Knowledge, attitudes, and behaviors questionnaire on environmental sustainability in intensive care unit (KABQES-ICU): Validity and reliability study

Introduction: Intensive care units (ICUs) are among the most resource-intensive clinical settings, contributing substantially to healthcare-related environmental impacts. Although nurses play a central role in shaping sustainable clinical practice, no validated instruments currently exist to comprehensively assess knowledge, behaviors, and perceived barriers related to environmental sustainability in ICU settings. Aim: To develop and psychometrically validate the Knowledge, Attitudes, and Behaviors Questionnaire on Environmental Sustainability in Intensive Care Units (KABQES-ICU) for use among ICU nurses. Methods: A multicentre, cross-sectional study was conducted among Italian ICU nurses using an online survey. Item generation was theory-driven, informed by a prior content analysis and the M-COM-B behavioral model, and refined through expert review and pilot testing. Psychometric evaluation included exploratory factor analysis (EFA), confirmatory factor analysis (CFA) using WLSMV estimation, and assessment of internal consistency, composite reliability, and convergent and discriminant validity. Results: Data from 278 nurses were analysed. EFA supported a five-factor structure encompassing climate change knowledge, home-based sustainability behaviors, work-based sustainability behaviors, workload and time-pressure barriers, and organizational infrastructure barriers, explaining 58.9% of total variance. CFA confirmed excellent model fit (CFI = 0.932–0.944; TLI = 0.925–0.937; RMSEA = 0.059–0.064). Internal consistency was satisfactory across all domains (Cronbach's α = 0.74–0.86; composite reliability >0.78). Factorial distinctiveness was supported, despite marginal convergent validity for selected behavioral domains. Conclusion: The KABQES-ICU is a conceptually robust and psychometrically sound instrument for assessing sustainability-related knowledge, behaviors, and barriers among ICU nurses. Implications for Clinical Practice.: The KABQES-ICU enables systematic identification of educational, organizational, and structural needs, supporting the design of targeted interventions to integrate environmental sustainability into routine intensive care practice without compromising patient safety.