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International Journal of Palliative Nursing 2014, Vol 20, No 9 435

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Abstract Background: Palliative care is not yet integrated into the health-care system in Saudi Arabia. King Faisal Specialist Hospital and Research Centre-Riyadh (KFSH&RC-Riyadh) is a tertiary care facility and regional cancer centre in Saudia Arabia with a highly multinational nursing workforce. Little is known about these nurses’ knowledge of and attitudes towards palliative care. Aim: To determine the palliative care knowledge and attitudes of the nursing workforce of KFSH&RC-Riyadh and any influencing factors. Method: A questionnaire including demographic data, the Palliative Care Quiz for Nurses (PCQN), and Frommelt Attitude Toward Care of the Dying scale (FATCOD) was completed by 395 staff nurses from 19 countries. Results: The nurses scored a mean of 111.66 out of 150 on the FATCOD scale and of 9.06 out of 20 on the PCQN. These scores indicate moderate attitudes towards but a knowledge deficit regarding palliative care. The nurses’ palliative care training and years of nursing experience significantly affected the scores. The level of palliative care integration in the nurses’ home countries was the most significant factor in multiple regression tests. Conclusion: Palliative care integration into the health-care system of the country in which nurses train significantly influences their knowledge of and attitudes towards palliative care. Incorporating palliative care into nursing education might promote positive attitudes towards palliative care in nurses while enhancing their knowledge and skills. Key words: Palliative care integration l Knowledge l Attitude l Nursing l Saudi Arabia

T he first palliative care service in Saudi Arabia was established in 1992 at King Faisal Specialist Hospital and Research

Centre-Riyadh (KFSH&RC-Riyadh). Since then, only a few hospitals in Saudi Arabia have adopted palliative care as a part of their service. No action has been taken to improve palliative care nation- ally, and aside from what is provided in the pri- mary health-care system, it remains a matter of local provision (Alsirafy et al, 2009; Lynch et al, 2013). As many as 86% of palliative care in- patients in Saudi Arabia die in hospitals, because hospice care is not available and in-home pallia- tive care services are insufficient (Alsirafy et al, 2009). Patients receive late referrals to palliative care services (Alsirafy et al, 2010), few patients with non-cancer conditions receive referrals to palliative care services at all (Ghanem et al, 2011), and there is a lack of education on palliative care in medical and nursing schools (Alamri, 2012).

Nursing is considered the cornerstone of pallia- tive care (Lynch et al, 2011), but insufficient pallia- tive care knowledge among nurses is a barrier to quality provision (Paice et al, 2008). Education regarding palliative care in general nursing curric- ula worldwide is considered by many to be inade- quate (Ahmed et al, 2004; Nakazawa et al, 2009; Choi et al, 2012). Nurses’ knowledge of and atti- tudes towards palliative care are influenced by their age, nursing specialty, experience, and educational level (Adriaansen and van Achterberg, 2008; Barrere et al, 2008; Abu-Saad Huijer et al, 2009; Ford and McInerney, 2011; Choi et al, 2012). Attitudes towards palliative care have been found to be improved by palliative care education inter- ventions in experimental studies (Frommelt, 2003; Mallory, 2003; Barrere et al, 2008; Zargham- Boroujeni et al, 2011). Many countries have now adopted a systematic approach to improving pallia- tive care education that focuses on developing teaching strategies, integrating palliative care into nursing curricula, ongoing nursing education, and promoting clinical experience (Brajtman et al, 2007; Ronaldson et al, 2008; Wilson et al, 2011).

KFSH&RC-Riyadh is a tertiary care facility that employs nurses of around 30 different nationali- ties. As palliative care is not yet integrated into the health-care system in Saudi Arabia, expatriate nurses’ knowledge of and attitudes towards pallia- tive care probably result primarily from the educa- tion and experience gained in their home country. Thus, there may well be variation in the nurses’ knowledge of and attitudes towards palliative care in Saudi Arabia. Lynch et al (2013) classified countries into six groups according to the level of palliative care integration in their health-care sys- tems. The criteria for the classification were based on data such as the level of public awareness, opi- oid availability, institutions providing palliative

Research

Knowledge of and attitudes towards palliative care among multinational

nurses in Saudi Arabia Gassan Abudari, Hassan Zahreddine, Hassan Hazeim, Mohammad Al Assi, Sania Emara

Gassan Abudari, Palliative Care Clinical Nurse Coordinator; Hassan Zahreddine, Oncology-Hematology Education Coordinator; Hassan Hazeim, Palliative Care Nurse; Mohammad Al Assi, Palliative Care Clinical Instructor; Sania Emara, Head Nurse, Palliative Care Unit, King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211, Saudi Arabia

Correspondence to: Gassan Abudari gabudari@kfshrc.edu.sa

International Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on October 28, 2015. For personal use only. No other uses without permission. . All rights reserved.

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care education, and availability of hospice and palliative care in the community. Nurses from countries with greater integration of palliative care into the education and health-care systems may have better knowledge of and attitudes towards palliative care.

Aim The aim of this study was to assess knowledge of and attitudes towards palliative care among mul- tinational nurses working at KFSH&RC-Riyadh and whether these are influenced by the nurses’ demographic variables and the level of palliative care integration in their home country.

Methods Design This study used a descriptive cross-sectional design in which nurses completed self-adminis- tered questionnaires. The questionnaires quanti- fied the nurses’ knowledge of and attitudes towards palliative care and included a demo- graphic questionnaire, the Palliative Care Quiz for Nursing (PCQN) (Ross et al, 1996), and the Frommelt Attitudes Toward Care of the Dying (FATCOD) scale (Frommelt, 2003).

Instruments The demographic questionnaire was developed by the authors and recorded variables such as age, gender, country of origin, palliative care experience and education, and nursing specialty.

The PCQN quantifies knowledge regarding palliative care. It comprises 20 questions with possible responses of ‘true’, ‘false’, and ‘I do not know’. The questions measure understand- ing of the philosophy and principles of pallia- tive care, pain and symptom management, and psychosocial care. Total scores are calculated by assigning a value of 1 to correct responses and 0 to incorrect and ‘I do not know’ responses. Thus, the total score can range from 0 to 20, with a lower score indicating poorer knowledge. The PCQN was used without mod- ification and has been validated in similar stud- ies (Kim et al, 2011).

The FATCOD scale assesses attitudes towards the care of dying patients and their families. It consists of 30 items that are scored on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Possible overall scores range from 30 to 150, with higher scores reflecting more positive attitudes. The scale contains both negative and positive statements, with reversed scores assigned to negative statements. The scale was used without modification and has previ- ously been validated (Barrere et al, 2008).

Setting and sample KFSH&RC-Riyadh is a 936-bed tertiary care facility and a regional cancer centre. It provides advanced care for the adult and paediatric popu- lation of Saudi Arabia, including critical care, cardiovascular, oncology, medical, and surgical care. There is a well-established palliative care unit in the hospital, which has existed since 1992. A total of 1942 nurses from 30 different nationalities were working at the hospital at the time of the study.

Ethical considerations The Research Ethics Committee at KFSH&RC- Riyadh approved the study. Participants were informed of the purpose of the study and given instructions for completing the questionnaire in a cover letter. The cover letter indicated that com- pletion of the questionnaire was voluntary and that anonymity would be maintained.

Data collection A total of 731 questionnaires were distributed to direct care nurses and hospital-based clinical instructors working in outpatient clinics or inpa- tient oncology, surgical, medical, cardiovascular, obstetric/gynaecologic, and intensive care wards. Completed questionnaires were received from 395 respondents (54% response rate) of 19 dif- ferent nationalities.

Data analysis Data analysis was performed with Statistical Package for the Social Sciences (SPSS) version 21.0 for windows (IBM). Descriptive statistics were used for the participants’ demographic data and knowledge and attitude scores. An independ- ent t-test was used to compare knowledge and attitudes for variables categorised with two groups, such as palliative care training. A one- way analysis of variance (ANOVA) was used for variables categorised with three or more groups, followed by post hoc pair-wise comparisons when the ANOVA revealed significant differ- ences. Pearson’s (r) correlations were used to determine the relationships between the PCQN and FATCOD scores. Finally, multiple regression analysis was used to investigate associations between the PCQN and FATCOD scores and sig- nificant independent variables.

Results Participant demographics Table 1 presents the demographic variables for all respondents. Table 2 presents the nurses’ original countries, classified according to the Lynch et al (2013) criteria for the level of pallia-

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tive care integration into their health-care sys- tem. The majority of the respondents were female (90.1%), younger than 40 years (71.9%), had less than 10 years of experience in nursing (56.2%), and held a bachelor’s degree in nursing (71.9%). About 50% were from coun- tries with ‘isolated’ palliative care provision. A minority of the nurses had received palliative care training (26%), which reflects the lack of palliative care education in nursing curricula. However, a majority of the nurses stated that they had palliative care experience (76.1%), which was probably attained by caring for the patients in their units.

PCQN analysis The mean PCQN total score was 9.06 (standard deviation (SD) 3.07). This relatively low score indicates poor knowledge of palliative care. Table 2 presents the four PCQN questions with the highest percentage of correct scores and the four with the lowest percentage of correct scores. Question 8 (‘Individuals who are taking opioids should also follow a bowel regime’) had the high- est percentage of correct responses (85.53%), whereas question 19 (‘The loss of a distant or contentious relationship is easier to resolve than the loss of one that is close or intimate’) had the lowest (20.46%).

Total PCQN scores varied according to nation- ality. In general, the mean scores were higher for nurses from countries with advanced palliative care integration, e.g. USA: n=13, mean score=13.0; Ireland: n=9, mean score=12.44, than for those from other countries, e.g. Philippines: n=144, mean score=9.02; Malaysia: n=51, mean score=7.27 (Table 3). The mean total score for nurses from Saudi Arabia (n=32) was 7.06, which reflects a deficiency in palliative care education.

According to the post-hoc analysis, the mean total PCQN score of the nurses from countries with advanced palliative integration (group 6: n=59, mean score=11.83) was significantly higher than those of the nurses in the other groups, e.g. those from countries with preliminary integration (group 5: n=73, mean score=8.36, P<0.001). There were no significant differences between the other groups. Within groups, the Malaysian nurses had a significantly lower mean total PCQN score than the rest of the nurses in group 5, according to post-hoc tests (P<0.001).

Nurses with palliative care experience (n=300, mean score=9.31) had significantly higher mean total scores than nurses with no palliative care experience (n=94, mean score=8.3, P=0.05). Nurses with palliative care training (n=102, mean score=9.98) had significantly higher mean total

scores than nurses without palliative care train- ing (n=291, mean score=8.74, P<0.001).

There was a significant difference between the groups according to nursing specialty on initial analysis. Oncology nurses (n=113) scored lower than expected (mean total score=9.51), whereas surgical nurses (n=49) had the highest mean total score (10.10). However, there was no significant difference between surgical and oncology nurses in post-hoc testing (P=0.998).

FATCOD analysis The mean total FATCOD score was 111.66 (SD 13.97). This score reflects a moderate atti- tude towards palliative care. Table 4 presents the four FATCOD scale items with the highest and lowest mean scores. Question 16 (‘Families need emotional support to accept the behaviour changes of the dying person’) had the highest mean score (4.51), whereas question 29 (‘Family members who stay close to a dying person often interfere with the professional’s job with the patient’) had the lowest (2.58).

Variable Number* Percentage

Age

20–30 years 161 40.9%

31–40 years 122 31.0%

41–50 years 60 15.2%

51–60 years 51 12.9%

Gender

Male 39 9.9%

Female 356 90.1%

Nursing experience

1–5 years 119 30.1%

6–10 years 103 26.1%

11–15 years 74 18.7%

16–20 years 54 13.7%

>20 years 45 11.4%

Level of nursing degree

Diploma degree 96 24.3%

Bachelor degree 284 71.9%

Master degree 9 2.3%

Other degree 6 1.5%

Palliative care experience

Yes 300 76.1%

No 94 23.9%

Palliative care training

Yes 102 26.0%

No 291 74.0%

*Some questions were not completed by all respondents.

Table 1. Respondent demographics

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Generally, mean total FATCOD scores were higher for nurses from countries with advanced palliative care integration, e.g. Ireland: n=9, m e a n s c o r e = 1 3 2 . 4 4 ; U SA : n = 1 3 , m e a n score=129.69, than for nurses from countries with less integration, e.g. Philippines: n=144, mean score=108.92; Jordan: n=21, mean score=105.43 (Table 3). The mean score for nurses from Saudi Arabia (n=32) was 101.69,

which reflects the need to improve palliative care education in Saudi Arabia.

Similar to the PCQN results, post-hoc analysis revealed that the total FATCOD scores of the nurses from countries with advanced palliative care integration (group 6: mean score=128.31) were sig- nificantly higher than those of nurses in the other groups, e.g. those from countries with a preliminary level of integration (group 5: mean=113.16,

Question

number Item

Percentage of

correct responses

Standard

deviation

8 Individuals who are taking opioids should also follow a bowel regime 85.53% 0.35

18 Manifestations of chronic pain are different from those of acute pain 83.38% 0.37

4 Adjuvant therapies are important in managing pain 75.52% 0.43

2 Morphine is the standard used to compare the analgesic effect of other opioids 70.59% 0.46

17 The accumulation of losses renders burnout inevitable for those who work in palliative care 23.02% 0.42

12 The philosophy of palliative care is compatible with that of aggressive treatment 21.99% 0.41

3 The extent of the disease determines the method of pain treatment 20.97% 0.41

The loss of a distant or contentious relationship is easier to resolve than the loss of one that is

close or intimate 20.46% 0.40

Table 2. Items from the Palliative Care Quiz for Nursing (PCQN) with the highest and lowest percentages of correct responses (n=395)

Level of palliative care

integration Country

Number of

respondents

Mean PCQN

total score (SD)

Mean FATCOD

total score (SD)

Group 1: No known activity Somalia 1 10.00 118.00

Group 2: Capacity building No respondents – – –

Group 3: Isolated provision

Egypt 2 8.00 (2.83) 116.50 (13.44)

Lebanon 11 9.27 (2.83) 106.36 (16.83)

Pakistan 11 8.18 (2.09) 102.45 (12.09)

Philippines 144 9.02 (2.77) 108.92 (10.12)

Saudi Arabia 32 7.06 (2.96) 101.69 (14.96)

Group 4: Generalised

provision

Czech Republic 7 9.14 (3.44) 114.29 (14.47)

India 32 8.38 (2.03) 106.56 (10.18)

Jordan 21 8.24 (2.86) 105.43 (9.58)

Portugal 2 11.00 (0.00) 133.00 (1.41)

Group 5: Preliminary

integration

Finland 3 10.00 (2.00) 132.67 (7.37)

Malaysia 51 7.27 (2.35) 109.22 (9.70)

New Zealand 11 10.73 (3.20) 125.09 (14.77)

South Africa 8 11.38 (2.97) 114.63 (15.63)

Group 6: Advanced

palliative care integration

Australia 7 11.29 (1.98) 125.43 (4.39)

Canada 10 11.30 (2.36) 126.50 (9.69)

Ireland 9 12.44 (2.46) 132.44 (13.32)

UK 20 11.25 (3.48) 127.45 (13.65)

USA 13 13.00 (3.58) 129.69 (10.66)

Total 395 9.06 (3.07) 111.66 (13.97)

FATCOD, Frommelt Attitudes Toward Care of the Dying scale; PCQN, Palliative Care Quiz for Nursing; SD, standard deviation

Table 3. Mean PCQN and FATCOD scores for each respondent’s home country, by level of palliative care integration according to Lynch et al (2013)

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P<0.001). There were no significant differences between the other groups. Within groups, the Malaysian nurses had a significantly lower mean total FATCOD score than the rest of the nurses in group 5, according to post-hoc tests (P<0.001).

There were significant differences between the total FATCOD scores of nurses in different age groups (F(3, 390)=5.22, P=0.002). Nurses aged 40–50 years scored significantly higher on the FATCOD (n=60, mean score=117.12) than nurses aged 20–30 years (n=161, mean score=111.53, P=0.038) and nurses aged 31–40 years (n=122, mean score=108.70, P=0.001).

Although nursing specialty significantly affected knowledge on initial testing, it did not significantly affect attitudes. Critical care nurses (n=66) had the highest mean total score on the FATCOD (113.08) but had a low mean total score on the PCQN (8.53). The mean total FATCOD score for nurses with palliative care experience (n=300, mean score=112.49) was sig- nificantly higher than that for nurses without pal- l i a t i v e c a r e e x p e r i e n c e ( n = 9 4 , m e a n score=109.10, P=0.04). Nurses who had pallia- tive care training had significantly higher mean t o t a l FAT C O D s c o r e s ( n = 1 0 2 , m e a n score=115.35) than those without palliative care training (n=291, mean score=110.43, P=0.02).

Correlation between palliative care knowledge and attitudes There was a moderate correlation between pallia- tive care knowledge of and attitudes towards pal- liative care (r=0.46).

Multiple regression analysis Variables significantly correlated with a higher mean total PCQN score after multiple regression analysis were palliative care training (β=0.132, P=0.008), nursing specialty (β=0.127, P=0.010), years of nursing experience (β=0.215, P=0.011), and level of palliative care integration (β=0.211,

P<0.001). These variables explained 12.1% of the variation in total PCQN scores (R2=0.135, adjusted R2=0.121).

Variables significantly correlated with higher total mean FATCOD scores after multiple regres- sion analysis were years of nursing experience (β=0.172, P=0.029), palliative care training (β=0.099, P=0.032), and level of palliative care integration (β=0.440, P<0.001). These variables explained 22.6% of the variation in total FATCOD scores (R2=0.236, adjusted R2=0.226).

Discussion The present study quantified palliative care knowledge and attitudes among nurses working in one of the largest tertiary care hospitals in Saudi Arabia. The study is distinctive because of the diversity of the participants. The health-care system in Saudi Arabia depends primarily on expatriate nurses. This creates a culturally diverse nursing workforce and variance in palliative care education that depends on the level of palliative care integration in the nurse’s home country. The results indicate that the nurses’ knowledge of and attitudes towards palliative care resulted, to some extent, from the amount of palliative care educa- tion in the nursing curriculum, the degree of pal- liative care integration into the health-care system, and continuing education opportunities for registered nurses.

The mean total score for the PCQN was 9.06 out of 20, which is considered low in comparison to studies performed in countries with advanced palliative care integration. Brajtman et al (2009) reported a mean score of 12.8 for 52 nursing edu- cators in Canada, and Knapp et al (2009) a mean score of 10.9 for 279 paediatric nurses in the USA. Most of the nurses in the present study were from countries with isolated provision of palliative care. A study in Korea, which has isolated provision of palliative care, reported a mean PCQN score of 8.95 for 368 nurses (Choi et al, 2012). This varia-

Question

number Item

Mean

score

Standard

deviation

16 Families need emotional support to accept the behaviour changes of the dying person 4.51 0.62

21 It is beneficial for the dying person to verbalise his/her feelings 4.44 0.71

18 Families should be concerned about helping their dying member make the best of his/her remaining life 4.40 0.79

4 Caring for the patient’s family should continue throughout the period of grief and bereavement 4.33 0.74

13 I would hope the person I’m caring for dies when I am not present 2.98 1.16

6 The non-family caregivers should not be the one to talk about death with the dying person 2.92 1.25

3 I would be uncomfortable talking about impending death with the dying person 2.71 1.12

29 Family members who stay close to a dying person often interfere with the professional’s job with the patient 2.58 1.06

Table 4. Items from the Frommelt Attitudes Toward Care of Dying (FATCOD) scale with the highest and lowest mean scores (n=395)

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tion among scores is probably mostly attributable to strategies for palliative care nursing education in the countries with advanced integration.

The mean FATCOD score for the nurses in the present study was 111.66; this is low in compari- son with other studies. Brajtman et al (2007) reported a mean score of 129.12 for 58 Canadian nursing students, and Lange et al (2008) a mean score of 129 for 355 American oncology nurses. However, a study performed in Japan, which has advanced palliative care inte- gration, reported a mean score of 107.5 for 190 Japanese nurses (Matsui and Braun, 2010). This variation may reflect cultural differences regard- ing death and dying between countries, as well as a lack of culturally focused palliative care train- ing (Glass et al, 2010).

Regarding the demographic variables, previous studies found that age had a significant effect on palliative care knowledge and attitudes (Barrere et al, 2008; Lange et al, 2008; Choi et al, 2012). In the present study, nurses aged 40–50 years had significantly higher mean FATCOD scores than those younger than 40 years. This finding is simi- lar to that of Lange et al (2008).

One valuable contribution of this study is that it investigated the knowledge and attitudes of nurses across all of the hospital’s clinical settings. Few studies have investigated whether nursing specialty significantly affects knowledge of or attitudes towards palliative care. Lange et al (2008) reported that nurses working in an oncol- ogy centre had positive attitudes towards death and caring for dying patients. Choi et al (2012) reported that nurses working in cancer units had greater knowledge about end-of-life care than nurses working in general wards or intensive care units. In the present study, nursing specialty had a significant influence on the nurses’ knowledge but not their attitudes.

Of the PCQN component categories for knowl- edge, the lowest percentage of correct answers was obtained for ‘principles and philosophy of pallia- tive care’ (31.2%). Ronaldson et al (2008) found poor understanding of this category among nurses working in residential aged-care facilities.

Nurses from Saudi Arabia scored modestly on both the PCQN and FATCOD, which may be due to a lack of palliative care education in nurs- ing education. However, as the study sample was representative of the actual population of nurses working in the Saudi Arabian health care system, only 32 Saudi Arabian nurses took part. Therefore, similar studies with more Saudi Arabian nurses and nursing students are needed to evaluate palliative care educational needs among Saudi Arabian nurses.

Level of palliative care integration Nurses from countries with an advanced level of palliative care integration scored significantly higher on the PCQN and FATCOD than the other groups. This is probably due to the availa- bility of palliative care nursing education pro- grammes in these countries (Wilson et al, 2011). Palliative care education should be embedded in nursing curricula to increase knowledge of and improve attitudes towards palliative care (Adriaansen and van Achterberg, 2008; Barrere et al, 2008; Paice et al, 2008). Nurses from coun- tries with preliminary integration of palliative care into mainstream care services had weak knowledge and attitude scores. According to Lynch et al (2013), Malaysia is classified in this group; however, Malaysian nurses had signifi- cantly lower PCQN and FATCOD scores than nurses from other countries in the same group. This affected the group results because the Malaysian nurses constituted 69% of the partici- pants in that group. This result questions the nature of palliative care education and training in Malaysia, which is not matching the level of pal- liative integration according to Lynch et al’s (2013) classification.

Relationship between knowledge and attitudes One of the key findings of this study was the pos- itive correlation between the PCQN and FATCOD scores. Many studies have found a sig- nificant effect of palliative care experience and education (which would be expected to result in higher knowledge) on attitudes towards palliative care (Khader et al, 2010). The majority of the nurses who participated in this study reported palliative care experience gained by frequent interactions with palliative care patients; how- ever, most of them had never received palliative care training. Nurses with training scored signifi- cantly higher on both measures than those with- out training. This finding supports results from previous studies (Mallory, 2003; Barrere et al, 2008) and illustrates the impact of palliative care training and education.

Given the differences in the nurses’ cultural background, experience, skills, and knowledge, palliative care education programmes should be integrated into the Saudi Arabian hospital sys- tem. Introducing palliative care during hospital orientation and integrating a palliative care link nurse role are among the strategies that have been found to be effective in bridging the gap in experience and knowledge (Cotterell et al, 2007). Moreover, conducting end-of-life training pro- grammes for a core group of nurses in each spe-

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cialty would allow these nurses to act as resources and advocates for palliative care in their specialties. The palliative care team of KFSH&RC-Riyadh is conducting palliative care education courses for nurses periodically.

Conclusion This study examined knowledge of and attitudes towards palliative care among multinational nurses working in a tertiary hospital in Saudi Arabia. Several factors affected the nurses’ knowledge and attitudes, such as their palliative care experience and training. The level of pallia- tive care integration in the nurses’ home coun- tries was also a significant factor.

Improving palliative care in Saudi Arabia and other countries with a low level of palliative care integration will require multi-institutional strate- gies. Such strategies should focus on establishing palliative care services at all levels of the health- care system. Furthermore, there is a need to add palliative care to nursing education, and to design training courses for undergraduate and postgraduate nurses that cover all aspects of pal- liative care, such as its principles and philosophy, communication, psychosocial support, pain and symptom management, and cultural views.

Declaration of interests This work had no external sources of funding. The authors have no conflicts of interest to declare.

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