Introduction

Over the past several decades, the application of ultrasonography has evolved significantly, moving from imaging laboratories to bedside evaluations in a wide array of medical settings. This shift has led to the widespread adoption of Point-of-Care Ultrasonography (PoCUS), which is now integral to the initial assessment, diagnosis, and management across various medical specialties1. In critical care environments particularly, ultrasonography has become indispensable, not only for procedural guidance but also for swiftly identifying and assessing multiple conditions such as pleural diseases, respiratory failure, and shock2,3. Similarly, PoCUS is highly valuable in emergency departments, where it facilitates rapid and accurate evaluation of patients, aiding in the timely diagnosis and treatment of acute conditions4,5. The clinical utility of ultrasonography, however, is highly dependent on the operator’s experience and skill set6,7. Mastery in image acquisition and interpretation is crucial, and so is the ability to effectively integrate ultrasonographic findings into clinical decision-making processes8.

The Knowledge, Attitude, and Practices (KAP) survey serves as a pivotal research tool, shedding light on a group’s understanding, beliefs, and actions regarding specific topics, particularly within the context of health literacy. It operates on the principle that enhanced knowledge positively influences attitudes, which in turn shape behaviors9,10. This framework is instrumental in examining the utilization of bedside ultrasonography by healthcare providers in intensive care units (ICUs) and emergency departments, where it is extensively applied under high-pressure conditions. Previous research highlights the significance of KAP in various contexts, such as the prevention of medical device-related pressure injuries11, decision-making processes regarding the use of physical restraints in pediatric and neonatal ICUs12, and the prevention of pressure ulcers13. These studies collectively underscore the crucial role of improving knowledge, attitudes, and practices among ICU nurses to elevate the quality of healthcare delivery and patient outcomes.

Despite the critical role of bedside ultrasonography in ICUs and emergency departments, its effective application is hindered by various challenges. Healthcare providers often face issues such as inadequate training, limitations in skills, equipment shortages, ambiguous clinical application scopes, quality control discrepancies, and legal and ethical concerns. These obstacles underscore the variability in recognition, attitudes, and practical usage of this technology across intensive care settings14,15.

This study aims to assess the current knowledge, attitudes, and practices concerning bedside ultrasonography among healthcare providers in both ICUs and emergency departments.

Methods

Study design and participants

This quantitative cross-sectional study was conducted from September 2023 to March 2024, at Xinjiang Regional Hospital, with the primary study participants being healthcare providers in the ICU and Emergency of the hospital. The study has been approved by Xinjiang Uygur Autonomous Region People’s Hospital clinical research Ethics Committee and informed consent has been obtained from all participants. To clarify the study design, we have explicitly described it as a “quantitative cross-sectional survey” to avoid ambiguity. The Xinjiang Uygur Autonomous Region has approximately 280 hospitals in total, and respondents in this study were drawn from 20 institutions (6 tertiary and 14 secondary hospitals), located across multiple regions including Urumqi, Altay, Yining, and Kashgar. Participants were healthcare providers (physicians and nurses) working in emergency departments or ICUs, as both groups routinely participate in patient care and may perform or contribute to PoCUS examinations.

Sample size determination

The sample size was calculated using the following formula:

$$\:\text{n}=\frac{{z}^{2}p(1-p)}{{d}^{2}}$$

z = 1.96 at 5% level of significance and 5%acceptable margin of error (d = 0.05). The proportion of the expected population based on previous studies or pilot studies is set at 50%. Using these parameters, the required sample size was calculated to be 384.

Questionnaire delivery

We employed Questionnaire Star (Changsha Ranxing Information Technology Co., Ltd), a specialized online questionnaire software platform, to design and distribute the questionnaire. The survey was developed using the WeChat-integrated Questionnaire Star Mini Program, and a QR code was created to facilitate data collection via WeChat. Participants accessed and completed the questionnaire by scanning this QR code. To ensure the quality and completeness of the responses, we restricted each IP address to a single submission and required responses to all items. Data were exported to an Excel spreadsheet from the Questionnaire Star platform. The research team then verified the completeness, internal consistency, and validity of all collected questionnaires.

Procedures

The questionnaire was developed based on insights drawn from previous literature and was refined through consultations with experts in relevant specialty areas. Following these initial steps, a small-scale pilot test involving 30 participants was conducted to assess reliability, yielding a reliability coefficient of 0.802, indicating satisfactory internal consistency.

The finalized questionnaire comprised four distinct sections (appendix). The first section gathered participant demographic information through eight questions. The second section assessed knowledge related to the study’s topic, featuring seven questions with scoring as follows: two points for a correct response, one point for an uncertain response, and zero points for an incorrect response, allowing for a total possible score range of 0–14. The third section aimed to measure attitudes using eight questions, each based on a five-point Likert scale that quantified the degree of the respondent’s attitude, with total scores ranging from 8 to 40. The fourth and final section evaluated practices through ten questions, nine of which utilized a five-point Likert scale to reflect the extent of action, except for the sixth question, which was open-ended and not scored. This section’s scores could range from 9 to 45. For each dimension, scores exceeding 70% of the maximum possible were considered indicative of adequate knowledge, positive attitudes, and proactive practices, respectively16.

Statistical analyses

Data analysis was performed using SPSS 27.0 and AMOS 26.0. The overall and dimensional Cronbach’s alpha coefficients of the questionnaire, along with the Kaiser-Meyer-Olkin (KMO) measure, were calculated to assess reliability and sampling adequacy. Descriptive statistics for demographic data and dimension scores were reported. For normally distributed data, means and standard deviations were used, while medians and percentiles were used for non-normally distributed data. Categorical demographic data were expressed as counts and percentages (n (%)). Comparative analyses utilized t-tests for normally distributed continuous variables between two groups, and the Wilcoxon-Mann-Whitney test for non-normally distributed data. For three or more groups, ANOVA and the Kruskal-Wallis test were applied based on the distribution and variance homogeneity. Correlation analyses were conducted using Pearson’s or Spearman’s coefficients depending on data normality. Univariate and multivariate regression analyses explored relationships between demographic data and dimension scores, with inclusion criteria of P < 0.1 and P < 0.25 in the univariate analysis for multivariate regression. Exploratory factor and path analyses were used to examine correlations within the KAP dimensions and relationships with baseline variables, considering results with a P-value of less than 0.05 as statistically significant.

Results

A total of 515 samples were obtained, and the following data were excluded: (1) 2 cases disagreed with this study; (2) 13 cases had answer times less than 66 s or greater than 1800 s; (3) 38 cases with IP duplication; (4) 11 cases with all answers consistent in the same dimension. Finally, 451 valid questionnaires were obtained. The Cronbach’s α coefficient of the questionnaire items in this study was 0.738. The KMO coefficient was 0.834, indicating good internal consistency. Out of 451 participants, 171 (37.92%) were aged 20–29 years, 245 (54.32%) were female, 304 (67.41%) had Bachelor’s Degree, 433 (84.74%) were nurses, 189 (41.91%) were working for more than 10 years, and 308 (68.29%) were working in the emergency department. The median (P25-P75) knowledge, attitude, and practice scores were 12 (10–12) (possible range: 0–14), 19 (17–21) (possible range: 8–40), and 25 (21–31) (possible range: 9–45), respectively. Analyses of demographic characteristics found that the knowledge scores varied from participants with different education (P = 0.032) and occupation (P < 0.001). As for the attitude score, there were difference among those with different length of employment (P = 0.028) and type of workplace (P = 0.007). The difference of practice score were found among those with different age (P < 0.001), gender (P = 0.014), occupation (P < 0.001), professional title (P = 0.032), and length of employment (P = 0.036) (Table 1).

Table 1 Baseline Characteristics.
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The distribution of knowledge dimensions shown that the three questions with the highest number of participants choosing the “Uncertain” option were “Currently, PoCUS can be applied remotely.” (K3) with 30.82%, “Diagnostic and therapeutic consultation ultrasound examinations should not be considered as supplements to PoCUS.” (K4) with 29.05%, and “Monitoring with PoCUS requires repeated examinations and the use of semi-quantitative or quantitative methods when appropriate.” (K5) with 21.51% (Fig. 1).

Fig. 1
figure 1

Knowledge dimension answer distribution.

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Responses to attitudes showed that 39.47% strongly agreed that the PoCUS skills required by emergency physicians are different, making it difficult for training mentors to cover all aspects (A3), 39.02% strongly agreed that a single-course PoCUS training may not be able to adapt to the complexities of clinical rotations (A5), and 49.45% strongly agreed that compared to online free emergency and critical care ultrasound training courses, they prefer to attend offline small-group courses (A8) Fig. 2).

Fig. 2
figure 2

Attitude dimension answer distribution.

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Responses to practice showed that 19.96% reported that it was almost not likely for them to use PoCUS as a decision-making tool for diagnosis (P1), 52.33% had hardly ever practiced PoCUS in the past 1 year (P2), and 21.95% hardly reviewed and updated their knowledge and skills related to bedside ultrasound examinations (P7) (Fig. 3).

Fig. 3
figure 3

Practice dimension answer distribution.

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In the correlation analysis, significant positive correlations were found between knowledge and attitude (r = 0.180, P < 0.001), knowledge and practice (r = 0.257, P < 0.001), as well as attitude and practice (r = 0.211, P < 0.001), respectively (Table 2).

Table 2 Correlation analysis.
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Multivariate logistic regression showed that with senior professional title (OR = 2.509, 95% CI: [1.029–6.120], P = 0.043) and working in secondary hospital (OR = 6.263, 95% CI: [1.134–34.610], P = 0.035) were independently associated with good knowledge (Table S1.1). Meanwhile, total knowledge score (OR = 1.234, 95% CI: [1.109–1.373], P < 0.001), with junior professional title (OR = 0.466, 95% CI: [0.234–0.929], P = 0.030), with intermediate professional title (OR = 0.328, 95% CI: [0.129–0.837], P = 0.020), with deputy senior professional title (OR = 0.252, 95% CI: [0.077–0.826], P = 0.023), and with senior professional title (OR = 0.241, 95% CI: [0.062–0.934], P = 0.040) were independently associated with attitude (Table S1.2). Furthermore, total knowledge score (OR = 1.259, 95% CI: [1.121–1.413], P < 0.001), total attitude score (OR = 1.168, 95% CI: [1.064–1.283], P = 0.001), and being nurse (OR = 0.490, 95% CI: [0.262–0.915], P = 0.025) were independently associated with practice (Table S1.3).

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.934, indicating that a substantial portion of the variance may be caused by the underlying factors, thus confirming the suitability of the data for factor analysis. Bartlett’s test of sphericity was significant (p = 0.000), supporting the factorial nature of the correlation matrix (Table S2).

The fit indices of the SEM model reached the desired range, indicating good model fit results (Table S3), the results showed that knowledge (β = 0.197, P = 0.009) and professional title (β = -0.127, P = 0.012) directly affected attitude. Knowledge (β = 0.194, P = 0.003), attitude (β = 0.181, P = 0.012), and occupation (β = -0.122, P = 0.020) have a direct effect on practice. Also, knowledge has an indirect effect on practice through attitude (β = 0.036, P = 0.003) (Table S4 and Fig. 4).

Fig. 4
figure 4

SEM Path. All variables are observation variables. The direction of causality is indicated by a single-headed arrow. The standardized path coefficients are shown next to the arrows.

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Discussion

Healthcare providers in the ICUs and emergency departments demonstrated adequate knowledge, negative attitudes, and inactive practices regarding bedside ultrasonography, indicating disparities between knowledge acquisition and its practical application in clinical settings. Given the identified gaps between knowledge, attitudes, and practices, targeted educational interventions and practice drills should be implemented to enhance the clinical application of bedside ultrasonography among ICUs and emergency departments healthcare providers.

Notably, the analysis revealed several significant differences in KAP across demographic and professional factors, while practices varied notably with age and occupation, a finding supported by the results of the multivariate logistic regression. Particularly, older healthcare providers and doctors exhibited better practice scores, potentially reflecting greater clinical experience and direct usage of ultrasonography, aligning with studies suggesting experience enhances procedural skills17,18.

Significant associations were identified between higher educational levels and knowledge, where those with a Bachelor’s degree or higher exhibited higher knowledge scores. This trend is reinforced by multivariate logistic regression results showing that professionals at higher career levels and those working in secondary hospitals had significantly better knowledge, possibly due to advanced educational settings providing more comprehensive ultrasonography training or a greater emphasis on ultrasonography in their roles19,20.

Significant differences were evident in practice scores between doctors and nurses, with doctors performing better. This might be explained by the nature of their job roles, where doctors are likely more frequently required to utilize ultrasonography directly compared to nurses. Besides, the results indicated no significant differences in practice related to professional titles, suggesting that holding a higher title does not necessarily equate to better practical skills in ultrasonography within the clinical setting. This could be attributed to the fact that advanced titles often come with increased administrative or teaching responsibilities that might limit hands-on clinical practice21,22.

Regarding the relationships among KAP, both correlation analyses and SEM confirmed significant positive relationships between knowledge and both attitude and practice, with knowledge also indirectly affecting practice through attitude. These interdependencies highlight the critical role of knowledge as a cornerstone for improving attitudes and practices, supported by previous research indicating that increased awareness and understanding can lead to more positive attitudes and diligent practices23. Interestingly, despite the correlation, there was a notable disconnect in the translation of positive attitudes into active practices, which might be explained by systemic barriers or insufficient hands-on training, suggesting that merely improving attitudes is not sufficient without simultaneous enhancements in practical training environments.

The general knowledge level among ICUs and emergency departments healthcare providers regarding Point-of-Care Ultrasound (PoCUS) is relatively high, particularly in recognizing its applicability across various specialties and the need for dynamic, real-time examinations. However, misconceptions about PoCUS’s capabilities, such as its use in remote applications and its role in diagnostic and therapeutic settings, suggest gaps in foundational understanding. To address these knowledge gaps, specific recommendations include the development of comprehensive curricula that integrate PoCUS into medical education at an early stage, focusing on its broad applications and critical role in modern diagnostics24,25,26. Furthermore, continuous professional development courses could be designed to update healthcare providers regularly about the evolving technologies and methods in PoCUS27.

Attitudes towards PoCUS are mixed, with a notable portion of staff uncertain about the feasibility of mastering PoCUS skills within 3–6 months and expressing concerns over the adequacy of hospital-initiated programs. To cultivate a more positive attitude, targeted interventions such as mentoring programs could be implemented, where experienced practitioners guide newer staff through hands-on practice and real-life scenarios. Additionally, enhancing hospital support for PoCUS, including addressing administrative issues like billing, would likely improve staff attitudes. Offering a mix of online and offline training options, tailored to individual learning preferences, can also make training more accessible and appealing28,29.

Practice levels show significant variability, with many providers using PoCUS only occasionally or sometimes. Practice can be specifically improved by instituting regular, mandatory simulation sessions that encourage routine use of PoCUS and build procedural confidence. Establishing standard operating procedures and guidelines for PoCUS use in clinical settings can also standardize practices and ensure consistency across the board. Collaboration among medical staff during PoCUS procedures should be encouraged through team-based training sessions, which not only improve skill levels but also foster a collaborative environment conducive to shared learning and experience exchange30,31.

In order to place our findings in a broader context, we compared them with results from similar studies conducted in diverse geographical and cultural settings, including North America, Europe, and other regions. These studies consistently reported adequate knowledge of POCUS among healthcare providers, but variations in attitudes and utilization patterns were observed, which may be influenced by differences in healthcare systems, training structures, and resource availability. For instance, a North American survey of hospital-based practicing internists across six institutions reported favorable attitudes toward POCUS but identified barriers such as lack of training, limited handheld devices, insufficient supervision, time constraints, and inadequate quality assurance processes32. Similarly, a mixed-methods study in Asian primary care physicians highlighted moderate knowledge and positive attitudes but persistent practical barriers including limited device access and insufficient clinical support33. In Europe, a cross-sectional study among pediatricians in Poland found low self-assessed competencies and infrequent routine use of POCUS, largely attributed to lack of formal training and institutional support34. This comparison underscores both the universal challenges in POCUS adoption, such as training gaps and resource limitations, and the context-specific factors that may shape its application in clinical practice.

To enhance the practical application of POCUS, it is crucial to leverage standardized evaluation schemes such as topographic approaches, stepwise assessment protocols, and numerical scoring systems. Well-established examples include the Rapid Ultrasound in Shock (RUSH) protocol, the Bedside Lung Ultrasound in Emergency (BLUE) protocol, and the Fluid Administration Limited by Lung Sonography (FALLS) protocol. These frameworks provide clinicians with a structured, step-by-step approach to performing and interpreting POCUS examinations, which can enhance diagnostic consistency, facilitate clear communication among care teams, and ensure that serial examinations are comparable and reliable. Incorporating such standardized schemes into training and routine practice could improve the robustness and interpretability of POCUS findings in both ICU and emergency settings.

Limitations

This study has several limitations that should be considered. First, its cross-sectional design limits the ability to infer causality between the knowledge, attitudes, and practices of healthcare providers. Second, the study was conducted using a convenience sampling approach, which, although it included participants from 20 hospitals (6 tertiary and 14 secondary) across multiple regions in Xinjiang, may not fully represent all healthcare providers in the region. Future multi-center studies with stratified sampling could enhance the generalizability of the findings. Third, while both physicians and nurses were included as healthcare providers in this study—reflecting their respective roles in PoCUS implementation—the proportion of nurses in our sample was relatively high, which may have influenced the overall results. Fourth, the reliance on self-reported questionnaires might introduce response bias, as participants could overestimate their knowledge or underreport negative attitudes and practices.

Conclusions

In conclusion, this study reveals that while healthcare providers in the ICUs and emergency departments exhibit adequate knowledge of PoCUS, their attitudes towards its use are somewhat negative, and their practices remain less active than expected. To bridge the gap between knowledge and practice, and improve attitudes towards PoCUS, targeted educational programs and practical training workshops should be implemented. These initiatives could emphasize the clinical benefits and applicability of ultrasonography, encouraging more proactive utilization by ICUs and emergency departments staff.