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Palliative Care Issues and Challenges in Saudi Arabia: Knowledge Assessment

Among Nursing Students

Article  in  Journal of palliative care · November 2017

DOI: 10.1177/0825859717743229

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Original Article

Palliative Care Issues and Challenges in Saudi Arabia: Knowledge Assessment Among Nursing Students

Omar Mohammad Khraisat, PhD, MSN, RN 1 ,

Mahmoud Hamdan, MSN, RN, CPHQ, CLSSMBB 2 ,

and Mohannad Ghazzawwi, MSN, RN 3

Abstract Background: Nurses are the heart of the palliative care team who provide high standards of care since they spend the longest time with patients. However, lack of adequate knowledge of palliative care is considered as one of the main obstacles to palliative care improvement. Aim: A survey was conducted to assess Saudi nursing students’ knowledge about palliative care. Methods: Using a descriptive design, 154 students who enrolled in first year and who will graduate within 1 year were surveyed in a nursing college located in Riyadh, the capital of Saudi Arabia. The Palliative Care Quiz for Nursing (PCQN) was used to assess students’ knowledge. Results: The sample mean age was 22.1 (standard deviation (SD): 2.2), and most of the students were predominately female (93; 60.4%) and the majority were senior students who will be graduated within the current academic year (105; 68.2%). The total mean score of palliative care knowledge was low at 7.30 (SD: 0.56; range: 0-13), and the number of correctly answered statements ranged from 16 (10.4%, statement no. 7) to 91 (59.1%, statement no. 18). Eleven misconceptions about palliative care among participants are conceptually categorized into 3categories: principle and philosophy of palliative care, pain and symptom management, and psychological and spiritual care. Conclusion: Integrating palliative care education within the nursing programs is the backbone to improve nursing students’ knowledge, namely, in principles of palliative care and symptom management.

Keywords knowledge, nursing students, palliative care, Saudi

Introduction

With an increased worldwide attention to integrate palliative

care with health-care systems, the World Health Organization

(WHO) declared that a public health strategy, education, and

training are required for integrating palliative care with health-

care systems. 1

Knowledge deficit of palliative care among

nurses is well-documented and is considered one of the main

barriers to provide high-quality palliative care. 2-4

There is an

agreement that nurses’ deficient knowledge might relate to

poor integration of palliative topic with the undergraduate nur-

sing programs. 5,6

Nursing students are poorly educated regarding palliative

care in undergraduate nursing curriculums. 7

In addition, little

attention is given to palliative care in most graduate nursing

curricula, leaving advanced practice nurses poorly prepared to

meet the needs of palliative care. 7

Saudi Arabia is known to be culturally different from the

West, where the concept of palliative care is originated. Two

decades ago, palliative care services in Saudi Arabia were

started at the King Faisal Specialist Hospital and Research

Centre (KFSH&RC) in Riyadh by Dr Isbister; from that time,

the field has slowly developed. 7

Nurses are the heart of the palliative care team in providing

high standards of care since they spend the longest time with

patients. 4

In Saudi Arabia, little is identified about palliative

care among nursing students. 1,8

Overall, the necessity for pal-

liative care has increased significantly. 5,6

There is a real need

for palliative care in Saudi Arabia. 1,8

For instance, a study that investigated third-year diploma

nursing students’ (sample size [N]: 83) knowledge about pal-

liative care in India showed a low level of knowledge, with low

total mean scores (mean ¼ 6.4 out of 20; standard deviation (SD): 1.6).

9 The generalizability of these results might be lim-

ited because of small sample and single setting. Another study

conducted in the United States revealed that students’

1 Nursing College, Jerash University, Jerash, Jordan

2 Nursing Department, King Saud Medical City, Riyadh, Kingdom of Saudi

Arabia 3

Nursing Department, Almaarefa College, Riyadh, Kingdom of Saudi Arabia

Corresponding Author:

Omar Mohammad Khraisat, Nursing College, Jerash University, PO Box 26150,

Jerash, Jordan.

Email: khraisat1111@hotmail.com

Journal of Palliative Care 2017, Vol. XX(X) 1-6

ª The Author(s) 2017 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0825859717743229

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knowledge about palliative care tended to increase as they

progressed toward the end of their study program. 10

However,

it was still considered to be limited and inadequate to allow

them to provide a high standard of care once they graduated

from nursing school. 10

Another study conducted in Lebanon to

assess nurses’ knowledge about palliative care found that those

nurses without an educational background (eg, teachers and

this may be because they have long theoretical experience)

have better knowledge of palliative care. 11

In addition, a con-

siderable number of nurses erroneously believed that the main

goal of palliative care is to prolong patients’ lives and that

palliative care could make patients feel hopeless and

depressed. 11

This study recruited a large number of nurses

(sample size [N]: 956) to reply to a specially developed ques-

tionnaire; however, the study instrument was not empirically

tested for reliability or validity. Further, the results of the study

of Chari et al 6

indicated average or poor knowledge of pallia-

tive care in final-year students of bachelor of nursing science

(BSc), which improved after the intervention of the palliative

workshop. 6

Knowledge deficiency appears not to be exclusive to

nursing students; a study was conducted among medical stu-

dents to investigate the palliative care knowledge. 12

In this

study, (sample size [N]: 176), medical students completed

the study questionnaire. About 50% of participants consid- ered that the content of palliative care was moderate, and

they also tended to have poor knowledge. Further, only 14% of the participants were able to answer 6 or 7 out of the

8 questions related to palliative care. 12

Additionally, a study

was conducted in Manipal University among (sample size

[N]: 326) undergraduate nursing students. In all, 61.7 % of students feel that resuscitation is appropriate in advanced

metastatic cancer; 67.5 % of students feel that all dying patients need palliative care and most of the students think

that palliative care is equivalent to pain medicine, geriatric

medicine, and rehabilitation medicine; 89% of students think that morphine causes addiction in palliative care setting; and

60.7% of students feel that prognosis should only be com- municated to the family.

13

Furthermore, many studies showed that nurses working in

nursing homes, pediatric, and critical care units also lack the

knowledge required to provide palliative care. 14-16

Two of

these studies 14,16

used the Palliative Care Quiz for Nursing

(PCQN) to assess knowledge, which is a validated assessment

of nurses’ knowledge regarding palliative care. Both studies

reported that nurses had insufficient knowledge regarding the

principles and practice of palliative care. 14,16

In Saudi Arabia, the palliative care concept was not familiar

for most nurses. 8

Majority of nurses provided physical care at

the end-of-life stage to keep the body intact, and some nurses

highlighted that dying patients did not feel pain to be treated

and did not have emotions to be supported. 8,16

Thus, in Saudi Arabia, limited evidence exists to assess the

nursing students’ knowledge about palliative care. This study

aimed to assess Saudi nursing students’ knowledge about pal-

liative care.

Methods

Sample

A descriptive design was used to assess Saudi nursing students’

knowledge about palliative care. The study was conducted over

a period of 4 months in a nursing college located in Riyadh, the

capital of Saudi Arabia. The inclusion criteria for this study

were nursing students who were studying a bachelor degree and

were able to understand written English.

To assess the knowledge of palliative care effectively, the

sample was drawn based on seniority—first-year nursing

students are considered the juniors and the students who will

graduate within the current academic year are considered the

seniors. The estimated sample size of 150 was calculated using

the Power Primer. 17

Institutional review board approval was obtained from the

selected nursing college. The participants were informed that

their participation was voluntary, and it is their right to with-

draw from the study at any time without penalty and that all

information obtained would be treated confidentially and anon-

ymously. Additionally, permission to use the questionnaire was

obtained from PCQN authors.

Data Collection

The English version of PCQN was used to measure partici-

pants’ knowledge of palliative care that was developed by

Ross, McDonald, and McGuinness in 1996. 18

The English

version of PCQN was used because English is the teaching

language of nursing colleges in Saudi Arabia. The PCQN

comprises 20 questions; the responses being true, false, or

don’t know. For each completed questionnaire, the total score

was calculated (the sum of the number of the correctly

answered items). This score can theoretically range from

0 (minimum score) to 20 (maximum score). However, PCQN

has 3 subscales (theoretical categories) that include the

following categories: philosophy and principles of palliative

care (items 1, 9, 12, 17), pain and symptom management

(items 2–4, 6–8, 10, 13–16, 18, 20), and psychosocial and

spiritual care (items 5, 11, 19).

The mean score of the PCQN subscales was calculated for

each by summing the scores of each item belonging to the

subscale and dividing this by the number of items. The PCQN’s

internal consistency of 0.78 is considered high. 18

A pilot study

was conducted with a sample of nursing students to evaluate

the clarity and appropriateness of the instrument to Saudi

Arabian culture. Reliability of PCQN was Cronbach a 0.70. In addition, information on participants’ demographics was

collected such as age, gender, level at school, and whether they

have received palliative education or not.

Data Analysis

Data were analyzed using SPSS version 17 for windows (SPSS

Inc, Chicago, Illinois). Data were screened for mistake entry

and missing data and outliers. There were no missing values

2 Journal of Palliative Care XX(X)

and outliers. The results were processed using descriptive

statistics (frequency, arithmetic mean, and SD).

Results

The sample consisted of (sample size [N]: 154) nursing stu-

dents, with mean age of 22.1 years (SD: 2.2). Participants were

predominately female (93; 60.4%) and the majority were senior students who will be graduated within the current academic

year (105; 68.2%). The mainstream of 120 (77%) participants reported having received no education about palliative care, as

shown in Table 1.

Knowledge About Palliative Care

The total mean score of knowledge was low at 7.30 (SD: 0.56;

range: 0-13). The number of correctly answered items ranged

from 10.4% on item 7 to 59.1% on item 18, as shown in Table 2. The items 18, 2, 4, and 20 had the most correct answers

59.1%, 55.8%, 52.6%, and 46.8%, respectively. All of these items belong to the pain and symptom management conceptual

category. Although nursing students’ performance on these

selected items were satisfactory, overall performance of other

items of philosophy and principles of palliative care and psy-

chosocial and spiritual care were not satisfactory.

The total mean score for the pain and symptom manage-

ment category (13 items) was low at 1.89 (SD: 0.78) of a

maximum score of 13. The mean scores on the other 2 con-

ceptual categories were even lower: on psychological and

spiritual care (3 items), 1.74 (SD: 0.84) of 3 (maximum

score), and on the philosophy and principles of palliative care

(4 items), 2.22 (SD: 0.85) of 4 (maximum score). Table 2

shows that only 3 items were correctly answered by more than

50% of students, while the other 17 items were answered correctly by fewer than 47% of students.

The results of this study show that nursing students have

insufficient knowledge about palliative care in Saudi Arabia.

For example, they believed that the extent of a disease could

determine the method of pain management (item 3, false), that

loss of a distant relation is easier to resolve than the loss of one

that is close or intimate (item 19, false), and that a placebo is

effective in treating pain (item 13, false). In addition, (89.6%) students believed that addiction is highly possible when mor-

phine is used for a long period (item 7, false).

In Table 3, the top 11 misconceptions about palliative care

among participants are presented. It is clear that students’ most

common misconceptions are not limited to 1 aspect of pallia-

tive care but fall into all 3 conceptual categories: principle and

philosophy of palliative care, pain and symptom management,

and psychological and spiritual care.

Discussion

This is the first survey carried out in Saudi Arabia to assess

nursing student’s knowledge about palliative care. The findings

of the study demonstrated that nursing students have

insufficient knowledge about the core, philosophy, and princi-

ples of palliative care. Their knowledge was severely poor, as

evidenced by the very low average PCQN mean score—7.30

(SD: 0.56); previous studies reported higher means. 2,13

In

addition, 15 items were answered correctly by <40%. The results revealed that nursing students participating in the

study held a considerable number of misconceptions about

palliative care. For example, they believed that the use of

placebo is effective in pain management; they associated the

severity and extent of disease with the selection of the pain

treatment method, and they believed that emotional detach-

ment is a prerequisite for the provision of palliative care ser-

vices. The results of this study were consistent with study of

Al Khalaileh and Al Qadire in which pain management needs

knowledgeable and trained nurses. 19

Because nursing stu-

dents are the nurses of the forthcoming, it is important to

ensure that students are adequately educated about pain man-

agement in nursing schools. 19

The results of this study were partially consistent with pre-

vious studies in regard to low knowledge level. 5,6

However,

some aspects were different, which might be associated with

the status of palliative care in Saudi Arabia. In this study,

nursing students’ knowledge mean score was lower than

reported from other parts of the world. 2,5,6

Additionally, nur-

sing students were not familiar with the concept, and miscon-

ceptions related to pain management, principles, and

philosophy of palliative care were prevalent. This can be

explained by the fact that, in Saudi Arabia, structured palliative

care programs for nursing profession are not available. 8

On top,

palliative care services are limited to some hospitals as training

courses. 8

Further research to examine the availability, ade-

quacy, distribution, and need for palliative care in Saudi Arabia

is strongly recommended.

Another explanation for this low mean score of knowledge

could be the lack of education content about palliative care in

nursing curricula. Previous studies have reported inadequate

education about palliative care in nursing schools’ curricu-

lums. 2,5,6

Moreover, using the English version of the question-

naire could hinder nursing students’ understanding of some

items; although all words are thought to be open to

Table 1. Sociodemographics of Participants.a

Variable No. %

Age Mean (SD) 22.1 2.2

Gender Male 61 39.6 Female 93 60.4

Level at school Junior (first-year nursing student) 49 31.8 Senior (will graduate within the year) 105 68.2

Whether received palliative care education or not? Yes 34 33 No 120 77

Abbreviation: SD, standard deviation. aN ¼ 154.

Khraisat et al 3

misinterpretation, an Arabic version of the questionnaire is

recommended for future work in the field.

However, it was still considered to be limited and not ade-

quate to enable them to provide high standards of care once

they graduated from nursing school. 10

Limitations

There are some limitations to this study. First, the sample was

recruited based on convenience sampling; hence, the partici-

pants who completed the survey might not entirely reflect the

knowledge of those who did not. This reduces the possibility of

Table 2. Descriptive Results of Students’ Answers on the PCQN.

Item Nursing Students’ Answers

Correct Wrong Item Frequency (%) Frequency (%)

1 Palliative care is only appropriate in situations where there is evidence of a downward trajectory or deterioration (F)

41 (26.6) 113 (73.4)

2 Morphine is the standard used to compare the analgesic effect of other opioids (T) 86 (55.8) 68 (44.2) 3 The extent of the disease determines the method of pain treatment (F) 23 (14.9) 131 (85.1) 4 Adjuvant therapies are important in managing pain (T) 81 (52.6) 73 (47.4) 5 It is crucial for family members to remain at the bedside until death occurs (F) 45 (29.2) 109 (70.8) 6 During the last days of life, drowsiness associated with electrolyte imbalance may decrease the need for

sedation (T) 31 (20.1) 123 (79.9)

7 Drug addiction is a major problem when morphine is used on a long-term basis for the management of pain (F)

16 (10.4) 138 (89.6)

8 Individuals who are taking opioids should also follow a bowel regime (T) 63 (40.9) 91 (59.1) 9 The provision of palliative care requires emotional detachment (F) 33 (21.4) 121 (78.4) 10 During the terminal stages of an illness, drugs that can cause respiratory depression are appropriate for

the treatment of severe dyspnea (T) 54 (35.1) 100 (64.9)

11 Men generally reconcile their grief more quickly than women (F) 33 (21.4) 121 (78.4) 12 The philosophy of palliative care is compatible with that of aggressive treatment (T) 50 (32.5) 104 (67.5) 13 The use of placebos is appropriate in the treatment of some types of pain (F) 29 (18.8) 125 (81.2) 14 High-dose codeine causes more nausea and vomiting than morphine (T) 52 (33.8) 102 (66.2) 15 Suffering and physical pain are synonymous (F) 43 (27.9) 111 (72.1) 16 Demerol is not an effective analgesic for the control of chronic pain (T) 51 (33.1) 103 (66.9) 17 The accumulation of losses renders burnout inevitable for those who work in palliative care (F) 27 (17.5) 127 (82.5) 18 Manifestations of chronic pain are different from those of acute pain (T) 91 (59.1) 63 (40.9) 19 The loss of a distant relationship is easier to resolve than the loss of one that is close or intimate (F) 25 (16.2) 129 (83.8) 20 Pain threshold is lowered by fatigue or anxiety (T) 72 (46.8) 82 (53.2)

Abbreviations: F, False; T, True.

Table 3. Common Student Misconceptions About Palliative Care.

Statement Conceptual Category

Drug addiction is a major problem when morphine is used on a long-term basis for the management of pain (F). Statement no. 7

Pain and symptom management

The extent of the disease determines the method of pain treatment (F). Statement no. 3 Pain and symptom management The loss of a distant relationship is easier to resolve than the loss of one that is close or intimate (F).

Statement no. 19 Psychological and spiritual care

The use of placebos is appropriate in the treatment of some types of pain (F). Statement no. 13 Pain and symptom management During the last days of life, drowsiness associated with electrolyte imbalance may decrease the need for

sedation (T). Statement no. 6 Pain and symptom management

The provision of palliative care requires emotional detachment (F). Statement no. 9 Philosophy and principles of palliative care

Men generally reconcile their grief more quickly than women (F). Statement no. 11 Psychological and spiritual care Palliative care is only appropriate in situations where there is evidence of a downward trajectory or

deterioration (F). Statement no. 1 Philosophy and principles of

palliative care Suffering and physical pain are synonymous (F). Statement no. 15 Pain and symptom management It is crucial for family members to remain at the bedside until death occurs (F). Statement no. 5 Psychological and spiritual care

Abbreviations: F, False; T, True.

4 Journal of Palliative Care XX(X)

generalizing the implications of the study. Second, this study

was limited to 1 college located in Riyadh, the capital of Saudi

Arabia, which limits the external validity of the findings.

Conclusion

The main aim of this study was to assess nursing students’

knowledge about palliative care. According to the results pre-

sented, it is noticeable that students’ knowledge was inadequate

regarding the philosophy and principle of palliative care as

shown by the low average for PCQN score. This result is similar

to Ronaldson et al’s study in 2015. 8

This study used the same

research instrument to evaluate students’ knowledge regarding

palliative care. 8

In addition, this study displays that the students

had a large number of misconceptions of palliative care. 8

Addi-

tionally, nursing students believed that palliative care is only

appropriate for advanced illness and deteriorated cases. 8

This

conclusion was also confirmed by another research study. 19

Remarkably, in this study, the number of nursing students

who received palliative education was lower than the number

of students who did not. However, the lack of knowledge about

palliative care among students could be a result of insufficient

palliative nursing teaching in the curriculum in Saudi Arabia.

Previous scholars stated that the number of educational hours in

palliative care nursing was inadequate. 10,11

In this study, the nursing course content was not evaluated.

However, 77% of students reported that during their study, they did not receive palliative care education. This finding empha-

sizes the need for palliative care nursing education integrated

within the nursing programs. Hence, in order to improve stu-

dents’ knowledge of palliative care, course content should

cover the principles of palliative care. For example, these prin-

ciples may consist of pain management and symptom control

and psychological and spiritual care. Moreover, there are many

studies that highlighted the importance of palliative care edu-

cation to improve nursing practice. 6,12,13,20

Thus, the impact of inadequate knowledge about palliative

care nursing will affect nursing quality of care in the future in

Saudi Arabia. In summary, there were significant differences in

the mean score of PCQN for prior palliative care education

among nursing students. One explanation is that those students

came from different years of study. It is recommended that

palliative care education should be a requirement through

including it as a part of the BSN courses. This can be achieved

by including palliative care topics in all specialized nursing

courses. More research should be carried out to assess the

course content of palliative care education in the nursing cur-

riculum to improve nursing knowledge about palliative care,

namely, in Riyadh, Saudi Arabia.

Acknowledgment

The authors would like to thank all who assisted in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for

the research, authorship, and/or publication of this article: This

research was funded by Jerash University.

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6 Journal of Palliative Care XX(X)

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