Globally, the incidences of life-limiting diseases such as cancer are increasing. It was estimated that from 2008 to 2030, increases of 100% and 81% in the incidence of cancer will be observed by low and medium Human Development Index countries, respectively.1 In Saudi Arabia, 15 807 new cases of cancer were recorded by the Saudi Cancer Registry in 2014.2 By 2030, the number of cancer patients is expected to rise 8- and 10-fold among females and males in the country, respectively.3 A previous study showed that the emotional functioning of cancer patients is closely associated with their satisfaction toward palliative care. The study suggested the need for health care workers to provide adequate psychosocial support to cancer patients in Saudi Arabia during palliative care.4 Furthermore, noncancer diseases, such as sickle cell disease, peripheral arterial disease, and advanced liver and kidney diseases, are also prevalent in the country, which prompt the need for palliative care.5 Thus, the demand for palliative care in the country increases owing to the aging population and increasing complexity of medical illnesses.
Palliative care is an approach for improving the quality of life of patients with a life-threatening illness and their family mostly by alleviating suffering through the early identification, assessment, and treatment of pain and other problems.6 Interventions in palliative care cover the physical, psychosocial, and spiritual aspects. The guidelines for quality palliative care released by the National Quality Forum state that the goals are to provide patients relief from suffering and to promote excellent quality of life for patients and their families.7
The role of nurses in palliative care is critical as they spend considerable time with patients and families, especially those who need palliative care.8 Thus, nurses are expected to provide palliative care on the basis of the scope of their practice. In Saudi Arabia, palliative care is continually growing as authorities respond to increasing prevalence of cancer and other life-limiting diseases in the country. The need for palliative care is essential as most cancer cases in Saudi Arabia are already in the advanced stage and often incurable when diagnosed.3 Palliative care in Saudi Arabia is still at its infancy stage and is not widely known by patients and even medical professionals despite the developments in the field of medicine. High-quality health care services in the kingdom, especially palliative care, have not been fully implemented in health care facilities.4 Several issues, such as the strict policies on the use of pain medications, poor awareness of the public regarding palliative care, and the location of the health care facilities equipped to deliver palliative care are far from each other, challenge the advancement of palliative care specialty in the country.3 Furthermore, the nursing workforce in the country is multicultural. Approximately 63.5% of the total 180 821 nurses working in the country in 2016 are expatriate nurses from Asian, European, and other Arab countries, whereas only 36.5% are Saudi nationals.9 This situation may have an implication of the practice of palliative care in the country.
Several studies had been conducted to evaluate the palliative care knowledge of nurses. Studies conducted among nurses in Jordan,10 India,11 and Iran12 reported low levels of palliative care knowledge among nurses, whereas studies conducted in Ireland,13 Australia,14 and Spain15 showed moderate levels of knowledge. However, few studies evaluated the knowledge of nurses regarding palliative care, especially that of nurses in Saudi Arabia, where the nursing workforce has multicultural background and the nursing profession is at the early stages of development. Literature about palliative care competencies of nurses in Saudi Arabia remains extremely limited despite the multicultural backgrounds and varying educational foundations of nurses working in the country. Therefore, this study assessed the palliative care knowledge of nurses working in 2 hospitals in Saudi Arabia.
This cross-sectional study was conducted in 2 hospitals in Riyadh, Saudi Arabia. The total population of nurses in the 2 hospitals was 2659. The sample size was calculated using the Survey Monkey sample size calculator. The computed required sample size was 336 nurses at 95% confidence interval and 5% margin of error. Eligible nurses were currently employed in either of the 2 hospitals, who had practiced nursing for more than a year regardless of nationality, and who can read, understand, and write in English. To ensure the achievement of the required sample size, 450 questionnaires were distributed through the convenience sampling technique. A total of 365 questionnaires were returned, providing a response rate of 81.1%.
A survey was used for collecting data from the respondents. Demographic data, including age, gender, years in the nursing profession, area of practice, and whether palliative care education was received 6 months before the study, were collected.
The Palliative Care Quiz for Nursing (PCQN), which was developed for the assessment of the palliative care knowledge of nurses, was used in this study.16 The PCQN presents 20 questions with response options of “true,” “false,” or “don’t know.” The tool has 3 domains, namely, “philosophy and principles of palliative care” (items 1, 9, 12, and 17; possible score range, 0-4), “pain and symptom management” (items 2, 3, 4, 6, 7, 8, 10, 13, 14, 15, 16, 18, and 20; possible score range, 0-13), and “psychosocial and spiritual care” (items 5, 11, and 19; possible score range, 0-3). Scores were obtained by adding the number of correct answers in the quiz (range, 0-20). High score implies high level of knowledge. An acceptable Cronbach’s α of .78 and a correlation coefficient (r) of 0.56 on a test-retest ascertained its reliability.16 The English version of the tool was utilized in this study because English is the medium of communication in the 2 hospitals.
Ethical Consideration and Data Collection
The study was part of the protocol approved by the King Saud University College of Medicine (project no.: E-17-2633). Data collection was performed from November to December 2017. The researcher coordinated with the nursing office of each hospital to obtain the schedule of the nurses for the entire month. The researcher approached the nurses during their break times for recruitment. Adequate information about the study, including the purpose of the study, expected participation of the nurses, potential risks and benefits of participation, voluntary participation, their right to withdraw participation, and protection of their confidentiality, was explained to each prospect participant. Those who agreed to participate were asked to sign an informed consent. Researcher gave them the questionnaire with an envelope to return the survey.
All statistical analyses were performed using the statistical software SPSS version 22.0 (IBM Corp, Armonk, New York). Mean, SD, frequency count, and percentage were obtained for the characterization of demographics of the respondents. Mean and SD were calculated for palliative care knowledge. Ranking was conducted on the items of the PCQN. Parametric analyses, such as t test, 1-way analysis of variance with post hoc Tukey honestly significant difference test, and Pearson product moment correlation, were performed for the examination of the association between the nurses’ demographics and their palliative care knowledge. A standard multivariate linear regression was performed for the examination of the significant demographic predictors of palliative care.
Of the 365 nurses, 182 nurses were working in the private hospital, and 183 nurses were employed in the public hospital. The majority of the respondents were female (71.5%) and bachelor of science in nursing degree holder (51.2%) and had received palliative care training or seminar in the last 6 months (66.0%). The respondents were working in various practice areas, with medical ward (30.1%) and surgical ward (35.6%) having the highest proportions; 33.4%, 43.8%, 19.7%, and 3.0% of the nurses were younger than 30, 30 to 39, 40 to 49, and older than 50 years. The mean years of experience as a nurse was 8.24 (SD, 6.82; range, 1-31 years; Table 1).
Palliative Care Knowledge of Nurses
The mean score of the respondents in the PCQN was 8.88 (SD, 1.75), with scores ranging from 0 to 14. Only 42 respondents (11.5%) scored higher than the midpoint of 10. As reflected in Table 2, item 18, “Manifestations of chronic pain are different from those of acute pain,” received the highest number of correct answer (89.0%), followed by item 8, “Individuals who are taking opioids should also follow a bowel regimen (laxative treatment)” (84.1%); item 4, “During the last days of life, drowsiness associated with electrolyte imbalance may decrease the need for sedation” (83.3%), and item 2, “Morphine is the standard used to compare the analgesic effect of other opioids” (78.6%). Item 5, “It is crucial for family members to remain at the bedside until death occurs,” received the lowest correct responses (6.6%), followed by item 7, “Drug addiction is a major problem when morphine is used on a long-term basis for the management of pain” (6.8%), and item 19, “The loss of a distant and contentious relationship is easier to resolve than the loss of one that is close or intimate” (8.8%).
In terms of the dimensions of the scale, 9 of the 13 items in the category pain and symptom management were answered correctly by the majority of the respondents (range, 58.1%-89.0%), whereas only 1 from the 4 items of the category philosophy and principles of palliative care was answered correctly by the majority of the respondents. On the other hand, the items in the psychosocial and spiritual care category were answered incorrectly by the majority of the respondents (range, 78.6%-93.4%). The mean score in the philosophy and principles of palliative care was 1.15 (SD, 0.78; range, 0-4), whereas the mean scores in pain and symptom management and psychosocial and spiritual care were 7.36 (SD, 1.58; range, 0-12) and 0.37 (SD, 0.61; range, 0-3), respectively.
The statistical analyses revealed that nurses who were working in the public hospital (mean, 9.07 [SD, 2.05]) exhibited higher knowledge on palliative care compared with nurses in the private hospital (mean, 8.68 [SD, 1.36]; t = −2.14; P = .033). Nurses who were younger than 30 years (mean, 8.62 [SD, 1.70]) had significantly lower knowledge compared with nurses in the 40- to 49-year range (mean, 9.44 [SD, 1.98]; P = .008). Nurses who received palliative care education in the last 6 months (mean, 9.14 [SD, 1.71]) manifested significantly higher knowledge than did nurses who did not (mean, 8.37 [SD, 1.73]; t = −4.04, P < .001).
Demographic Factors Influencing the Nurses’ Palliative Care Knowledge
The respondents’ demographics were entered into a regression analysis for the prediction of palliative care knowledge. The regression model was statistically significant (F14,350 = 5.29, P < .001), accounting for approximately 14.2% variance in palliative care knowledge (R2 = 0.175, adjusted R2 = 0.142). Only type of hospital, age, and attendance to palliative care education in the last 6 months were revealed as significant factors that influence the nurses’ knowledge on palliative care. Specifically, the mean score of the nurses in the public hospital in the PCQN was 1.38 higher (P < .001; 95% confidence interval [CI], 0.79-1.96) than that of the private hospital nurses. The PCQN mean score of nurses who were in the 40- to 49-year range exceeded those of nurses who were <30 years old by 0.83 points (P = .013; 95% CI, 0.18-1.48). Moreover, nurses who received palliative care education in the last 6 months had 1.65 points (P < .001; 95% CI, 1.16-2.15) higher in their PCQN mean score compared with nurses who did not.
In this study, the palliative care knowledge among nurses in Saudi Arabia was assessed, and the demographic factors influencing such knowledge were explored. The results indicated that the palliative care knowledge of the nurses was extremely low, and some of the demographic characteristics of the respondents were associated with and significantly influenced the knowledge of the nurses.
The inadequacy of palliative care knowledge among nurses reported in this study is at the same low level as those reported in previous studies among nurses in Jordan (mean, 8.30),10 India (mean, 7.16),11 and Iran12 (mean, 7.59) but lower than those reported among nurses in Ireland (mean, 11.80),13 Australia (mean, 11.70),14 and Spain (mean, 10.8).15 The current findings also reflect the poor knowledge of the nurses in the philosophy and principles of palliative care, in pain and symptom management, and in the psychosocial and spiritual aspects of palliative care. Notably, although most items in the pain and symptom management dimension received correct responses from the majority of the nurses in this study, the mean score was still considered low. This result is similar to the findings among nurses in Jordan.10 Furthermore, the results also indicate misconceptions in 10 items in the scale. For example, 93.4% of the surveyed nurses thought that family members must remain at the bedside until death occurs, and 93.2% thought that drug addiction is a major problem when morphine is used on a long-term basis for pain management.
Moreover, approximately 92.1% of the nurses believed that the loss of a distant and contentious relationship is easier to resolve than the loss of one that is close or intimate. Based on the ranking of the items of the study, the nurses had the lowest knowledge on the items related to psychosocial and spiritual care category, which is similar to the results reported in the study conducted in Spain.15 Despite the strong spirituality connected with Saudi Arabia, being the center of Muslim faith, some studies have reported the poor spiritual aspect of care among nurses in the country.17,18 These outcomes can be attributed to the insufficient curricular content related to spiritual care in the nursing curricula of the country.17 Moreover, the majority of the nurses working in the country were from other countries, such as the Philippines and India, which have different cultures, traditions, religions, and beliefs.19 These differences may have an implication on how they can provide competent spiritual care to patients. Perhaps appropriately addressing the various spiritual backgrounds of the nurses and patients, as well as providing interventions to improve the spiritual care competencies of nurses, is critical most specially among non-Muslim and non-Arab nurses.
The low knowledge on palliative care among nurses in this study reflects the current status of palliative care in the country. Despite the efforts of the Ministry of Health of the country and health care facilities in developing the palliative aspect of care in the countries, various challenges continuously hinder the progress of this area. Since the start of palliative care services in the country 2 decades ago, its development has been slowed down by several challenges, such as unavailability of services related to palliative care, absence of policy related to opioid availability, and poor public awareness of palliative care services.3 Another plausible explanation of the low palliative care knowledge of the nurses in this study is the inadequate curricular content related to palliative care in the nursing curricula. A previous study conducted among nursing students in Saudi Arabia reported a lower level of palliative care knowledge (mean, 7.30) compared with the current finding.20 Furthermore, the focus of nursing education is largely on biomedical care models, hence leaving some aspects of life behind. Although the curricular content was not explored in this study, previous studies reported that nursing schools provide inadequate palliative care education among nursing students.21,22 It was recommended that investing on palliative care education among health care workers is critical and should be done in Saudi Arabia for the improvement of palliative care in the country.3
Nurses who were working in the public hospital had higher palliative care knowledge than did the private hospital nurses. This finding cannot be compared with other studies owing to the lack of literature comparing palliative care knowledge between nurses working in public and private hospitals. However, some studies reported the gaps regarding the quality of care provided by nurses in different types of hospitals. For instance, in a study conducted in Iran, which compared the quality of nursing services provided by a private and a public hospital, nurses in public hospitals demonstrated higher levels of nursing skills and other quality nursing service indicators than did nurses in private hospitals.23 The higher knowledge of palliative care among nurses in public hospitals might be attributed to the abundant opportunities of continuing professional development provided by the Ministry of Health. Furthermore, the government is investing huge budgets for government hospitals for the improvement of the quality of health care services they provide, and issues regarding hospital resources, including educational resources, have not been observed in these hospitals.24 Nonetheless, future studies should examine the factors associated with the difference in palliative care knowledge between types of hospitals.
Furthermore, receiving palliative care education in the last 6 months seemed to positively impact the palliative care knowledge among nurses. Similar finding was reported in a previous study.14 The benefits of attending palliative care education on knowledge, attitudes, beliefs, and practices of nurses and other health care professionals have been studied. For example, a multicenter study of intensive care unit nurses reported the improvement of palliative care skills of nurses who underwent palliative care training. Moreover, nurses’ ability to assess and identify patient needs related to palliative care and their competence in creating nursing care plans for patients requiring palliative care were significantly enhanced after the training.25 Another study conducted among nurses in Spain reported that nurses who had educational background in palliative nursing had better palliative care knowledge than did those without similar experience.26 Therefore, palliative care education of nurses is an invaluable tool in improving not only the knowledge of nurses but also their attitudes and competency in providing palliative nursing care.
Despite the valuable contributions of this study, several limitations are acknowledged. First, the use of convenience sampling may have implications for the generalizability of the findings. Hence, careful interpretation of the findings is necessary. Second, the study is conducted in only 1 private and 1 public hospital. Future studies should include wider settings for the validation of the current findings. Third, the cultural backgrounds of the nurses were not considered in the study. Considering the multicultural nature of health care facilities in the country, exploring the impacts of multicultural backgrounds of nurses on their knowledge is of great importance. Fourth, the contents covered in the palliative training/seminars attended by the respondents in this survey were not explored. This might have given a more meaningful interpretation as to why nurses who attended these activities had significantly higher knowledge compared with those who did not have similar experience. Future studies may explore this variable in relation to palliative care knowledge to better understand their relationship.
The findings provided a valuable overview of the status of palliative care in the country. The nurses’ poor knowledge is alarming and needs intervention. Continuing education on palliative care should be implemented by hospital administrations in the country, and palliative care education should target the weakness of the nurses, especially those revealed in the study, such as on the psychosocial and spiritual care, some aspects of pain and symptom management, and philosophy and principles of palliative care. Constant coaching of the nurses’ progress in terms of palliative care should be conducted by nurse managers. The findings have also implication to nursing education. Nursing education should also strengthen its curriculum by integrating concepts regarding palliative care. Palliative care should also be reinforced in the clinical practice such that gaps between classroom and clinical learning are addressed and the development of palliative care competency of future nurses is ensured.
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