Knowledge and attitude towards palliative care and associated factors among nurse: a cross-sectional descriptive study

Palliative care(PC) is an intervention that reduces pain and improves the quality of life for those coping with the consequences of life-threatening diseases [1]. According to the World Health Organization (WHO), PC is a form of nursing care, which helps patients and their families improve their quality of life in the face of life-limiting diseases by preventing and improving the patient’s suffering and by identifying the cause. This enhances the primary treatment and prevention of pain as well as other physical, psychological, spiritual, and social problems [2].

The concept of PC was first proposed in the early 1980s [3]. Furthermore, these practices are effective in reducing the suffering of patients suffering from chronic diseases [4]. PC includes advanced care planning, physical and emotional support, social support, grief support, and bereavement support. The patient is also spiritual, therefore, PC is not only intended to relieve pain, but also to facilitate the patient’s psychological preparation for death. According to traditional definitions, PC refers to the care provided to patients who are dying [5]. By 2060, it is estimated that 48 million individuals will die annually owing to severe health conditions [6]. Through the current century, cancer has been one of the most challenging diseases worldwide [7] and it is the third leading cause of mortality in Iran following cardiovascular diseases and traffic accidents [8]. The WHO has introduced PC as a solution for improving the life quality of patients with refractory diseases and their families. According WHO, 34% of patients requiring PC are cancer patients, only14% of whom receive PC. It is notable that about 78% of these patients live in the low or middle-income countries [9]. Caring for cancer patients includes all stages of the disease, from diagnosis to the end of patients’ life. Therefore, PC which provides comprehensive care for the patient and his/her family is emphasized for these patients [10]. In Iran, PC is not provided coherently for cancer patients. Despite the importance of this topic, PC has become a major challenge for the health system [8].

PC may also be needed for patients suffering from dementia, kidney failure, multiple sclerosis, parkinson’s disease, rheumatoid arthritis, neurological disorders, congenital abnormalities, and resistant tuberculosis [11]. It has been shown that chronic patients are increasing, there is a shortage of manpower and critical care beds in medical centers, incurable patients are often hospitalized at the end of their lives in hospitals and special departments, and end-of-life care costs are increasing [12]. The issue of PC has been raised more than ever before.

Since nurses are at the forefront of patient care and provide palliative and end-of-life care for patients [13] they are also the primary point of communication between the patient, his or her family, and members of the treatment team. Consequently, it is imperative to have sufficient knowledge and competence in the field of PC. The lack of sufficient knowledge in the field of PC has been identified as one of the major challenges in obtaining these services [14].

The two factors of knowledge and attitude are considered essential factors in the implementation of PC by nurses, so nurses should have adequate information about PC and a positive attitude and motivation [15]. According to the definition of attitude, it is an expression of a person’s feelings, opinions, and beliefs and is created by their emotions [16]. It is important that nurses adopt a positive attitude towards PC in order for the program to be successful. A nurse’s attitude toward palliative care is influenced by a variety of factors, including their motivation, socio-cultural factors, beliefs, family relationships, previous experiences, and economic status. These factors can vary from community to community as well as within clinical departments, and have an effective effect on the implementation of PC [3].

According to a systematic study, nurses’ personal characteristics, including age, nursing experience, education about end-of-life care, level of education, and direct experience in caring for dying patients, are associated with a greater level of knowledge and positive attitude toward care for dying patients [17]. According to Hosseinzadegan et al.‘s study conducted in Iran, nurses have a positive attitude and average knowledge and skill in pain assessment and management [16]. A similar study conducted in Northern Ireland found that only 20% of participants had accurate information about PC, and one of their misconceptions was that PC is only available to people in their last six months of life [18]. Further, a study found that nurses do not have sufficient knowledge about PC, but their attitude toward providing these services was positive [13]. According to Ghazanchaie et al., nurses in neonatal critical care units have positive attitudes toward PC [3]. The implementation of PC has been hampered by a number of factors, including insufficient resources, incorrect usage of technology, a lack of human resources, a lack of knowledge among parents and differences in culture and religion as well as the lack of PC teams [1, 19]. Also, evidence suggests that PC in Iran is only offered in isolated and limited centers. Most patients are deprived of this kind of care, and home-based PC does not have any place in Iran’s health system. Patients with incurable conditions who require PC services are lost in the system, and in most cases do not receive proper and timely services they need [8, 10, 20, 21]. Also, the traditional attitude of healthcare staff towards the management of incurable conditions, the lack of transparency in the protection of healthcare staff against discontinuation of unnecessary treatments or unreasonable expectations of patients and their families, as well as social and cultural differences are barriers to the promotion of PC in Iranian society [21]. There are currently no systematic structures for providing PC in Iran [10, 22]. In Iran, the existing knowledge on PC has not been well-defined and has not been seriously addressed in the education curriculum of nurses [8].

Most of the studies conducted in Iran have evaluated the knowledge and attitude of nurses in the field of pain management or end-of-life care, a sub-branch of PC, as well as other areas of palliative care and the factors influencing it. In light of this, there is a lack of research regarding Iranian nurses’ knowledge and attitudes regarding PC. Knowing a nurse’s level of knowledge and attitude is essential to planning and implementing effective health and treatment measures, since nurses play a significant role in the health and treatment systems.

Approximately 71.6% of nurses were female, 89.5% had rotation shift, 95.7% were nurses, and 82.2% held a bachelor’s degree. It is estimated that the mean work experience was 9.75 ± 6.75 years, 20.8% of respondents had formal training in PC, 55.9% had previously cared for a terminally ill patient, and 84.9% had previously cared for a dying patient (Table 1).

Based on the results of this study, the mean score of PC knowledge was 10.15 ± 2.91. We found statistically significant differences between the mean knowledge scores based on job position (p = 0.02), experience caring for dying patients (p = 0.002), and job satisfaction (p = 0.02). The results of the study also indicated that the mean score of PC attitude was 55.32 ± 10.56, which was below average. The results of the independent sample t-test indicate that there is a statistically significant difference between the mean score for attitude and the variable of prior formal training in palliative care (p = 0.03). Accordingly, individuals who had previously received formal PC training received higher scores (Table 1).

The univariate regression model showed that age (B = 0.08, p = 0.045), education level (B=-2.58, p = 0.009), experience caring for dying patients (B = 0.87, p = 0.004), job position (B=-1.11, p = 0.04), and job satisfaction (B = 0.51, p = 0.02) are all effective predictors of mean knowledge scores (R ²=0.062, Adjusted R = 0.055; Table 2).

A backward univariate regression test was also conducted for the dependent variable, attitude, and all demographic variables were entered into the model, and then non-significant variables were removed one by one until the model was constructed. The results indicated that the work experience (B=-0.42, p = 0.03), the experience caring for terminally ill patients (B = 2.60, p = 0.02), the formal training in PC (B=-2.68, p = 0.01), and the need for further training (B=-4.45, p = 0.0001) significantly affected the mean attitude score (R ²=0.129, Adjusted R = 0.110; Table 3).

This study aimed to examine nurses’ knowledge and attitudes towards PC working in a hospital. The nurses who participated in this study achieved a higher mean knowledge score than the average. The results of Hosseinzadegan et al.‘s study in Iran showed that nurses have moderate knowledge in PC. A weakness to moderate level of nursing knowledge has also been observed in other studies conducted in Iran [29‐32] and other countries [4, 15, 33‐37]. According to other research, nurses in critical care units possess a higher level of PC knowledge [38]. This results are consistent with the findings of the present study. However, Alipoor et al.‘s study [39] and Dehghannezhad et al.‘s study in Iran showed that nurses have limited knowledge in PC [19]. According to the above finding, experience of caring for terminally ill and dying patients may have contributed to the improvement of nurses’ knowledge to some extent. According to the results of this study, almost half of the nurses had received experience of caring for terminally ill and dying patients, which may have contributed to their increased knowledge. In addition, the differences in findings between similar studies may be explained by differences in demographics, study context, research tools, and sample sizes. There is also the possibility that in other studies nurses did not receive formal training in PC, which led to different results and this lack of knowledge could be the result of the flaws in the curricula or on‑the‑job training programs in the health system, it is necessary to develop new strategies for increasing the knowledge of palliative care in Iran. In Iran, PC is a new approach and the care givers’ insufficient knowledge and lack of awareness and expertise with regard to these services, especially among physicians and nurses, is considered a barrier against the provision of PC services [24].

The results of the present study showed a positive and significant statistical relationship between age, the experience of caring for dying patient and the level of knowledge of nurses, indicating that nursing knowledge of palliative care increases as one becomes older and has more experience caring for dying patients. The results of another study in Iran showed that there is a significant relationship between the average score of PC knowledge and the age of the nurse, which is in line with the results of the present study [24]. In this regard, some studies indicate that the experience of dealing with the patients in need of PC has a direct and positive impact on caregivers’ knowledge of and attitude towards care providers [24, 25, 40]. Another study also found a positive relationship between age of the working period and nurses’ knowledge of PC [41]. The results are consistent with those of Abudari et al., who found that nurses’ knowledge of PC is related to their age [42]. It can be interpreted that this finding is related to the holding of in-service training courses for nurses during the present study. There is a direct correlation between an individual’s age and their ability to receive information. As a person’s age increases, his or her ability to receive information increases as well. A person’s ability to perform this function is influenced both by their senses and by their brain and individual health. As someone grows older, they become more mature and stronger in terms of their abilities to think and work.

According to the results of the study, there is a negative and significant relationship between educational level (bachelor’s degree) and knowledge score, which means that nurses with a bachelor’s degree had a lower knowledge score than nurses with a master’s degree. In this regard, the another study in Iran also show that as the level of education increases, caregivers’ knowledge regarding PC improves [24]. In a systematic review, health care providers with a bachelor’s degree had a higher level of PC knowledge [43]. Interpreting this finding, it can be said that the nursing curriculum in Iran does not provide comprehensive training in PC, but the nursing master’s curriculum provides the necessary training. Furthermore, it has been shown that different levels of education among individuals can influence the level of knowledge and nursing care provided to patients [41].

According to other findings, the job satisfaction can influence nurses’ ability to increase their knowledge. According to the interpretation of this finding, interest in the field and job satisfaction influence the pursuit and search for knowledge in medical personnel [44]. As a result, nurses’ satisfaction with their profession in this study increases their desire to learn and increase their knowledge. In addition, nurses who worked in the wards had a greater knowledge of PC than head nurses. Several studies have demonstrated that PC training history, personal study, age, and PC experience are directly related to PC knowledge [16, 31, 32]. The greater requirement that nurses participate in in-service training courses and the experience of working with patients has resulted in higher knowledge levels among nurses than among head nurses due to the fact that head nurses are more involved in departmental management activities and are unable to interact directly with patients.

According to the results of this study, nurses participating in this study have a low attitude towards PC at the end of life. In this regard, the results of Dehghannezhad et al.‘s study also showed the low attitude of nurses towards PC [19]. Also the results of Azami-Agdash et al. showed that the scores of attitudes regarding hospice care among the nurses were low [45]. The results of another study in Jordan also showed that the attitude of nurses towards PC is low [23]. In Masharipova et al.‘s study, The majority of nurses (93%) have a neutral or negative attitude toward caring for dying patients [46]. While, according to the results of a another studies in Iran, nurses have a moderate attitude toward PC [3, 32, 47]. Compared to the results of the current study, these findings are different. According to the results of the present study, it can be said that despite the fact that the knowledge score was favorable, this score may not have changed their attitudes. There are also other factors that may have affected their attitude, such as the physical environment of the department, the availability of manpower, the existing facilities. Furthermore, studies have indicated that a variety of factors can influence an individual’s attitude, including their success, demographic characteristics and different care departments [36]. It is evident from this issue that training and holding theoretical and practical training sessions is essential for improving the participants’ positive attitudes. Also it said that differences in the attitude of nurses may indicate differences in beliefs and cultural characteristics of the above regions that need to be investigated.

As a result of the present study, there was a statistically significant relationship between the attitude of nurses with work experience, the experience of caring for a terminally ill patient, and receiving formal training. Consequently, nurses with more experience caring for terminally ill patients had a more positive attitude towards PC providers. It has also been found that people who have participated in formal PC training courses have a more positive attitude toward this type of care than those who have not. Based on Ashrafzadeh et al.‘s study, nurses in Iran showed varying levels of knowledge and attitude based on their age, education, prior experience caring for terminally ill patients, and work environment [32]. In Dehghannezhad et al. ‘s study, the participants who had the experience of providing cancer care had a more positive attitude than the other participants [19]. The results of the study by Hojjati et al. also showed that there is a positive and significant relationship between attitude and participation in the training workshop and work experience in nurses, which is in line with the results of the present study [26]. In the study Etafa et al. showed nurses’ experience was significantly associated with nurses’ attitudes toward PC [37]. Also, another study in which nursing attitudes were associated with years of experience, found that 43.7% of the nurses had unfavorable attitudes toward PC [48]. In the study of Younis et al., a relationship between gender, type of university, and participation in palliative care training courses with attitudes toward caring for dying patients was reported [49]. According to Kassa et al., there is also a significant correlation between nurses’ attitudes and education, work experience in the internal department, and having received training [4]. Working experience is a variable that indirectly affects one’s attitude and performance [41].

Also, nurses who have cared for patients before death have a high score, indicating that their frequent interactions with dying patients are associated with a more positive attitude towards caring for them. Experience in the workplace indirectly influences a person’s performance and attitude. Working hours and experience in managing cases will be related to their skills. The development of a person’s behavior and attitude when making decisions related to implementing the appropriate actions requires time and experience. In general, the longer a person works, the better and more skilled he becomes at his job [41].

Nurses’ knowledge about palliative care is acceptable, but they do not have a positive attitude towards implementing PC. There seems to be a need for providing training in all PC (both knowledge and attitude) to improve the nurse’s attitude and knowledge. There is a lot of evidence regarding the inadequacy of PC training programs in various medical disciplines in Iran. Although, in general, there is no formal direct training under the title PC regarding the basics and principles of PC during general medicine and nursing undergraduate programs [24]. Therefore, it is necessary to pay attention to the improvement of knowledge and awareness, with special attention paid to factors affecting the attitude towards supportive PC, in order to assist in solving existing problems and improving the quality of PC by examining the obstacles and facilitators associated with implementing PC.