The Mediating Role of Self‐Efficacy in the Relationship Between Knowledge and Palliative Care Practices Among ICU Nurses in Timor‐Leste: A Cross‐Sectional Study

BACKGROUND: Access to palliative care remains limited in low- and middle-income countries, including Timor-Leste, where healthcare systems face structural and resource constraints. In intensive care units (ICUs), nurses play a critical role in delivering PC. However, the translation of knowledge into clinical practice remains inconsistent. Self-efficacy has been proposed as a key psychological mechanism that may bridge this gap. PURPOSE: This study aimed to examine the mediating role of self-efficacy in the relationship between knowledge and palliative care practices among ICU nurses in Timor-Leste. METHODS: A cross-sectional study was conducted among 107 ICU nurses. Data were collected using convenience sampling with validated instruments: the Palliative Care Knowledge Test (PCKT), the Self-Efficacy in Palliative Care Scale (PCSE-S), and the Palliative Care Self-Reported Practices Scale (PCPS). Rasch analysis was applied to transform ordinal data into interval-level measures. Pearson correlation and regression-based mediation analyses were performed using Jamovi. RESULTS: A total of 107 ICU nurses participated in this study. The mean Rasch person measures were 0.515 (SD = 0.985) for palliative care practice, 0.136 (SD = 1.210) for self-efficacy, and -2.623 (SD = 0.973) for knowledge. Knowledge was significantly associated with self-efficacy (β = 0.316, p < 0.001), while self-efficacy was significantly associated with palliative care practice (β = 0.514, p < 0.001). In contrast, knowledge was not directly associated with palliative care practice (β = 0.0002, p = 0.998). Mediation analysis using bias-corrected bootstrap confidence intervals demonstrated a significant indirect effect of knowledge on palliative care practice through self-efficacy (β = 0.163, p = 0.003, 95% BC CI [0.0548, 0.365]), indicating that self-efficacy significantly mediated the relationship between knowledge and palliative care practice. CONCLUSION: Self-efficacy may represent an important pathway linking palliative care knowledge with practice among ICU nurses. Interventions may consider strengthening both palliative care knowledge and self-efficacy, particularly in resource-limited ICU settings. IMPLICATIONS FOR NURSING: Nursing education and clinical practice should incorporate strategies that strengthen nurses' self-efficacy alongside palliative care knowledge. Practice-based training, simulation, clinical mentoring, and supportive supervision may help nurses apply their knowledge more confidently in palliative care delivery, particularly in resource-limited ICU settings.