Background: Palliative care sometimes perceived as hastening death or care delivered when active treatment failed. Nurses play a significant role in providing palliative care, but nurses, as well as other health care worker, need training about palliative care in order to achieve the intended goals.

Aim: Explore the level of knowledge and attitude for the staff in King Saud Medical City (KSMC) Riyadh, Saudi Arabia toward palliative care. 

Method: A quantitative, cross-sectional study, 323 questionnaires were completed by the staff nurses covering medical-surgical, oncology and ICU. The tool consists of demographical data, Palliative Care Quiz for Nursing(PCQN), Frommlet Attitudes Toward Care of Dying (FATCOD) scale.

Result:  Poor knowledge toward palliative care founded among respondent PCQN mean total score (9.229) out of 20 SD (2.402) while Moderate attitude showed FATCOD mean total score 97.817 out of 150, SD (8.325). The area of assignments significantly affects the Knowledge of the staff; oncology unit reported higher score than the other areas, right knowledge has been shown, mean score for oncology unit (11.36), SD (3.53).

Conclusion: Institutional strategy has to be implemented in the Middle East a to improve the palliative care services, palliative care nursing education has to be added to the undergraduate curricula in every nursing school, formal training and courses for post graduated nurses is necessary.

Keyword: nurses, knowledge, attitude, palliative care, saudi Arabia

WHO, World Health Organization; ICU, Intensive Care Units; KSMC, King Saud Medical City; PCQN, Palliative Care Quiz for Nursing; FATCOD, Frommlet Attitudes Toward Care of Dying scale

Palliative care is to relieve the suffering of patients and their families and to improve their quality of life through physical, psychosocial and spiritual approaches through early identification, correct assessment and right treatment of pain and other symptoms according to World Health Organization (WHO). Oncology patients are not the only targeted population for palliative care.¹ According to the WHO report (2018), patients with chronic respiratory illnesses, cardiovascular diseases, HIV, and diabetes are all in need of palliative care. Palliative care considered fundamental human rights.²

Annually, around 40 million people in need to palliative care and the majority of them in the middle- low-come countries 78% (WHO).

Palliative care sometimes perceived as hastening death or care delivered when active treatment failed.³ Recently, palliative care accepted as an appropriate treatment option to begin at diagnosis of any life-threatening illness, instead of being initiated within few weeks or days from death.⁴

Nurses are often the first health care provider among multidisciplinary palliative care teams to assess the patient and recognize their suffering.⁴ They also spend the most time with patient compared to all other healthcare worker.⁵ Nurses who work in Intensive Care Units (ICU) usually received little information and education about end of life care, even though most of the death inside hospitals occur in the ICU.⁶

Nurses are key persons at the bedside, coordinating care for the patient.⁷

Nursing is considered the cornerstone for palliative care.⁸ Nurses play a significant role in providing palliative care, but nurses, as well as other health care workers, need to be trained and educated about palliative care in order to achieve the intended goals.^1,10.General nursing school curricula worldwide do not include sufficient training around palliative care.⁹ Nurses' experiences, knowledge, beliefs, and training all play a significant role in improving staff attitude toward palliative care.^4,11,12

Nurses' attitude toward palliative care affects their behavior toward their patient and their families.⁴ Nurse's attitude and knowledge toward palliative care reflect how much staff nurses are aware and competent to provide a high quality of palliative care. Attitudes are believed to be an essential determinant of behavior.¹³ although a change in attitude will not necessarily lead to a change in behavior.⁴ However, in experimental studies, palliative care education has been supported as an intervention method for improving staff attitude toward palliative care.¹⁰

The first palliative care service in Saudi Arabia started in 1992 at King Faisal Specialist Hospital and Research Centre-Riyadh (KFSH&RC-Riyadh).^10,13 In 1998, palliative care services were also developed in Jeddah to meet the need of cancer patients.¹ Since that time, palliative care services in the Kingdom of Saudi Arabia have expanded.^1,13

Aim

Explore the staff nurses’ level of knowledge and attitude toward palliative care. in King Saud Medical City (KSMC)

Method: Study design

This descriptive, cross-sectional study uses a quantitative approach. Participants completed a self-administered questionnaire consisting of three sections: (1) demographic data,

(2) Palliative Care Quiz for Nursing (PCQN),¹⁴ and (3) the Frommlet Attitudes Toward Care of Dying scale (FATCOD).¹¹

Setting

King Saud Medical City (KSMC) is a 1400 bed tertiary hospital and regional trauma center in Riyadh, Saudi Arabia. Medical, surgical, oncology, and palliative care services provided within the scope of the city for both adult and pediatric patients.

Sample

The nursing team consist of approximately 4000 nurses providing administrative educational direct patient care and supportive. A convenience sample of staff nursing working in oncology, medical and surgical units, and intensive care units(ICU) were invited to participate. Sample size for the study is 310, Sample increased to 350 for more generality.

Inclusion criteria

Staff nurses who are working in Adult ICUs, CCU, Medical Surgical, Oncology unit

Exclusion criteria

Staff nurses working in diagnostic, pediatric &maternity ICUs, pediatric &maternity wards.

Ethical considerations

The Institutional Review Board at King Saud Medical City approved the study.

Participants informed of the purpose of the study and instructions given for completing the questionnaire in a cover letter. The cover letter indicated that completion of the questionnaire is voluntary and we will not collect any personal identifiers. All questionnaires kept in a secured office, and data access was exclusively for the study team.

A total of 350 questionnaires distributed in 36 units through the head nurses and clinical instructor working in adult ICUs, medical-surgical, and oncology units. Consequently, three hundred twenty-threes were filled the questionnaires and returned to the head nurses, Affording 92% response rate.

Data analysis was performed using the statistical software package STATA (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX). Demographic characteristics of participants and knowledge and attitude scores were analyzed descriptively. The t-test and analysis of variance (ANOVA) were used to compare FATCOD and PCQN scores among the main variables such as age, gender, position, KSMC, and total experiences, and area of assignment. The correlation between FATCOD and PCQN specified by Pearson's (r) correlation. The top five accurate PCQN responses were determined as well as the top five heights FATCOD means.

Instruments

Three tools were used to collect study data. The authors’ formulated a questionnaire for the demographical data consisting of the variables that may affect the staffs’ attitude and knowledge toward palliative care, such as, age, gender, years of experience, designation, nationality, and area of assignments.

The FATCOD scale was used to determine the staff attitude toward palliative care. This tool recognized as one of the reliable and valid tools with (0.87) interclass correlation coefficient, 0.83 Cronbach's alpha.^13,15 Its consist of 30 items utilizing a 5-point Likert scale. The choices range from the actual item 1 for (strongly disagree) to five (strongly disagree) The total score will range from 30-150, with a higher score indicating a more positive attitude. The score reversed for the negative items. The attitude level categorized by the scores corresponds to a good attitude (≥76), Moderate attitude (51-75%) and poor attitude (≤50).

The PCQN tool was used to assess the knowledge of the staff toward palliative care. Its reported acceptable level of internal consistency (α = 0.78) (Ross et al., 1996), the moderate correlation coefficient of 0.56. This tool consists of 20 questions. One point will count for each right answer; zero is given for the incorrect and/or an "I don't know answer." Scores classified as Good knowledge (≥76%), Fair knowledge (51-75%) and poor knowledge (≤50%).

Participant Demographics Table 1 shows respondent demographic data. The majority of the respondent were female (97.5%), between 25-30 years of age (42.9%), working as staff nurses (69.5%), nearly half have experience of 4-10 years in the nursing field (48.9%), most of them are of Filipino nationality (44.7%), followed by the Indian nationality (43.4%), assigned in the critical care area (41.8%).

FATCOD

The analysis for FATCOD demonstrated that the staff had a moderate attitude toward palliative care with a mean total score of 97.817 (SD 8.325) out of 150. Table 2 shows the participants' attitude toward palliative care, with 96.28% indicating moderate attitude, while 2.79% had a good attitude. Less than 1% (0.93%) of nurses had a poor attitude toward palliative care.

Table 3 presented the four FATCOD question with the highest and lowest mean scores. The highest score was for the item 18 (families should be concerned about helping their dying member make the best of his/her remaining life) with a mean score of 4.382, (SD 0.786), followed by the item 21(it is beneficial for the dying person to verbalize his or her feelings) with mean score of 4.275 (SD 0.74). Item 20 (families should maintain as healthy an environment as possible for their dying member) had to mean score of 4.170 (SD 0.783). The fourth highest mean score was 4.077 (SD 0.0879) for item 4 (caring for the patient’s family should continue throughout grief and bereavement). The lowest mean score was for item 15 (I am afraid to become friends with a dying person) mean score was2.040 (SD0.864). The second lowest mean score was for the item 6 (I would not want to care for a dying person), followed by the item 5&19 (as a patient nears death, the non-family caregiver should withdraw from his /her involvement with the patient) mean score was (2.058) SD (0.968). (the dying person should not be allowed to decide on his / her physical care) Mean score was (2.182) (SD 0.051). no significant differences between the age groups, experience, working area, nationality and the mean score for FATCOD.

PCQN

The analysis for PCQN reflected that the participant had poor knowledge (mean total score of 9.229; SD=2.402). Table 4 shows the participant knowledge level toward palliative care; 0.62% of the participant had good knowledge, 27,86% had fair knowledge, and 71,52% had poor knowledge. Table 5 presented the four highest percentage of the correct answer and the lowest percentage of the correct answer for PCQN. The highest percentage of the correct answer was for item 18 (manifestation of chronic pain are different from those of acute pain) was 82.35% responded correctly. For item 8 (individuals who are taking opioids should also follow bowel regime) was 82.04% answered correctly, followed by item 4 with 81.7% correct answers (adjuvant therapies are important in managing pain). Finally, 76.16% of staff correctly answered item 2 (morphine is the standard used to compare the analgesic effect of other opioids).

The lowest percentage of correct answers was for item7 (drug addiction is a major problem when morphine used on a long term basis for the management of pain). The second lowest percentage (21.36%)was for item 19 (the loss of the distant or contentious relationship is easier to resolve than the loss of one that is close or intimate). Item 3 (the extent of the disease determines by the method of pain treatment), was answered correctly 22.91 %, followed by item 12 (the philosophy of palliative care is compatible with that of aggressive treatment) with 28.79% of correct answers.

The result shows that there are considerable variances between the PCQN mean score for oncology staff compared to other unit staff. PCQN mean score for oncology nurses was 11.36 (SD=3.53), indicating that they have fair knowledge about palliative care, while the other areas result shows poor knowledge (critical area mean score=8.7, (SD=2.24), stroke unit mean score =8.37, (SD=3.46), and medical-surgical unit mean score was 9.4, (SD=2.71).

Discussion

This cross-sectional study was conducted in one of the largest and oldest hospitals serving the public sector in Saudi Arabia.

The staff providing the care for palliative patients are not receiving adequate or sufficient palliative care training. A palliative care course was added to the annual courses calendar last year, but the priority for attendance given to the oncology unit staff, so training for all nurses who need it was not accessible. Assessment of the knowledge and attitude of staff toward palliative care was required since they never evaluated before. This study's results helped to create a preliminary image of staff knowledge and attitude toward palliative care that reflect the care provided for palliative patients.

The respondents’ poor knowledge of PCQN and moderate attitude mean score for FATCOD, which is similar for the other studies conducted previously in an Arab country. Gassan and his colleague reported PCQN mean score 9.06 and FATCOD mean score 111.6 for 395 staff in KFSH.⁹

Another study in Iran reflected that the staff had moderately to neutral attitude toward palliative care for 140 staff working in ICU and oncology in three different hospitals (2.99±0.29 out of 5).⁴ In Palestine, in one descriptive, cross-sectional study, the author reported that the staff nurses had poor knowledge and moderate attitude towards palliative care. 20.8% of the respondents had a good overall knowledge of palliative care. 59.4% had the training of palliative care, and 6.2% had a good attitude towards palliative care.¹⁶

Different nurse's nationalities represented in the study site . 44.7% of the participant is from Philippine, 43.4% is Indian, 0.3% Jordanian, and 10.7 is Saudi. Lynch and his team classified the country to groups depending on the level of the integration of palliative care in their health care system. Philippine under group 2 capacity building. India and Saudi Arabia as a group three isolated provision. Jordan in group 4 generalized provision.⁸ If we have a look for the history of palliative care initiation, we will notice that the term had presented in 1980 in India, but still, they have a lot of obstacles and barrier to provide the PC.¹⁷ The Philippines started palliative care services in the late 1980s for patients with cancer patients.¹⁸ while in Jordan Palliative care initiative have been launched with the cooperation of WHO in 2011.¹⁹  but still, they have many challenges and barrier they are facing in their journey to improve the palliative care in their country Comparing the history of palliative care evolution in our regions and advanced region which established and started the services in palliative care since 1967 in London, in USA 1970. Attention for palliative care was given later in the Middle East. There is a gap around 10 to 20 years; it gives us an explanation for the result we got from our study since the regions for our participant still in the early stage of in palliative care integration in their health care system.

In line with that that Multi-National institutional strategy has to be implemented in the Middle East a to improve the palliative care services, national policy on palliative is required, palliative care nursing education as to be added to the undergraduate curricula in every nursing school, formal training and courses for post graduated nurses is necessary.

In this study, there was a low positive correlation between knowledge and attitude toward palliative care. R-value is (0.1645), p-value (0.003), though in the literature Ms. Olivia stated that moderate positive correlation founded in her study which conducted for nurses in a rural region in Ireland, in the other hand Ms. Karkada indicated negative correlation in a study conducted for third-year diploma nurses.

Analysis for demographic data age, gender, years of experience doesn’t reflect any significant impact on the nurse’s knowledge and attitude toward palliative care while in the literature they indicate that the age contribute the staff knowledge and attitude.^3,20 The significant was founded only in the specialty of nurses. Oncology nurses have shown a higher level of knowledge means score for PCQN compared to the other staff who are working in the other units. That can have relayed to the education and training that they received in the last year, and the integration of palliative care education in the continues nursing education in their unit.

This finding is consistent with the literature,^4,21 also it can be related to the experience they got it of dealing with cancer and EOL patients.

In this study, there was no budget; it not funded by an external source.

We would thank all the registered nurse who responded and helped in the study, the research coordinator. Muhammed Alshiekh who analyzed the data and facilitate research conducting process and special thanks for Dr. Sandra Holmes for her continues to support, encouragement and valuable recommendations.

The authors declare no conflicts of interest.

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