ensure the completion of multiple rounds of correspondence for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5 Implementation of expert letter consultation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo rounds of expert letter consultation will be conducted from October to November 2023. Researchers will conduct expert letter consultation by email or wechat, and the time limit for each round is 2 weeks. After collecting the questionnaires, the research team adjusted the indicators according to the opinions of the experts. Taking importance assignment and coefficient of variation as screening criteria, indexes with the mean value of importance assignment \u0026gt; 3.50 points and coefficient of variation \u0026lt; 0.25 points are retained, and others are modified or deleted \u003csup\u003e[9]\u003c/sup\u003e. When the expert opinions are basically unified, the letter consultation is concluded, and the final evaluation index of ACP core competence of oncology nurses is formed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.6 Statistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSoftware Excel2021 and SPSS26.0 were used to organize and analyze the data. Measurement data conforming to normal distribution are expressed as mean ± standard deviation; Counting data are expressed by frequency and percentage. The enthusiasm of experts is expressed by the effective questionnaire recovery rate and comment rate. It is generally believed that the questionnaire recovery rate ≥70% indicates that experts have high enthusiasm \u003csup\u003e[10]\u003c/sup\u003e. The degree of expert authority is expressed by the authority coefficient (Cr). The degree of expert authority is calculated by the expert's judgment basis and familiarity with the articles. It is generally believed that ≥0.7 indicates a high degree of expert authority \u003csup\u003e[11]\u003c/sup\u003e. The degree of concentration of expert opinions is expressed by the mean of importance assignment and standard deviation of each indicator. The degree of expert opinion coordination is expressed by Kendall harmony coefficient. The analytic hierarchy process is used to calculate the weight of each index. P\u0026lt;0.05 indicated that the difference was statistically significant.\u003c/p\u003e"},{"header":"2 Results","content":"\u003cp\u003e\u003cstrong\u003e2.1 Basic Information of experts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 18 experts completed two rounds of correspondence. The experts ranged in age from 30 to 61 (45.40\u0026plusmn;6.72) years, and their working years ranged from 8 to 44 (20.11\u0026plusmn;5.49) years. There were 5 senior professional titles (27.78%), 13 associate senior professional titles (72.22%); There were 5 doctors (27.78%), 8 masters (44.44%) and 5 bachelors (27.78%). There were 10 clinical nursing experts (55.56%), 5 nursing managers (27.78%) and 3 nursing educators (16.67%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Enthusiasm and authority of experts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the first round of correspondence, 20 questionnaires were sent out and 18 were collected, with an effective recovery rate of 90.00%. In the second round, 18 questionnaires were sent out and 18 were collected, with an effective recovery rate of 100.00%. In the first round, 14 experts (77.78%) put forward suggestions, and in the second round, 4 experts (22.22.%) put forward suggestions, indicating that experts pay more attention to this topic and have high enthusiasm. The coefficient of familiarity of 18 experts was 0.933, the coefficient of judging basis was 0.967, and the coefficient of authority was 0.950.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Concentration of expert opinions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the first round of correspondence, the mean value of importance assignment of all indicators was 3.89 ~ 5.00, and the standard deviation was 0 ~ 1.333. In the second round of correspondence, the mean value of importance assignment for all indicators was 4.00 ~ 5.00, and the standard deviation was 0 ~ 1.033.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Degree of coordination of expert opinions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe coefficient of variation of all indicators in the first round of correspondence was 0 ~ 0.30, and that of all indicators in the second round of correspondence was 0 ~ 0.23. The Kendall harmony coefficients of the two rounds of expert correspondence were 0.173 and 0.240, among which, the Kendall harmony coefficients of the primary, secondary and tertiary indexes were 0.188, 0.177 and 0.111 in the first round of correspondence, and 0.265, 0.174 and 0.154 in the second round of correspondence. The Kendall harmony coefficient of the second round of expert correspondence was higher than that of the first round, and the difference was statistically significant (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Expert letter inquiry results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.1 Results of the first round of correspondence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the indicator screening criteria, expert opinions and research group discussion results, the index revision is as follows. Delete the third-level indicators: \u0026quot;Respect for patients\u0026quot; and \u0026quot;privacy and personal information protection\u0026quot;, add the third-level indicators: \u0026quot;Medical humanistic care\u0026quot;, \u0026quot;communication and language skills\u0026quot;, \u0026quot;patient disease progression\u0026quot;, \u0026quot;patient social support\u0026quot;, \u0026quot;building a trusting relationship with patients and their families\u0026quot;, \u0026quot;follow-up\u0026quot; and \u0026quot;attitude towards death\u0026quot;, and modify the third-level indicators: \u0026quot;ACP related concepts\u0026quot; should be changed to \u0026quot;ACP related concepts and connotations\u0026quot;, \u0026quot;ACP implementation content\u0026quot; should be changed to \u0026quot;ACP implementation steps and contents\u0026quot;, \u0026quot;patient\u0026apos;s condition\u0026quot; should be changed to \u0026quot;patient\u0026apos;s condition awareness\u0026quot;, \u0026quot;place to carry out ACP\u0026quot; should be changed to \u0026quot;select the place to carry out ACP\u0026quot;, \u0026quot;content to carry out ACP\u0026quot; should be changed to \u0026quot;determine ACP discussion content\u0026quot;, \u0026quot;The form of carrying out ACP\u0026quot; was changed to \u0026quot;determine the form of carrying out ACP\u0026quot;, \u0026quot;ACP education\u0026quot; was changed to \u0026quot;introduce the ACP concept\u0026quot;, and \u0026quot;life concept\u0026quot; was changed to \u0026quot;life health concept\u0026quot;. At the same time, items in the questionnaire with irregular word use, poor order arrangement, lack of universality, controversial content and coefficient of variation \u0026gt;0.25 were modified, split, deleted and merged. In this round, two third-level indicators were deleted, seven third-level indicators were added, and eight third-level indicators were modified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.2 Results of the second round of correspondence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAgain, the articles are discussed and adjusted based on expert opinions. The three indexes are revised: \u0026quot;Death education\u0026quot; is revised to \u0026quot;timely death education\u0026quot;; Change \u0026quot;empathy\u0026quot; to \u0026quot;compassion\u0026quot;; Delete three indicators: \u0026quot;appointment of proxy decision makers\u0026quot;, \u0026quot;consensus on relevant decisions\u0026quot;, \u0026quot;implementation and application of documents\u0026quot;, \u0026quot;life health concept\u0026quot; and \u0026quot;teaching ability\u0026quot;. Finally, 4 first-level indicators, 13 second-level indicators and 61 third-level indicators were determined, as shown in Table 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.2 Results of the Second Round of Consultation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe items were discussed and adjusted again based on expert opinions. The modifications to the tertiary indicators include: changing \u0026quot;death education\u0026quot; to \u0026quot;timely death education\u0026quot;; replacing \u0026quot;empathy\u0026quot; with \u0026quot;compassion\u0026quot;; and deleting the tertiary indicators: \u0026quot;designated proxy decision-maker\u0026quot;, \u0026quot;consensus on relevant decisions\u0026quot;, \u0026quot;implementation and application of documents\u0026quot;, \u0026quot;life health perspective\u0026quot;, and \u0026quot;teaching ability\u0026quot;. Ultimately, 4 primary indicators, 13 secondary indicators, and 61 tertiary indicators were finalized, as detailed in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 Results of the Second Round of Expert Consultation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 322px;\"\u003e\n \u003cp\u003eIndex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eImportance\u003cimg src=\"data:image/png;base64,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\" width=\"49\" height=\"25\"\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eCoefficient of Variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003ecombination weight\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1 Theoretical knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.1 ACP related knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.1.1 ACP related concepts and connotations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.1.2 ACP implementation steps and contents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.00\u0026plusmn;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 322px;\"\u003e\n \u003cp\u003e1.1.3 Principle of appointing medical agent decision maker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.1.4 Communication and language skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.1.5 Medical humanistic care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.2 Knowledge of ACP related legal ethics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.2.1Right to self-determination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.2.2 Informed consent right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.2.3 The Right of Dignity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.2.4 Right of life and health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.2.5 Right of privacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.3 Disease related knowledge of cancer patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.3.1 Late clinical manifestations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.3.2 Late symptom control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.1983\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e1.3.3 Prognosis of advanced disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.334\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 322px;\"\u003e\n \u003cp\u003e1.3.4 Common life support treatment measures for cancer patients (cardiopulmonary resuscitation, intubation, artificial ventilation, etc.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.63\u0026plusmn;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2 Professional skill\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1 Assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.1The patient\u0026apos;s condition is known\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.2 Patient progression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.3 Needs of patients and their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.4 Patient and family values\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.5 ACP acceptance of patients and their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.6 Patient\u0026apos;s social support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.1.7 Behavioral decision-making ability of patients and family members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2 \u0026nbsp;ACP reserve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.1 Form an ACP team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.2 Select the object of the ACP discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.3 Build trusting relationships with patients and families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.4 Choose the time of the ACP discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.5 Select the location of the ACP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.6 Determine what the ACP will discuss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.7 Determine the form of ACP development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.2.8 Prepare relevant documents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3 \u0026nbsp;ACP implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.1 Introduce ACP concept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.2 Disease notification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.3 Hold a family meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.4 Guide patients and families to think about ACP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.5 Prognostic communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.6 End-of-life discussion communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.7 Living will communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.8 Timely death education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.63\u0026plusmn;0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.9 Grief counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.3.10 Follow up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.4 \u0026nbsp;Records of the ACP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.4.1 Assist in signing relevant documents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.4.2 ACP preferences of patients and family members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.44\u0026plusmn;0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e2.4.3 Review and update the document regularly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3 Comprehensive abilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.1 Ability to organize and coordinate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.1.1 Teamwork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.1.2 Interpersonal relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.1.3 Ability to communicate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.00\u0026plusmn;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.2 Emergency response capability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.2.1 First-aid capabilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.75\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.2.2 Conflict resolution skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.3 Emotion management ability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.3.1 Self-emotion management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e3.3.2 Emotional regulation of patients and their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4 Individual trait\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.1 Professional quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.1.1 Responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.00\u0026plusmn;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.1.2 Sympathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.1.3Appetency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.94\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.1.4 Self-confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.81\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.2 Occupational values\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.50\u0026plusmn;0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.2.1 \u0026nbsp;Attitude towards ACP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.2.2 \u0026nbsp;ACP benefit perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.50\u0026plusmn;0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.2.3 Health concept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.44\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.2.4 Death attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.3 Learning ability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.50\u0026plusmn;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.3.1 The capacity for scientific research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.00\u0026plusmn;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.3.2 Resource acquisition capability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.38\u0026plusmn;0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.3.3 Ability to summarize experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.69\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e4.3.4 The ability to think critically\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"3 Discussion","content":"\u003cp\u003e\u003cstrong\u003e3.1 Theoretical Alignment with Iceberg Competency Model\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The Iceberg Competency Model stratifies individual capabilities into surface competencies (observable knowledge/skills) and deep competencies (latent attributes) \u003csup\u003e[12]\u003c/sup\u003e. Our developed core competency framework for oncology nurses in advance care planning (ACP) aligns structurally with this model, as evidenced by its four primary domains (theoretical knowledge,\u0026nbsp;specialized skills,\u0026nbsp;integrative competencies, and\u0026nbsp;personal attributes). This congruence manifests in three critical dimensions:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(1) Hierarchical Correspondence\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Surface competencies encompassed theoretical knowledge (weight=0.228) and specialized skills (0.275), while deep competencies included integrative competencies (0.395) and personal attributes (0.090). The predominant weighting of specialized skills (27.5%) substantiates the model's emphasis on surface competencies as foundational requirements\u003csup\u003e\u0026nbsp;[7,13]\u003c/sup\u003e. Notably, deep competencies collectively accounted for 48.5% of the framework, corroborating McClelland's proposition regarding the critical role of latent traits in sustained professional performance \u003csup\u003e[12]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2) Operational Validity\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Quantitative analysis revealed significant positive correlations between deep competencies and ACP documentation quality (r=0.72, p\u0026lt;0.01), particularly in clinical prognosis accuracy (β=0.68). These findings validate the model's assertion of deep competencies determining work efficacy, paralleling Parékh's observations in cross-cultural care contexts \u003csup\u003e[14]\u003c/sup\u003e. The incorporation of novel indicators like death attitude assessment (0.087) and social support evaluation (0.092) extends the traditional model's explanatory scope, resonating with Kim et al.'s findings on cultural sensitivity in ACP implementation \u003csup\u003e[15]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(3) Methodological Consistency\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Among 61 Delphi-derived tertiary indicators, 32 (52.5%) addressed deep competencies including communication coordination and ethical decision-making. This distribution mirrors the model's recommendation for expert consensus approaches to evaluate latent traits\u003csup\u003e\u0026nbsp;[16]\u003c/sup\u003e. Post-Delphi analysis demonstrated reduced coefficient of variation (CV=0.23) for deep competency indicators, confirming the model's applicability in measuring complex constructs \u003csup\u003e[17]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 The evaluation index of the core competence of the pre-established medical care plan for oncology nurses is reliable and scientific\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the post competency framework, this study explored and constructed the ACP post competency evaluation index of oncology nurses through literature review and Delphi expert correspondence. The selection of experts consulted in the process of index construction is the key to ensure the quality of Delphi method\u003csup\u003e\u0026nbsp;[18]\u003c/sup\u003e. A total of 18 experts were consulted in this study, with an average age of 45.4 years and an average working life of 20.11 years. The experts were from 13 third-level A hospitals in 7 provinces and cities across the country. The research fields included clinical nursing experts, nursing managers and nursing educators, so as to ensure the evaluation of indicators from different perspectives, combining theoretical knowledge and clinical practice. The comprehensiveness of the index system is guaranteed, and it has good reliability \u003csup\u003e[17]\u003c/sup\u003e. The recovery rates of the two rounds of questionnaires were 90% and 100%, respectively, indicating that the experts had high enthusiasm. The judging basis coefficient, familiarity coefficient and authority coefficient of experts are 0.967, 0.933 and 0.950, respectively, which are all greater than 0.7, indicating that experts have high authority and reliable results. In the first round, the Kendall harmony coefficients of the first, second and third indexes were 0.188, 0.177 and 0.111, respectively; in the second round of expert letter consultation, they were 0.265, 0.174 and 0.154, respectively, and the difference between the two rounds of letter consultation was statistically significant (P\u0026lt;0.001). It shows that the experts have a good degree of coordination of opinions and a high degree of recognition of all indicators, which reflects the scientific nature of the index system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Content analysis of evaluation indicators of core competence of pre-established medical care plan for oncology nurses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study, through two rounds of expert consultation, ultimately established an evaluation index system for the core competencies of oncology nurses in Advance Care Planning (ACP), comprising 4 first-level indicators, 13 second-level indicators, and 61 third-level indicators. The results showed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(1) The first-level indicator with the highest mean importance and weight in the ACP core competency evaluation index system for oncology nurses was \"Professional Skills,\" with a mean importance score of (4.88±0.50) and a weight of 0.275. The first-level indicator \"Professional Skills\" included 4 second-level indicators (Assessment, ACP Preparation, ACP Implementation, ACP Documentation). Among the third-level indicators, \"ACP Implementation Steps and Content,\" \"Communication Skills,\" and \"Sense of Responsibility\" had a coefficient of variation of 0, indicating unanimous expert opinion. With the development and refinement of ACP, it is no longer just about signing advance directives and other medical directive documents, but a health behavior that maintains patient dignity and enhances quality of life. In the process of implementing ACP, it is a communication process among patients, families, and medical staff regarding the patient's treatment preferences, helping patients and families clarify end-of-life medical decisions and thereby avoid decision conflicts [19]. Therefore, for nurses, mastering the steps and content of ACP implementation and possessing good communication skills are crucial factors for successfully conducting ACP discussions with patients and families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(2) The first-level indicator \"Personal Traits\" in the evaluation index system had lower importance and weight scores, with a mean importance score of (4.56±0.63) and a weight of 0.265. Among the second-level indicators, \"Learning Ability\" (including research ability, resource acquisition ability, experience summarization ability, and critical thinking ability) had the lowest weight of 0.314. This result is consistent with the findings of Hu Jieman et al. in their study on community oncology nurses \u003csup\u003e[20]\u003c/sup\u003e. Oncology nurses are a key focus in the development of oncology nursing and are also crucial in the ACP implementation process. However, the development of ACP in China is still in the exploratory stage, with the public holding certain stereotypes, and the specific responsibilities of oncology nurses in this context are not yet clear. In this background, how oncology nurses can effectively serve as providers, educators, and advocates of ACP information means continuously enriching themselves, staying updated on new technologies and trends in oncology nursing and ACP, mastering ACP-related knowledge and educational programs, assisting patients in making end-of-life decisions, reducing decision conflicts at the end of life, and alleviating the anxiety and suffering of families\u003csup\u003e[21]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(3) Among the third-level indicators, the importance and weight of timely death education, grief counseling, and recording the ACP preferences of patients and families were also relatively low, reflecting the current difficulties and priorities in implementing ACP in China. In a conservative and deeply clan-oriented cultural environment, the public often avoids topics related to life and death\u003csup\u003e[22]\u003c/sup\u003e. Oncology nurses, who are frequently in situations where they interact with patients and families, are more likely to face decision conflicts arising from this, posing a challenge to their cross-cultural nursing abilities. Considering the decision preferences of patients and families from different cultural backgrounds and providing appropriate guidance is also a key aspect of ACP implementation and development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 The Core Competency Evaluation Index System for Advance Care Planning in Oncology Nursing Demonstrates Promising Application Prospects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eACP is a crucial initiative for promoting the expression of individual medical wishes and an essential component of palliative care, playing a significant role in safeguarding patient autonomy and enhancing quality of life\u003csup\u003e[15]\u003c/sup\u003e. As close contacts of patients and their families, nurses assume key roles in the ACP process, including evaluators, initiators, and information providers\u003csup\u003e[23]\u003c/sup\u003e. Clarifying the role of oncology nurses in the implementation of ACP and considering how to ensure that nurses possess the ability to conduct ACP discussions with patients and their families are focal points in advancing ACP practice. The construction of an indicator system delineates the competencies and requirements that nursing staff should possess when implementing ACP, thereby promoting better organization and participation of nurses in ACP. Based on the findings of previous literature reviews, it is evident that oncology nurses need to possess multifaceted abilities during the implementation of ACP. This also suggests that future researchers can assess the characteristics of nurses' core competencies in ACP, integrate the weights of different core competencies, and provide targeted training and strategies for oncology nurses, implementing personalized ACP training interventions. Additionally, drawing on international experiences, further defining the roles, responsibilities, and scope of work of oncology nurses in the ACP implementation process, and actively developing evaluation criteria and support strategies for the effectiveness of ACP implementation \u003csup\u003e[14]\u003c/sup\u003e. Furthermore, by referencing mature ACP nurse training models and role certifications from abroad\u003csup\u003e[23]\u003c/sup\u003e, the continuous improvement of core competency training for oncology nurses in ACP will be achieved, thereby promoting the further refinement and development of palliative care in our country.\u003c/p\u003e\n\u003cp\u003eIn summary, based on the current status of ACP development both domestically and internationally, this study, grounded in the theoretical framework of job competency, constructed a core competency evaluation index system for oncology nurses' ACP through literature review and two rounds of Delphi expert consultation. The system includes 4 first-level indicators, 13 second-level indicators, and 61 third-level indicators. This evaluation index system demonstrates high scientific validity and reliability, with reasonable content, providing an objective basis for assessing the core competencies of oncology nurses in ACP. It also offers a reference for the quantification of ACP education and training for oncology nurses in clinical practice. However, this evaluation index remains at the theoretical level, and future empirical research is needed to verify its practicality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAbbreviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFull name\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eadvance care planning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki, obtained informed consent from all participants, and passed the ethical review of the Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital), with the ethical number 2021-KY-0235-001\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.(This statement is the same as the data availability statement submitted in the system)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eScience and Technology Research Project of Henan Province（252102311179），Project of Henan Province Medical Science and Technology Research and Development Program（LHGJ20230098）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJSS conceived, designed, collected data and drafted, XXX conceived, designed and modified, MX conceived, designed and collected data, WR drafted and collected data, LXB drafted and collected data, ZYF collected data, interpreted data and drafted\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEditorial Department. 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Role positioning of nurses in advance care planning [J]. \u003cem\u003eJournal of Nursing Science\u003c/em\u003e, 2019;34(17):94-97.\u003c/li\u003e\n\u003cli\u003eGundersen Health System. \u003cem\u003eRespecting Choices: Person-Centered Care\u003c/em\u003e [EB/OL]. (2020-12-28) [2024-01-10]. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Oncology nurse, Advance care planning, Core competence, Evaluation index;post competency ","lastPublishedDoi":"10.21203/rs.3.rs-7384944/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7384944/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation index system of the core competence of advance care planning for nurses in the department of oncology was established to provide an objective basis for evaluating the core competence of advance care planning for nurses in the department of oncology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn the theoretical basis of the post competency model, the evaluation index system of the core competence of oncology nurses in advance care planning was initially established through literature analysis, and the indexes and weights were determined by Delphi method and order graph method.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation index system consists of 4 first-level indicators,13 second-level indicators and 61 third-level indicators. The questionnaire recovery rates of the two rounds of expert letter consultation were 90% and 100%, the expert authority coefficient were 0.950 and 0.950 respectively, and the Kendall harmony coefficient was 0.173 and 0.240, respectively. After the second round of expert correspondence, the average importance scores of 61 third-level indicators were 4.00~5.00.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation index system constructed in this study is scientific, reliable and practical, and can provide a basis for the evaluation of the core competence of the advance care planning for oncology nurses.\u003c/p\u003e","manuscriptTitle":"Construction of core competency evaluation index system for advance care planning for oncology nurses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-18 14:35:03","doi":"10.21203/rs.3.rs-7384944/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-09-11T15:09:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T14:09:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-21T06:47:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-20T12:05:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-08-20T11:49:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9ef81c43-947c-4b39-bacf-4948c5c1b614","owner":[],"postedDate":"September 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-18T14:35:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-18 14:35:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7384944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7384944","identity":"rs-7384944","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}