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Assessment of the Educational and Health Care System–Related Issues From Physicians' and Nurses' Perspectives Before Developing a Palliative Care Program Within the Palestinian Health Care System

A Cross-sectional Study

Abu-Odah, Hammoda PhD, RN; Molassiotis, Alex PhD, RN; Liu, Justina Yat Wa PhD, RN

Author Information
Journal of Hospice & Palliative Nursing: June 2022 - Volume 24 - Issue 3 - p E59-E75
doi: 10.1097/NJH.0000000000000840
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Education of health care professionals (HCPs) is considered one of the primary constructs of the World Health Organization (WHO) public health strategy that offers the best approach for integrating palliative care (PC) within a country's health care system (HCS).1 According to the World Health Assembly, it is vital to incorporate content related to PC into educational programs.2 It positively impacts HCPs' knowledge, attitudes, and skills, which acts as a foundation for improving PC services.3,4 Professional knowledge and attitudes are also key factors affecting the successful provision of PC services.4,5 In contrast, insufficient knowledge and negative attitudes about PC may interfere with the professionals' relationship with patients and with referring patients to services.6

Health care professionals play a pivotal role in palliative and end-of-life care (EoLC).7 They are responsible for delivering PC services.8 Physicians and nurses are the 2 leading valuable PC team members responsible for addressing patients' needs.8 They spend most of their time developing a care plan to support patients and their families as well as actively participating in the decision-making process.9 Evidence, however, has portrayed unpreparedness or the inability of physicians and nurses to provide appropriate PC, which might be related to educational-related issues such as inadequacies in education, training, and negative attitudes of professionals about caring for the dying.4 Other evidence has demonstrated that HCS-related issues (ie, unavailability of resources and services) may play a role in the inability of HCPs to deliver appropriate PC services.10,11 For instance, limited physical infrastructures, such as buildings, equipment, supplies, and beds were significant barriers to delivering PC.10 Lack of a comfortable and private space can impact on professionals' ability to interact and communicate efficiently with patients and their families.11 Thus, educational and HCS-related issues need to be assessed before developing a PC program within a country's HCSs.4,12 Such gained information can also help evaluate learning needs, refine services, and develop educational intervention programs for HCPs.

Several studies have been conducted to assess educational and HCS-related issues13,14; however, a paucity in research conducted in the Middle East is reported,5,13 as this region comprises a wide range of economically diverse countries. Some Middle Eastern countries experience financial constraints and low resources, with little or no cancer treatment capabilities,15 whereas others are advanced economy countries with high-level of cancer care provided to communities.2 These countries differ from one with other regard to wealth, health insurance coverage, health expenditures, availability of treatments, quality of services, workforce, and PC availability in the HCS. Further to that, large differences in population size,16 sociocultural aspects, and religion play a significant role in deciding on the PC approach. There are also differences regarding HCSs concerning professional education, and HCP responsibilities, and roles. These factors should be considered and explicitly collected for countries with no PC introduced into their HCSs.

Palestine is a country that has not streamlined PC services into its HCS. It differs from other countries as it experiences a significant increase in cancer diagnosis, population density, economic and finance constrains shortage of drugs, and a fragmented HCS.17 This study aimed to assess the educational and HCS-related issues that physicians and nurses may face, before developing a PC program into the existing HCS. This creates a clear gap and raises concerns to this research area. Knowing the gap is vital for developing an intervention to improve the quality of health services provided to patients and the provision of PC services into the HCS.


Study Design

A cross-sectional quantitative study design was adopted in this study.


This study was carried out in the medical and oncology departments at the 2 leading hospitals in the Gaza Strip–Palestine (Al-Shifa Hospital and the European Gaza Hospital), where cancer patients are more likely to be treated and receive follow-up care.18

Characteristics of Study Participants and Sample Size Calculation

A convenience sample of physicians' and nurses working in the medical and oncology departments of the 2 leading hospitals in the Gaza Strip was invited to participate in this study. Participants were eligible if they were working at one of the aforementioned 2 hospitals. Participants who were working at medical and oncology departments were included in this study where cancer patients are more likely to be treated, and follow-up care is provided. Physicians and nurses were excluded if they were working at other governmental and nongovernmental hospitals because these hospitals do not provide services and care to cancer patients.

The Thompson equation was utilized for calculating sample size, where N = population size (335), Z = confidence level (95%), d = error proportion (0.05), and P = probability (50%). The sample size was calculated to be 160 participants. This was increased to 176 participants to compensate for nonrespondents, where the average nonresponse rate was reported as 10% in a recent Palestinian study.19 The sampling was done proportionally according to their respective populations (nurses and physicians') in each hospital.

Instruments Utilized in This Study

Knowledge About PC

The Palliative Care Knowledge Test (PCKT)20 was adopted to assess participants' knowledge of PC. In this study, based on the health expert panel opinion, 3 questions (Q4, Q6, Q12) of the PCKT were excluded because they were not practically applicable to the Palestinian context. For instance, “pentazocine” was not utilized in Gaza hospitals. For Q15, “Some dying patients will require continuous sedation to alleviate suffering,” the panel suggested to exclude it as it does not belong to the psychological subscale or transfer it to belong to pain subscale. The panel recommended adding more questions to the questionnaire to replace the excluded one. Three new items were added, which were selected based on previous literature. These items were as follows: (1) “Palliative care is exclusively for people who are in the last six months of life” (philosophy subscale),21 (2) “Palliative care is specifically for people with cancer” (philosophy subscale),21 and (3) “When cancer pain is mild, morphine should be used more often” (pain subscale).22 Thus, the modified version includes 20 items constructed into 5 subscales: philosophy (4 items), pain (6 items), dyspnea (3 items), psychiatric problems (3 items), and gastrointestinal problems (4 items). Each item has 3 answers (“correct,” “incorrect,” and “unsure”), and each professional chooses 1 answer. The correct answer was scored 1 point, whereas a zero point score was for an incorrect or unsure answer. The total score for all correct responses is 20. The score out of 20 was converted to a percentage, and the higher percentage reflects better knowledge of PC.

Attitudes Toward EoLC and Care of the Dying

Two instruments were adopted comprehensively to assess HCPs' attitudes. The Bradley Attitude Questionnaire23 was utilized to assess professionals' attitudes towards EoLC. It is a self-administered questionnaire that included 12 items; most of the items focused on PC's efficacy, with less emphasis on communication and professional responsibility. In this study, the panel suggested excluding the item “Hospice supports physician-assisted suicide” because it is not relevant to the Islamic culture. They also suggested replacing the term “hospice care” with “PC” to fit the study aims. Each item is ranked into 5 categories, where scores ranged from 5 (strongly agree) to 1 (strongly disagree). The mean scores were calculated, with a higher mean reflecting a more positive attitude towards EoLC.

The second instrument, Frommelt Attitudes Toward Care of the Dying (FATCOD Form B) Scale,24 was adopted to assess the influence of education on HCPs' attitudes towards caring for dying patients.14,25 The panel was satisfied with FATCOD version because it was previously utilized in Middle East countries. It comprises 30 items divided into 2 halves (15 items with contents about positive attitudes and 15 items with content on negative attitudes) using a 5-point Likert scale. The mean scores were calculated and converted to a percentage, and the higher percentage reflects a more positive attitude toward the care of the dying. Combining these 2 instruments is expected to provide a more comprehensive view of professionals' attitudes towards PC and issues related to care of the dying.

Resources About PC Services/Barriers

The PC Needs Assessment instrument was adopted to assess educational needs, availability of PC-related resources, and barriers to the provision of PC into the HCS.13 It is a comprehensive instrument using both quantitative and open-ended questions, covering the following areas: PC services available, satisfaction with and barriers to PC provision and service delivery, available resources, populations requiring assistance, educational program topics attended in the past 2 years, and preferred learning methods. The panel was satisfied with this version because it was previously utilized in Middle East countries.

Sociodemographic and Professional Characteristics

Sociodemographic characteristics included age, gender, and professional education. Health professionals' variables included profession (physician or nurse), rank/status (head, subhead, senior, staff), work setting (medical or oncology), years of experience, and previous experience in dealing with patients with advanced illness. Additional items related to PC training included the following questions: Did you receive training related to PC. If yes, what type of training did you receive? How long did you receive this training? Where did you receive the training?

Translation and Adaptation of the Instruments Utilized in This Study

The WHO STEPS (STEPwise approach to surveillance)26 was adopted for translation and adaptation of all aforementioned study instruments into Arabic. Forward translation and expert panel back-translation were applied to ensure the quality of translation. Pretesting was conducted on 15 representative target HCPs to test the final Arabic version and data collection procedure before the actual data collection. Item-level content validity index and average scale-level content validity index were adopted to evaluate the content of the Arabic version of questionnaires.27 Internal consistency (n = 30) was calculated using Cronbach α coefficient, and results showed acceptable reliability of all instruments (Table 1).

TABLE 1 - Instruments Used for Assessing Physicians' and Nurses' Perspectives
Name (Acronym)
Original Instrument Modified Arabic Version Scoring & Interpretation
Items and Domains Validity and Reliability Items and Domains Validity and Reliability
Palliative Care Knowledge Test (PCKT)33
Used for measuring the HCPs' knowledge regarding PC
20 items covering 5 domains:
philosophy (2 items), pain (6 items), dyspnea (4 items), psychiatric problems (4 items), and gastrointestinal problems (4 items)
A significant difference in the score for each domain
The κ coefficient was from 0.26 to 0.74
Intraclass correlation was 0.88
The Kuder-Richardson formula was 0.81
20 items covering 5 domains:
philosophy (4 items), pain (6 items), dyspnea (3 items), psychiatric problems (3 items), and gastrointestinal problems (4 items)
S-CVI/Ave = 0.83
S-CVI-UA = 0.80.
α coefficient was .81
The correct answer was scored 1 point
A total score for all correct responses is 20
Total scores were converted to a percentage, and a higher percentage reflects a good knowledge
The Bradley Attitude Questionnaire36
Used for measuring HCPs' attitudes toward EoLC
12 items The overall intraclass r coefficient was 0.86
Weighted κ coefficients >0.60
11 items Validity
S-CVI/Ave = 0.91
S-CVI-UA = 0.91
α coefficient was .63
Likert scale (1-5)
Mean scores
The higher mean reflects a more positive attitude
Frommelt's Attitude Toward Care of the Dying Scale (FATCOD)37,70
Used for assessing doctor and nurse attitudes toward caring for terminally ill persons and their families
30 items
15 items with contents about positive attitudes
15 items with contents about negative attitudes
An interrater agreement was 0.98
Pearson coefficient was a 0.90
No changes Validity
S-CVI/Ave = 1.00
S-CVI-UA = 1.00
α coefficient was .86
Likert scale (1-5)
Mean scores converted to a percentage
The higher percentage reflects a more positive attitude
Palliative Care Needs Assessment Instrument25
Used for determining awareness, knowledge, education, barriers, and resources regarding PC services
Seven sections:
current PC services; satisfaction with and barriers to PC provision and service delivery; available resources; populations requiring assistance; educational program topics attended in the past 2 y; and preferred learning methods
NA No changes S-CVI/Ave = 1.00
S-CVI-UA = 1.00
α coefficient was .90
Frequency and percentage of items
Abbreviations: CVI, content validity index; EoLC, end-of-life care; HCP, health care professional; PC, palliative care; S-CVI, scale-level content validity index; UA, universal agreement.

Data Entry and Analysis

Data were analyzed using SPSS software version 25 (IBM Corp, Armonk, New York). Descriptive statistics were calculated to summarize sociodemographic and professionals' characteristics as well as instruments and their subscales. Independent-samples t test and analysis of variance were utilized to examine differences between professionals' knowledge and attitudes toward PC with demographic and professionals' characteristics. All variables with P ≤ .25 in univariate analysis were selected for a generalized linear regression. All statistical tests were 2-tailed, and P < .05 was treated at a significant level. For open-ended responses, qualitative content analysis was adopted for categorizing the data based on similarities and differences.

Ethical Considerations

Each HCP was provided a full explanation of the study before making a decision to voluntarily participate. Professionals were informed that participation was voluntary. The Human Subjects Ethics Sub-committee at The Hong Kong Polytechnic University approved this study (HSEARS20200414006). Administrative approval was also obtained from the Palestinian Ministry of Health (SN476303).


Characteristics of the Participants

Of the 200 questionnaires distributed to participants, 174 were collected. Of 174 collected questionnaires, 5 questionnaires were excluded because of significant missing data. A total of 169 participants were included in the final analysis, with a response rate of 87%. Descriptive statistics for the participants are displayed in Table 2. Most participants (n = 137 [81.1%]) were nurses. Most nurses (n = 94 [68.6%]) held a bachelor's degree. Only 9.5% of HCPs had previous PC training, and all of them were nurses. The mean age of physicians was 38 and none had received any training in PC.

TABLE 2 - Characteristics of Participants (N = 169)
Characteristics Total
N = 169
n = 32 (18.9%)
n = 137 (81.1%)
n (%) n (%) n (%)
 Male 88 (52.1) 8 (25.0) 80 (58.4)
 Female 81 (47.9) 24 (75.0) 57 (41.6)
Age,a mean ± SD, y 32.87 ± 7.77 38.00 ± 8.00 31.68 ± 7.24
 20–30 62 (40.3) 6 (20.7) 56 (44.8)
 30–39 63 (40.9) 11 (37.9) 52 (61.6)
 ≥40 29 (18.8) 12 (41.4) 17 (13.6)
Educational level
 Diploma or less 34 (20.1) 2 (6.2) 32 (23.4)
 Bachelor 105 (62.1) 11 (34.4) 94 (68.6)
 Postgraduateb 30 (17.8) 19 (59.4) 11 (8.0)
Professional status
 Head 13 (7.7) 6 (18.8) 7 (5.1)
 Subhead 13 (7.7) 6 (18.8) 7 (5.1)
 Senior 6 (3.6) 1 (3.0) 5 (3.7)
 Staff 137 (81.1) 19 (59.4) 118 (86.1)
Work setting/clinical area
 Medical departments 81 (47.9) 11 (34.4) 70 (51.1)
 Oncology/hematology departments 88 (52.1) 21 (65.6) 67 (48.9)
 Al-Shifa Hospital 103 (60.9) 25 (78.1) 78 (56.9)
 European Gaza Hospital 66 (39.1) 7 (21.9) 59 (43.1)
Total years of working experience 7.57 ± 5.53 8.37 ± 5.02 7.39 ± 5.64
 <5 77 (45.6) 12 (37.5) 65 (47.4)
 ≥5 92 (54.4) 20 (62.5) 72 (52.6)
Years of experience in the department 6.14 ± 4.95 7.91 ± 5.27 5.73 ± 4.80
 <5 99 (58.6) 15 (46.9) 84 (61.3)
 ≥5 70 (41.4) 17 (53.1) 53 (83.7)
Palliative care–related issues
History of PC training
 Yes 16 (9.5) 0 (0) 16 (11.7)
 No 153 (90.5) 32 (100) 121 (88.3)
Abbreviation: PC, palliative care.
a Missing data 26.0%.
b Comprises master's degree or PhD or clinical board.

Knowledge of HCPs About PC

Overall knowledge score was 42.8 ± 11.02, indicating that HCPs had insufficient knowledge about PC. Despite the lower overall score, the philosophy subscale reported the highest score (62.42 ± 25.60). The lowest score of <50 was observed in 4 of 5 PCKT subscales. The differences between physicians' and nurses' knowledge are highlighted in Table 3.

TABLE 3 - Knowledge of Health Care Professionals About Palliative Care (n = 169)
Knowledge Domains (0-100) Total Physicians Nurses
Mean ± SD Mean ± SD Mean ± SD
Philosophy 62.42 ± 25.60 55.46 ± 22.66 64.05 ± 26.05
Pain 40.03 ± 16.99 34.37 ± 16.36 41.36 ± 16.92
Dyspnea 32.34 ± 26.08 47.91 ± 20.63 28.71 ± 25.94
Psychological problems 41.81 ± 27.22 40.62 ± 26.41 42.09 ± 27.49
Gastrointestinal problems 36.24 ± 23.60 39.84 ± 19.93 35.40 ± 24.37
Total knowledge score 42.86 ± 11.02 42.65 ± 7.06 42.91 ± 91

Attitudes of HCPs Toward End of Life and Care of the Dying

Bradley Attitude Questionnaire's total score was 3.31 ± 0.38, reflecting that HCPs had positive attitudes toward EoLC. The total score of FATCOD attitudes was 3.14 ± 0.30, reflecting that HCPs had positive attitudes toward the care of the dying. Nurses had higher scores in attitude about the care of the dying than physicians (3.18 ± 0.30 and 2.96 ± 0.19, respectively; P < .001). The detailed responses of professionals about end of life and care of the dying items are presented in Tables 4 and 5.

TABLE 4 - Health Care Professionals' Responses Toward End-of-Life (n = 169) “Bradley Scale”
Question Item Strongly Agree/Agree
n (%)
Neither Agree Nor Disagree
n (%)
Disagree/Strongly Disagree
n (%)
Mean ± SD
Q1. Most of my physician (nurse) colleagues feel that when their patients receive palliative care, it reflects their own failure.a 18 (10.7) 52 (30.8) 99 (58.6) 3.68 ± 0.92
Q2. Many of my physician (nurse) colleagues are uncomfortable discussing the option of palliative care with patients and their families.a 55 (32.6) 50 (29.6) 64 (37.8) 3.13 ± 1.07
Q3. Physicians do not have a role in palliative care.a 39 (23.1) 21 (12.4) 109 (64.5) 3.65 ± 1.14
Q4. Most elderly patients who are dying want their doctors to determine what care is best for them. 115 (68.1) 27 (16.0) 27 (16.0) 3.52 ± 1.02
Q5. Palliative care generally meets the needs of the family better than conventional care does. 92 (54.5) 46 (27.2) 31 (18.3) 3.41 ± 0.98
Q6. An interdisciplinary team approach interferes with patient care.a 25 (14.8) 75 (44.4) 69 (40.8) 3.30 ± 0.90
Q7. I feel knowledgeable enough to discuss palliative care with patients and families. 73 (43.2) 57 (33.7) 39 (23.0) 3.18 ± 0.93
Q8. Most patients' symptoms, such as pain, shortness of breath, and nausea, are not controlled any better with palliative care than with conventional care they would otherwise receive.a 81 (47.9) 44 (26.0) 44 (26.0) 2.76 ± 1.04
Q9. I usually order (request) as much pain medication as needed to keep terminally ill patients pain-free. 100 (59.2) 36 (21.3) 33 (19.6) 3.43 ± 0.96
Q10. I usually tell patients that curative treatment is no longer successful as soon as I know. 40 (23.7) 37 (21.9) 92 (54.4) 2.62 ± 1.12
Q11. Most elderly patients do not want to be told if they are dying. 117 (69.2) 23 (13.6) 29 (17.2) 3.72 ± 1.16
Total score 3.31 ± 0.38
a Indicates a reversed question (strongly disagree was coded as 5).

TABLE 5 - Self-rated Attitude Responses of Participants Assessed About Care of the Dying (n = 169) (Frommelt Scale)
Question Item Strongly Agree
n (%)
n (%)
n (%)
n (%)
Strongly Disagree
n (%)
Mean ± SD Weighted Mean (%)a
Q1. Giving care to the dying person is a worthwhile experience. 22 (13) 117 (69.2) 15 (8.9) 11 (6.5) 4 (2.4) 3.84 ± 0.81 76.78
Q2. Death is not the worst thing that can happen to a person. 8 (4.7) 83 (49.1) 27 (16.0) 29 (17.2) 22 (13) 3.15 ± 1.16 63.03
Q3. I would be uncomfortable talking about impending death with the dying person.b 12 (7.1) 84 (49.7) 28 (16.6) 37 (21.9) 8 (4.7) 2.67 ± 1.04 53.48
Q4. Caring for the patient's family should continue throughout the period of grief and bereavement. 20 (11.8) 95 (56.2) 37 (21.9) 14 (8.3) 3 (1.8) 3.68 ± 0.85 73.58
Q5. I would not want to care for a dying person.b 20 (11.8) 52 (30.8) 22 (13.0) 51 (30.2) 24 (14.2) 3.04 ± 1.28 60.84
Q6. The nonfamily caregivers should not be the one to talk about death with the dying person.b 28 (16.6) 75 (44.4) 33 (19.5) 28 (16.6) 5 (3.0) 2.44 ± 1.0 49.06
Q7. The length of time required to give care to a dying person would frustrate me.b 16 (9.5) 57 (33.7) 33 (19.5) 52 (30.8) 11 (6.5) 2.91 ± 1.13 58.22
Q8. I would be upset when the dying person I was caring for gave up hope of getting better.b 20 (11.8) 91 (53.8) 34 (20.1) 23 (13.6) 1 (0.6) 2.37 ± 0.88 47.42
Q9. It is difficult to form a close relationship with the dying person.b 20 (11.8) 52 (30.8) 45 (26.6) 48 (28.4) 4 (2.4) 2.78 ± 1.05 55.76
Q10. There are times when death is welcomed by the dying person. 23 (13.6) 62 (36.7) 54 (32.0) 25 (14.8) 5 (3.0) 3.43 ± 0.99 68.68
Q11. When a patient asks, “Am I dying?” I think it is best to change the subject to something cheerful.b 22 (13.0) 91 (53.8) 31 (18.3) 24 (14.2) 1 (0.6) 2.35 ± 0.90 47.06
Q12. The family should be involved in the physical care of the dying person if they want to. 40 (23.7) 85 (50.3) 23 (13.6) 18 (10.7) 3 (1.8) 3.83 ± 0.96 76.74
Q13. I would hope the person I'm caring for dies when I am not present.b 43 (25.4) 46 (27.2) 33 (19.5) 39 (23.1) 8 (4.7) 2.54 ± 1.22 50.84
Q14. I am afraid to become friends with a dying person.b 35 (20.7) 55 (32.5) 36 (21.3) 35 (20.7) 8 (4.7) 2.56 ± 1.16 51.18
Q15. I would feel like running away when the person actually died.b 11 (6.5) 51 (30.2) 33 (19.5) 49 (29.0) 25 (14.8) 3.15 ± 1.19 63.08
Q16. Families need emotional support to accept the behavior changes of the dying person. 26 (15.4) 91 (53.8) 37 (21.9) 13 (7.7) 2 (1.2) 3.74 ± 0.85 74.90
Q17. As a patient nears death, the nonfamily caregiver should withdraw from his/her involvement with the patient.b 11 (6.5) 42 (24.9) 38 (22.5) 57 (33.7) 21 (12.4) 3.20 ± 1.14 64.12
Q18. Families should be concerned about helping their dying member make the best of his/her remaining life. 31 (18.3) 77 (45.6) 32 (18.9) 23 (13.6) 6 (3.6) 3.61 ± 1.04 72.28
Q19. The dying person should not be allowed to make decisions about his/her physical care.b 5 (3.0) 64 (37.9) 37 (21.9) 45 (26.6) 18 (10.7) 3.04 ± 1.09 60.88
Q20. Families should maintain as normal an environment as possible for their dying member. 47 (27.8) 74 (43.8) 28 (16.6) 15 (8.9) 5 (3.0) 3.84 ± 1.02 76.96
Q21. It is beneficial for the dying person to verbalize his/her feelings. 28 (16.6) 93 (55.0) 23 (13.6) 14 (8.3) 11 (6.5) 3.66 ± 1.05 73.38
Q22. Care should extend to the family of the dying person. 24 (14.2) 93 (55.0) 30 (17.8) 19 (11.2) 3 (1.8) 3.68 ± 0.91 73.72
Q23. Caregivers should permit dying persons to have flexible visiting schedules. 30 (17.8) 87 (51.5) 37 (21.9) 13 (7.7) 2 (1.2) 3.76 ± 0.87 75.46
Q24. The dying person and his/her family should be the in-charge decision makers. 25 (14.8) 70 (41.4) 52 (30.8) 19 (11.2) 3 (1.8) 3.56 ± 0.93 71.24
Q25. Addiction to pain-relieving medication should not be a concern when dealing with a dying person. 25 (14.8) 73 (43.2) 37 (21.9) 28 (16.6) 6 (3.6) 3.49 ± 1.04 69.86
Q26. I would be uncomfortable if I entered the room of a terminally ill person and found him/her crying.b 25 (14.8) 67 (39.6) 37 (21.9) 33 (19.5) 7 (4.1) 2.58 ± 1.08 51.64
Q27. Dying persons should be given honest answers about their condition. 29 (17.2) 71 (42) 46 (27.2) 20 (11.8) 3 (1.8) 3.60 ± 0.96 72.20
Q28. Educating families about death and dying is not a nonfamily caregiver's responsibility.b 19 (11.2) 44 (26) 50 (29.6) 46 (27.2) 10 (5.9) 2.90 ± 1.10 58.06
Q29. Family members who stay close to a dying person often interfere with the professionals' job with the patient.b 36 (21.3) 66 (39.1) 34 (20.1) 29 (17.2) 4 (2.4) 2.40 ± 1.07 48.12
Q30. It is possible for nonfamily caregivers to help patients prepare for death.b 20 (11.8) 82 (48.5) 40 (23.7) 23 (13.6) 4 (2.4) 2.46 ± 0.95 49.26
Total Frommelt score 3.14 ± 0.30 62.8%
a Indicates a reversed question (strongly disagree was coded as five).
b Weighted mean is calculated by multiplying the percentage of responses in each category (strongly disagree to strongly agree) by its respective score (1–5), adding up these products and dividing by 5.

Educational Needs and HCS-Related Issues

Educational Needs

Approximately 75.1% of HCPs wished to learn more about PC. Fewer than half of HCPs recalled attending an educational program related to PC. For instance, 45% of HCPs participated in a symptom management program, and approximately 43.8% of respondents reported that they attended training on pain management, communication skills, and care for the caregivers. Only 28.4% had participated in the EoLC program. Respondents identified various preferred methods to learn more about PC. Approximately 80% of them liked attending professional meetings or workshops, bringing PC consultants to provide training, taking an intensive course on PC, and approximately 68% of respondents favored web-based learning.

Health Care System–Related Issues

Availability of PC Services in Study Settings

The most common existing PC service offered in Gaza hospitals was discharge planning for patients with chronic illness (48.5%), ethics committee (45.6%), and quality improvement for pain and symptom management (42.6%). In contrast, programs of bereavement (21.9%), interdisciplinary care for dying patients (25.4%), and program for staff support in caring for dying patients (28.9%) were the least available services in their settings. Detailed descriptions of existing PC services are presented in Table 6.

TABLE 6 - Palliative Care Services Available in the Setting
Existing Services n %
Discharge planning for patients with chronic illness 82 48.5
Ethics committee 77 45.6
Quality improvement for pain management 72 42.6
Quality improvement for symptom management 72 42.6
Program to promote advance care planning (advance directives) 65 38.5
Palliative care team or consult service 61 36.1
Communication among health care team related to palliative care 61 36.1
Pain management consultative team or service 58 34.3
Physicians who are certified in hospice and palliative medicine 58 34.7
Palliative care unit 57 33.7
Access to palliative care resources outside of your hospital 57 33.7
Nurses who are certified in hospice and palliative nursing 54 32.0
Professional education program on palliative care 52 30.8
Contractual relationship with a hospice or home care program 50 29.6
Quality improvement for end-of-life-care 50 29.6
Program for staff support in caring for dying patients 49 28.9
Interdisciplinary care program for dying patients 43 25.4
Bereavement program 37 21.9

Palliative Care Satisfaction and Barriers

More than half of respondents (n = 100 [59.2%]) were satisfied with religious and spiritual care provided to patients. They were also satisfied with pain (n = 89 [52.7%]) and symptom management (n = 86 [50.9%]) services. On the other hand, more than half of the HCPs reported that advance directives were not addressed in their setting. They were also dissatisfied with the discharge planning provided to patients.

The most common barriers to the provision of PC into HCSs as provided by study participants were patients'/families' avoidance of issues around dying (n = 154 [91.1%]), lack of training for staff related to PC (n = 151 [89.3%]), lack of designated beds for PC services (n = 146 [86.4%]), limited community awareness related to PC (n = 145 [85.8%]), and lack of knowledge about PC by HCPs (n = 144 [85.2%]) (Table 7).

TABLE 7 - Barriers to the Provision of Palliative Care
Rank Possible Barriers to Providing Palliative Care n (%)
1 Patients'/families' avoidance of issues around dying 154 (91.1)
2 Lack of training for staff related to palliative care 151 (89.3)
3 Lack of designated beds for palliative care services 146 (86.4)
4 Lack of community awareness related to palliative care 145 (85.8)
5 Lack of knowledge about palliative care by health care professionals 144 (85.2)
6 Lack of home care availability 142 (84)
7 Lack or inadequacy of written policies and procedures about palliative care 140 (82.8)
8 Lack of volunteers in community 140 (82.8)
9 Lack of policy and guidance availability 140 (82.8)
10 Cultural, religious, and/or spiritual beliefs influencing end-of-life care 138 (81.7)
11 Patients'/families' fear of addiction to pain medications 138 (81.7)
12 Personnel shortages/time constraints 138 (81.7)
13 Lack of access to hospice services 137 (81.1)
14 Improper communication among interdisciplinary team 137 (81.1)
15 Professionals' fear of causing addiction by administering pain medications 135 (79.9)
16 Differences in opinion among health care professionals about palliative care 135 (79.9)
17 Fear of legal action by leadership or government 133 (78.7)
18 Lack of student nurse interest related to palliative care 133 (78.7)
19 Health care professionals' personal discomfort with death 130 (76.9)
20 The patient/family is not part of the decision-making process 129 (76.3)
21 Lack availability of medications/opioids (narcotics) 128 (75.7)
22 Communication difficulties among health care professionals, patients, and/or families 126 (74.6)

Factors Associated With Professionals' Knowledge and Attitudes Toward PC

The findings in generalized linear regression showed that educational level (β = −7.44, P = .006) and previous training in PC (β = 6.91, P = .013) were independently associated with professional's knowledge toward PC. Professionals' rank (β = −5.79, P = .024) and previous training in PC (β = 4.14, P = .016) were independently associated with attitudes about EoLC. Independent associations were also reported between profession/discipline (β = −6.15, P = .031) and working setting (β = 2.57, P = .005) with attitudes toward care of the dying (Table 8).

TABLE 8 - Generalized Linear Regression Model for Factors Associated With Professionals' Knowledge and Attitudes About Palliative Care
Domain Variable β SE 95% CI Wald P
Knowledge about palliative care Education
Diploma or less −7.44 2.72 −12.79 to −2.10 7.45 0.006a
Bachelor −1.55 2.21 −589 to 2.78 0.49 0.482
Master/PhD Ref
Duration of present work experience 0.25 0.45 −0.65 to 1.15 0.17 0.582
<5 y −1.41 1.71 −4.78 to 1.94 0.68 0.409
≥5 y Ref
Previous training in palliative care
Yes 6.91 2.78 1.46 to 12.37 6.18 0.013a
No Ref
Attitudes about care at end of life Profession
Physician −1.50 1.30 −4.05 to 1.05 1.32 0.249
Nurse Ref
Professionals' rank
Head 2.36 1.86 −1.30 to 6.03 1.60 0.206
Subhead 1.06 1.90 −2.66 to 4.79 0.314 0.575
Senior −5.79 2.56 −10.81 to 0.76 5.09 0.024a
Staff Ref
Previous training in palliative care
Yes 4.14 1.72 0.77 to 7.54 5.79 0.016a
No Ref
Attitudes toward dying care Profession
Physician −3.38 1.25 −5.84—0.91 7.20 0.007a
Nurse Ref
<30 y 1.13 1.90 −2.60 to 4.86 0.35 0.552
30–39 y −1.30 1.39 −4.02 to 1.42 0.87 0.350
≥40 y Ref
Male 0.65 0.93 −1.17 to 2.48 0.49 0.481
Female Ref
Professionals' rank
Head −8.70 1.91 −4.61 to 2.87 0.20 0.649
Subhead −1.24 1.91 −4.99 to 2.52 0.42 0.516
Senior −2.75 2.83 −8.31 to 2.80 0.94 0.332
Staff Ref
Working setting
Medical departments 2.57 0.92 0.76 to 4.38 7.76 0.005a
Oncology departments Ref
Duration of the total work experience
<5 y 0.11 1.36 −2.55 to 2.77 0.00 0.935
≥5 y Ref
Abbreviation: CI, confidence interval.
a Difference is significant at the .05 level.

Qualitative Part

Existing PC Activities, Available Resources, and Motivation

Of 169 professionals included in this study, 99 professionals responded to the qualitative question: “What would make it possible for you and your staff to attend a PC class or course?”; 55% reported that the main motivator was the need for learning more about PC and getting a certificate in this aspect, whereas approximately 42% of them were motivated by improving their skills to alleviate patients' complications. Furthermore 80 professionals replied to the question: “What is your setting doing well to provide PC?”; approximately 44% reported that his/her setting did not do anything to provide PC, whereas approximately half stated planning workshops for patients and their families besides creating a PC team. When asked about existing resources that could be used to help improve PC, half referred to a nongovernmental organization support and availability offering logistics, and roughly 19% of them reported nothing.


This is the first study carried out in Palestine that assessed educational and HCS-related issues from physicians' and nurses' perspectives. Although nurses and physicians had reported insufficient knowledge of PC, their attitudes toward EoLC and care of dying patients were positive. Most professionals showed their interest to learn more about PC. Findings also revealed that discharge planning for patients with chronic illness was the common PC services available in both hospitals. The unwillingness of patients/families to talk about death and a lack of training for staff related to PC were the common barriers to providing PC in Gaza as reported by professionals. Educational level and previous PC training were independently associated with HCPs' knowledge and attitudes toward PC.

Palestine is ranked by the WHO at group 3a countries “Isolated PC provisions”—countries that had activities for development of PC—but it is still patchy in scope and not well supported because of limited resources, dependency on donors, and limited availability of morphine.2 Despite these activities, the majority of Palestinian nurses and physicians reported significantly lower knowledge of the principle of PC. This result is in line with previous studies conducted in Palestine,28 and Jordan,29 but contradict those observed in countries with PC integration, such as Saudi Arabia30 and China,31 whose knowledge ranged between 53% and 54%, compared with 42% in this study.

Nurses and physicians reported a high level of knowledge in PC philosophy. This study finding is congruent with a previous study showed that 77.5% of participants had a high knowledge in PC philosophy.14 A high level of philosophy attributed to fundamental items belongs to this aspect, which focus on definition and target population, which make it easier for professionals to remember and answer items correctly.14 On the other hand, remarkably lower scores in dyspnea, psychiatric, gastrointestinal, and pain aspects were observed in this study. The lower level might be justified by lack of training in PC14 and a short training period that can influence the quality of training materials delivered to participants.

Our results revealed that significant differences in overall PC knowledge were favored for those who had previous training and completed a higher educational level. Al-Drees et al30 reported the positive effect of continuous training on professionals' knowledge. Insufficient training and a short training duration among our participants might be one explanation for their poor knowledge of PC. It could also be related to the fact that in-service education was not conducted regularly in hospitals because of workforce shortage. Good knowledge of PC is associated with positive attitudes, enhancing practices, communication skills, and pain management14,30; thus, this lack of education will affect the optimal health care provision. Therefore, in-service PC education programs are needed to enhance HCPs' knowledge and skills, particularly in managing dyspnea, gastrointestinal symptoms, and pain.

Positive attitudes toward EoLC and care of the dying were reported among the Palestinian HCPs. Attitudes make a significant contribution to the quality of PC services provided. These results match those observed in previous studies conducted in Muslim countries,32,33 However, they contradict those applied in China.31 This might be justified by the cultural and the religious differences with regard to death across nations.34 Islamic culture and religious backgrounds of our HCPs that accept death as a normal process act as vital roles in developing positive attitudes. The positive attitudes of HCPs in the Gaza Strip should be considered an important indicator to integrate a PC program in the Palestinian HCSs.

The majority of HCPs would like to learn more about PC for enhancing their knowledge and attitudes, which is consistent with previous work conducted in the Middle East countries.13 The passion and interest of HCPs to learn more about PC are considered a chance for integrating education and training program within Gaza HCSs. Even though half of the HCPs attended pain/symptom management and communication skills educational sessions in their work setting in the past 2 years, their knowledge about pain and dyspnea management was still low. This might be attributed to the content of educational sessions they attended or the length of the educational session ranging between 2 weeks and 4 months. Thus, comprehensive educational programs should be designed and revised by an expert before introducing programs to HCPs. Educational programs, as reported by HCPs, should focus on end of life–related issues. They suggested utilizing online modules and web-based instruction as main educational strategies that positively affect delivering educational activities. The web-based learning is increasingly utilized as a tool to support a formal program and as a means for providing online learning.35,36 Evidence has confirmed the positive influence of online PC training on professionals' knowledge and attitude.37 Health academic organizations can therefore adopt web-based techniques as an effective teaching method for HCPs. These techniques have the potential to improve and accelerate the provision of PC in settings where there was a lack of staff to attend traditional courses.

Discharge planning for patients with chronic illness was the most common existing PC service available in Gaza hospitals, as shown in this study. This result matches with those of Silbermann et al,13 who assessed services in Middle East countries. Discharge planning is a routine feature of HCS and a central component of consultation in hospitals.38 Before discharge, HCPs provide patients and their families with supportive information about disease progression, follow-up, managing symptoms, and addressing physical and psychological concerns.38 Although discharge planning is viewed as important, professionals are reluctant to talk and discuss the patients' disease progression, fearing the families' pessimism. Many families do not prefer to talk about death.39 Our findings support this explanation, which revealed the unavailability of bereavement programs, interdisciplinary care for dying patients, and programs for staff support in caring for dying patients. It is also supported by our finding that showed HCPs were dissatisfied with the discharge plan provided to the patients. Thus, there is an urgent need for providing communication programs for staff on how to care for and discuss dying-related issues with patients and their families.

Avoidance and unwillingness of patients'/families' to talk about death was the main barrier to providing PC in the Gaza Strip, as reported by our HCPs. The study result is congruent with those reported in previous research.40,41 Talking openly about death is one of the main objectives for keeping patients free of suffering.42 Talking about death may be influenced by patients' dignity,43 families' views of death,43 the ritual of death,43 religious beliefs,44 and cultural background.43 In the Islamic culture, people believe in Allah/God and agree that there is a journey after death, and there will be a physical resurrection on the Day of Judgment.45 Despite the strong Islamic faith, patients and their families are unwilling to discuss any death-related issues. Integrating spiritual care in health care settings is a priority for overcoming these issues by activating the role of Sheikh, a person who is respected for his piety and religious background, in delivering words and meanings that support patients and their families.

Lack of PC training for HCPs is another significant barrier to providing PC in the Gaza Strip. Several studies have reported that the inadequately trained PC workforce was the most critical barrier to PC provision.46 The Palestinian Ministry of Health should design plans for the training of workforce by increasing national and international professional collaboration programs, incorporating in-service training, and integrating PC into curricula and practice.

Strengths and Limitations of the Study

This study has some limitations. Adopting a cross-sectional design makes it difficult to conclude of causal relationship. Moreover, adopting a small convenience sample size makes difficulties in generalizing the study findings. Although 4 instruments that cover several components (ie, philosophy, pain, dyspnea, gastroenteritis) were utilized, other components, such as interprofessional collaboration and communication, preparation for and care at the time of death, care plan, and ethical issues in EoLC, were not measured. Despite these limitations, the lack of previous similar studies conducted in Palestine is the principal strength and uniqueness of the study. The findings of this study are considered a base informational resource for the Ministry of Health in developing PC in Gaza. The results also provided valuable insights into how HCPs perceived PC.


This study has shown that Palestinian HCPs had insufficient knowledge of PC, particularly knowledge of pain, dyspnea, and gastrointestinal problems. This study also revealed that a significant factor influencing professionals' PC knowledge and attitudes was educational level and previous training in PC. Therefore, integrating formal and informal PC education with care services and health curricula is a priority. Educational and training programs should be comprehensive, covering the basic and advanced PC principles, including gastrointestinal and psychiatric problems and pain management. The positive attitudes of professionals in this study should be considered an impetus to integrate the PC program in the HCS and health education programs.


The authors thank statistician Dr Paul Lee for his advice and direction during the analysis of the data. The authors also thank all of the Palestinian HCPs who are caring for patients with advanced cancer and participated in this study.


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cross-sectional study; educational needs; experience; health care system; Palestine; palliative care

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