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ASSESSMENT OF NURSES’ KNOWLEDGE AND ATTITUDE ABOUT PALLIATIVE

CARE AMONG NURSES AT UNIVERSITY TEACHING HOSPITAL OF KIGALI.

KARIKWERA MARIE CLAIRE

College of Medicine and Health Sciences

School of Nursing and Midwifery

Master of Science Degree in Nursing (Pediatric Track)

2017

ASSESSMENT OF NURSES’ KNOWLEDGE AND ATTITUDE ABOUT PALLIATIVE

CARE AMONG NURSES AT UNIVERSITY TEACHING HOSPITAL OF KIGALI.

KARIKWERA MARIE CLAIRE

Student Registration Number: 216342430

A dissertation submitted in partial fulfilment of the requirements for the degree of

MASTER OF PEDIATRIC TRACK.

In the College of Medicine and Health Sciences.

Supervisor: Dr Lakshmi Rajeswaran

July, 2017

Declaration

I do hereby declare that this dissertation submitted in partial fulfilment of

the requirements for the degree of MASTERS OF SCIENCE in

NURSING, at the University of Rwanda/College of Medicine and Health

Sciences, is my original work and has not previously been submitted

elsewhere. Also, I do declare that a complete list of references is provided

indicating all the sources of information quoted or cited.

Date and Signature of the student

12/6/2017

a. Authority to submit the dissertation

Surname and First Name of the Supervisor: Dr Rajeswaran Lakshmi

In my capacity as a supervisor, I do hereby authorize the student to

submit his/her dissertation.

Date and Signature of supervisor/Co-Supervisor

12/6/2017

Acknowledgements

I am so thankful to god almighty that sustained me and allowed me to

achieve this work by his grace.

I would like also to thank the Government of Rwanda through the

Ministry of health for the scholarship of my studies.

I deeply address my sincere thanks to my supervisor Dr. Rajeswaran

Lakshmi for her guidance, commitment, time and constructive advice

throughout this work.

A special thanks goes to the teaching staff of for the knowledge they

offered to me.

I recognize all individuals who contributed to the success of this work.

May the almighty God bless you all!

iii

Abstract

Introduction: Palliative care (P.C) is an approach that improves the

quality of life of patients and their families facing the problem associated

with life-threatening illness, through the prevention and relief of suffering

by means of early identification, perfect assessment, treatment of pain

and other physical, psychosocial and spiritual problems. In previous years

palliative care was known as the care of the patient who is close to death

but now, the capacity of palliative care has expanded to include patients

who may live for many years with chronic disease.

The aim of the Study: The study aimed to assess knowledge and

attitude of the nurses working at University Teaching Hospital of Kigali

about palliative care.

Methods: Descriptive, cross sectional quantitative study design and the

convenience sampling procedure were used for conducting the study. A

sample of 139 nurses working in the pediatric and surgical ward was

chosen for this study. Data were collected by using questionnaire with

demographic data and palliative care Quiz for Nurses (PCQN) which was

developed by the researchers. Pilot study was conducted among 16

nurses.

Results: Study results have shown that only 9.3% of the respondents had

good knowledge towards PC, 8.63% had in service-education on

palliative care and no one had a good attitude towards PC.

Conclusion: The nurses had fair knowledge, but their attitude towards

PC was poor. Recommendations are that integration of the national health

policy related to PC in the national curriculum of nurse education and

provide training related to PC for the nurses.

Keywords: Knowledge, Attitude, Palliative care, Registered nurses.

LIST OF SYMBOLS AND ACRONYMS

AIDS: Acquired Immune Deficiency Syndrome

CMHS: College of Medicine and Health Sciences.

CHUK: Centre Hospitalier Universtaire de Kigali

HIV: Human Immune Virus

IRB: Institute review board.

MOH: Ministry of Health

PC: Palliative care.

WHO: World Health Organization

UTHK: University Teaching Hospital of Kigali

PCQN: Palliative Care Quiz for Nursing

PLWHA: Person Living With HIV/AIDS.

FATCOD: Frommelt Attitude Toward Care Of the Dying scale.

SPSS: Statistical Package for the Social Sciences

TABLE OF CONTENTS

Declaration .................................................................................................. i

Acknowledgements .................................................................................... ii

Abstract .....................................................................................................iii

LIST OF SYMBOLS AND ACRONYMS ............................................... iv

TABLE OF CONTENTS ........................................................................... v

LIST OF TABLES .................................................................................... ix

LIST OF FIGURES ................................................................................... x

CHAPTER I: INTRODUTION ................................................................. 1

I.1. Introduction ......................................................................................... 1

I.5. Research objectives ............................................................................. 4

I.5.1. Main objective .................................................................................. 4

I.5.2. Specific objectives ............................................................................ 4

I.6. Research questions .............................................................................. 4

I.7. Significance of the study ..................................................................... 4

I.8. Conceptual and operational definitions ............................................... 5

I.9. Organization of the study .................................................................... 5

Conclusion ................................................................................................. 6

CHAPTER II: LITERATURE REVIEW .................................................. 7

II.1. Introduction ........................................................................................ 7

II.2. Theoretical literature .......................................................................... 7

II.2.1. Knowledge about palliative care ..................................................... 8

II.2.3. Empirical Literature ...................................................................... 12

II.3. Attitudes toward palliative care ........................................................ 13

II.4. Critical Review and Research Gap identification ............................ 14

II.5. Conceptual framework ..................................................................... 14

CHAPTER III: METHODOLOGY ......................................................... 15

III .1. Introduction .................................................................................... 16

III. 2. Research design ............................................................................. 16

III.3. Research approach .......................................................................... 16

III.4. Research setting .............................................................................. 16

III.5. Population ....................................................................................... 18

III.6. Inclusion and exclusion criteria ...................................................... 18

III. 7.Sampling ......................................................................................... 19

III.7.1. Sampling strategy......................................................................... 19

III.7.2.Sample size ................................................................................... 19

III.8. Data collection ................................................................................ 20

III.8.1. Data collection instruments.......................................................... 20

III.8.2 Data collection procedure ............................................................. 21

III.9. Data analysis ................................................................................... 22

III.10. Ethical considerations ................................................................... 22

III.11. Data management.......................................................................... 23

III.12.Data dissemination ......................................................................... 23

Conclusion ............................................................................................... 23

CHAPTER IV: RESULTS ..................................................................... 24

4.1. Introduction ....................................................................................... 24

CHAPTER V: DISCUSSION .................................................................. 35

V.1. Socio-demographic information ...................................................... 35

V.2. Knowledge about palliative care ...................................................... 35

V.3.Attitude about palliative care ............................................................ 36

V.4. Limitations of the study ................................................................... 36

V.5. Summary .......................................................................................... 36

CHAPTER VI: CONCLUSIONS AND RECOMMENDATION ........ 37

VI. 1. Recommendation ........................................................................... 37

VI .1.1.Recommendation for nursing practice ......................................... 37

VI .1.2.Recommendation for nursing education ...................................... 37

VI .1.3.Recommendation for nursing research ........................................ 37

APPENDIX II .......................................................................................... 40

QUESTIONNAIRE ................................. Error! Bookmark not defined.

CONSENT TO PARTICIPATE IN A RESEARCH STUDY ................. 40

vii

APPENDIX II .......................................................................................... 47

PERMISSION OF USING PCQN AS TOOL. ........................................ 47

viii

LIST OF TABLES

Table 1TableII.1 ....................................... Error! Bookmark not defined.

Table 2Table 1.4.1.Demographic and characteristics of the sample ....... 24

Table 3Table .4.2. The relationship between level of knowledge on

palliative care and socio- demographic variables. ................................... 25

Table 4Table4.3. the relationship between level of attitude on palliative

care and socio- demographic variables. ................................................... 27

Table 5Table 4.4 Nurse’s knowledge about palliative care. .................... 28

Table 6Table.4.5 the nurses ‘attitude of palliative care. .......................... 33

LIST OF FIGURES

Figure 1WHO 3-step Ladder ..................................................................... 9

Figure 2 Protocol for analgesic ladder ..................................................... 10

Figure 3Conceptual framework ............................................................... 14

Figure 4Rwanda map ............................................................................... 18

Figure 5 The nurses' knowledge levels of palliative care ........................ 32

Figure 6The nurses' attitude of palliative care ......................................... 34

CHAPTER ONE: INTRODUTION

1.1. Introduction

This chapter covers the background of the study, the problem statement, broad objectives,

specific objectives, significance of the study.

According to WHO( 2016),” Palliative care is an approach that improves the quality of life of

patients and their families facing the problem associated with life-threatening illness, through

the prevention and relief of suffering by means of early identification, perfect assessment

treatment of pain and other problems, physical, psychosocial and spiritual.”

For the children palliative care is the full dynamic care of the mind, spirit as well as the body

of the child and its family (WHO, 2016).The goals of palliative care are to relieve the

symptoms and not to treat the cause (National Cancer Institute,2016,p.2).Every woman, man

or child with a chronic ill has the right to palliative care and in order to give high-quality

palliative care and any health care provider must be trained about palliative care ( Downing,

Marston, Selwyn, & Ross-gakava,2013,p.7).

Worldwide palliative care is still a developing science. Yet, it must be accessible and

sustainable for all patients living with life limiting diseases as a necessary service (Downing

et al.2016, p.7).

In Africa, palliative care has started in Zimbabwe in 1979 with Island Hospice, while, in 1990

Kenya began palliative care with Nairobi Hospice to help the patients with cancer and those

who are affected by HIV/AIDS and in Uganda palliative care began in 1993 and first

Ugandan hospice created at Kampala (Kariuki et al.2013, p. 4).

In Rwanda, Palliative care has started in 2011 by a registered Nurse called Grace

Mukankuranga, she started the first clinical hospice, known as the Rwanda Hospice and

Palliative Care Center (RHPCC) and she started her service after receiving a seed grant and

training on palliative care in the UK(Angela & David, 2011,p.8) .

In order to increase the understanding of palliative care, in 2004 Rwandan Ministry of Health

sent a group of the health care providers to Uganda. Following that, some non-government

organizations like the Society of Women Against AIDS (SWAA) and Help the Hospices UK,

and Intra Health International HIV/AIDS Clinical Services Program organized training on

palliative care for the health providers coming from in four district hospitals(Kibagabaga,

Nyagatare, Rutongo and Byumba)( Rwanda Ministry of Health,2011,p.3).

1.2. Background of the study

The World Health Organization (WHO’) has improved community wellbeing approach by

integrating palliative care into health forces. But until now many persons still have the

problem with access to palliative care services as well as effective pain management, the

reasons are: providing and sharing, opiophobia for the patients and the health care providers

caused by insufficient knowledge about the use opioids (Powell et al.2014, p.3).

Kenya, Tanzania, Uganda and South Africa have included palliative care into healthcare plan

as a strategic arrangement to support patient with malignant disorders while Rwanda and

Swaziland has established national palliative care policies to sustain the strategy ( Ntizimira

et al.,2014,p.6). According to Rwanda national palliative care policy (2011,p.9), palliative

care is new approach with several independent community-based organizations or non-

governmental organization (NGOs) given that home care to weak people, particularly people

living with HIV/AIDS (PLWHIV). Palliative care during domicile care was maintained by

Partners in Health which has trained community health workers (CHW) recognized as

coaches and they give out antiretroviral medicine and hold up patients in increasing their

adherence to medication. But, Rwanda lacks the capacity to deliver palliative care at all levels

(Rwanda National Palliative Care Policy 2011,p. 4).

According to Fadare et al (2014,p.7), the thinking, awareness, approach, experiences and the

behaviour of the health care providers during evaluation and treatment of the patients are the

key points for successful palliative care deliverance. Palliative care teaching must be focusing

on diverse audiences such as policy makers, healthcare providers, non-· professional health

employees and the common community in order to increase their skills, knowledge and their

attitudes (Downing et al.2010, p.11). Since palliative care is a new approach in Africa, its

teaching must be continuous and be available from early pre-registration schooling for health

care professionals and for post-graduate students.

1.3. Problem statement

Palliative care is a recent concept in Rwanda and pain management idea is yet to be included

in healthcare structure (Ntizimira, Nkurikiyimfura, Mukeshimana, Ngizwenayo, Mukasahaha

et al., 2014, p.2). A study done in Rwanda by Uwimana & Struthers in( 2012), showed that

above 50% of health care providers were not educated in palliative care reason why it is

difficult to provide palliative care services. Despite many advantages of the palliative care for

the patients and their families, many nursing programs do not prepare a separate course in

palliative care as part of their curriculum. The nurses also had reduced understanding but had

modest feeling towards palliative care. (Ayed, 2015, p.17).

Rwanda National Palliative Care Policy (2011), maintains that by 2020 all people with

chronic disease, their families, and caregivers living in Rwanda have right to use palliative

care services so this can be achieved by preparing all the health care professionals with

adequate knowledge and attitude on palliative care.

Many health care providers are not well trained in palliative care because the lack of course

content connected to releive pain as well as palliative care (Ayed, 2015,p.8).

By 2013, University of Rwanda College of Medicine and Health Sciences School of Nursing

and Midwifery (CMHS) included palliative care in it undergraduate curriculum where the

nursing students can study this course in level four as “Palliative Care and Hospice in the

module of Specialized Nursing”. This course has 30 hours.

Even if CMHS has integrated palliative care in the undergraduate curriculum in the recent

year some hospitals are not yet establishing palliative care policy for example at UTHK there

is no palliative care policy. This motivated the researcher to embark on assessing the nurses’

knowledge and attitude towards palliative care.

1.4. Aim of the research

The aim of this research was to assess knowledge and attitude of the nurses working at

UTHK about palliative care.

1.5. Research objectives

1.5.1. Main objective

To assess knowledge and attitude of the nurses working at UTHK about palliative care.

1.5.2. Specific objectives

1. To assess the knowledge level of palliative care among the Nurses working in the

pediatric ward and surgical ward at UTHK.

2. To evaluate the nurses’ attitudes about palliative care among the Nurses working in the

pediatric ward and surgical ward at UTHK.

1.6. Research questions

1. What is the existing level of knowledge of Nurses work at UTHK in the Pediatric ward and

surgical ward about palliative care?

2. What is the attitude of the Nurses work at UTHK in the Pediatric ward and surgical ward

about palliative care?

1.7. Significance of the study

The aim of this study was to assess the knowledge and the attitude of the Nurses work in the

pediatric ward and surgical ward at UTHK about palliative care.

The researcher was chose pediatric ward because she was already working in this ward and

she needs cared for cases need palliative care. She also choose surgical ward because the

children there have surgical problems such as spin cord injuries, burns, and other physical

injuries are admitted to this ward.

This study will express real information to the policy maker, about the knowledge and the

attitude that Nurses working at UTHK in that wards have on palliative care.

The UTHK and Ministry of health will benefit from this study by acquiring updated

information about knowledge and attitude toward palliative care in referral hospitals of

Rwanda, specifically in pediatric and surgical wards at UTHK and this will help them to plan

and act accordingly in this domain, like to establish palliative care services at all levels of the

healthcare system and organize the training of the nurses about palliative care.

The information generated from this study also could be useful for helping the nurses to

provide quality palliative care to the patients.

Furthermore, this study will be a basis for future researcher in this field.

1.8. Conceptual and operational definitions

Knowledge: Knowledge is an information and understanding about a subject which a person

has, or which all people have, or” information and skills acquired through experience or

education; or what is known in a particular field or in total; facts and information”

(dictionary.com, 2016). In this study, knowledge is conceptualised as nurses understanding

and awareness about the principles of palliative care.

Attitude: Attitude is a” feeling or opinion about something or someone, or a way of behaving

that is caused by this” (dictionary.combridge, 2016). According to oxforddictionaries.com

(2016), attitude is” a way of thinking or feeling about something”.

In this study, the attitude is conceptualised as feelings or way of thinking of the nurses toward

palliative care.

Palliative care: According to WHO(2016 ,para.1),” Palliative care is an approach that

improves the quality of life of patients and their families facing the problem associated with

life-threatening illness, through the prevention and relief of suffering by means of early

identification and perfect assessment and treatment of pain and other problems, physical,

psychosocial and spiritual”.

Palliative care in this study is all activities done by health providers or care giver for the

benefits of a patient who has chronic diseases in order to relieve symptoms without to cure.

1.9. Organization of the study

Introduction of the study, background of the study, problem statement, aim of the study,

objectives (main and specific objectives) of the study, research questions, significance of the

study, definition of concepts, conclusion to chapter one ,literature review which include

introduction, theoretical literature, empirical literature, critical review and research gaps and

conceptual framework and methodology which include: Introduction, research design,

research approach, research setting, population, sampling, sampling strategy, sample size,

data collection, data collection instruments, data collection procedure, data analysis, ethical

considerations, data management, data dissemination, limitations and challenges and

conclusion to chapter three, chapter four included results, chapter five included discussion

and chapter six included conclusion and recommendations of the study.

Conclusion

Palliative care is essential because it has many benefits for the people living with chronic

disease, their family as well as the country in terms of health, development and financial

benefits as stated above by different researchers. The high prevalence of palliative care need

was observed in the developing countries where the78%of people needs palliative care

(WHO, 2015, para.3). Many gaps were observed in developing countries with low prevalence

of palliative care services integration into health care system. The support towards palliative

care is essential in fighting against major problems related to chronic diseases; such problems

are poverty due to prolonged admission of the patient in the hospital (Henry, 2011, p.4).

CHAPTER TWO: LITERATURE REVIEW

2.1. Introduction

This chapter discusses the introduction of a literature review on palliative care, theoretical

literature, empirical literature, critical review, research gap identification and conceptual

framework. The research origins such HINARI, Pub med, Google scholar, has been used to

identify the relevant literature studies conducted between 2011-2016.

2.2. Theoretical literature

The Center to advance Palliative Care(CAPC) define palliative care as the necessitate for

expert interdisciplinary care fixed on sign and excellence of life for persons of any age and at

any phase of a grave sickness(McCaskey et al. 2013,p.9). Worldwide, the number of persons

living with HIV/AIDS (PLWHA) is increasing and the health care givers and plan creators

look for available health care services for those people as well as to improve the quality of

their life is needed (Uwimana & Struthers, 2012, p.3).

Each year, 40 million persons require palliative care, 78%of them reside in low and middle

income countries global, which only 14% of those can access palliative care services. The

major cause is a lack of training in palliative care for health providers (WHO, 2015, para.3).

A study done in Rwanda by Uwimana & Struthers 2012, p.9), with the purpose of

investigated meet and unmet palliative care needs of PLWHA in selected areas in Rwanda.

The sample was 306 participants include People living with HIV/AIDS, health care providers

and coordinators of HIV/AIDS units. They used quantitative and qualitative as methodology;

the data were analysed separately and triangulated. The results showed that mainly PLWHA

needs palliative care such as pain reliefs, symptom management, financial support, and food

maintain but they not found and above 50% of health care providers were no trained in

palliative care therefore insufficient procedure and funds were a barrier to provide palliative

care services. Although palliative care services is developing, there are many issues that

affect the availability of palliative care, such as inconvenience of delivering and sharing, a

lost ‘opiophobia’ between patients and health works with inadequate perceptive of how and

when to utilize opioids by the doctors and trained nurses working in rural areas( Powell et

al.,2014, p.11).

Palliative care is needed in developing countries because there is an increase in chronic

diseases such as cancer, human immunodeficiency virus infection and sickle cell diseases

(Henry, 2011, p.4).

Palliative care began in 1950 by Dr. Cicely Saunders who expressed her ideas toward modern

hospice care based on close observation and pain management of the patient who was nearing

the ending of life. In 1960, Psychiatrist in the United States Elisabeth Kübler-Ross,

established the importance of effective communication and respect while caring for the

patient at the end of life. In 1974, Dr.Balfour Mount, a surgical oncologist at Canada defined

the word palliative care to demonstrate the difference between palliative care and

hospice(Loscalzo, 2008,p.465).

Before 1928 penicillin was discovered, the common health care was palliative in nature but

new therapies to treat as well as expand life have been made available and from 1960, the

hospice started to end-of-life care to the people living with terminal illness.

Palliative programs became visible in hospitals similar to the Cleveland Clinic and Medical

College of Wisconsin and in 1995 the landmark Support schoolwork mentioned the capacity

as well as barriers to give successful, complete care designed for the people living with

chronic disease (McCusker et al. 2013,p.9).

Palliative care services must provide by all health and social care providers working with life

limiting conditions patients, this care is given when the patient is awake, death and as well as

bereavement period(Ryan 2014,p.4).

2.2.1. Knowledge about palliative care

The word” palliate” is derived from the Latin ward palliates which means to “cloak or

cover.” therefore it is expected to express care to hush-up the patient with another layer of

comfort and support(McCusker et al. 2013,p.2).

Hospici is a service or program planned to make available a helpful setting designed for

meeting the physical as well as emotional wishes of the terminally sick (Merriam-Webster

Dictionary, 2016.p.16).

Pain is a disagreeable sensory and emotional incident connected by real or possible tissue

injures (dictionary.combridge, 2016, p.24).

Pain can be caused by physiological factors, psychological factors and ecological factors like

background, diagnosis, panic, anxiety and coping strategies and there are many types of pain

such as Nocicepteve pain (Ministry of Health Rwanda, 2012,p.6).

WHO 3-step Ladder

1 mild

2 moderate

3 severe

Morphine

step 1 and/or Adjuvants

A/Codeine

A/Dihydrocodeine

Tramadol

step 1 and/or Adjuvants

Aspirin

Paracetemol

NSAIDs

Adjuvants

APCA

(WHO, 2016)

Figure 1 WHO 3-step Ladder

Paracetamol

Paracetamol and diclofenac or codeine

Diclofenac and codeine

Paracetamol or Diclofenac and oral morphine

Subcutaneous morphine infusion plus paracetamol or diclofenac

Possible hospital protocol for analgesic ladder

Moderate pain

Mild pain

Severe pain

Ministry of Health Rwanda, (2012,p.17)

Figure 1 Protocol for analgesic ladder

Figure 2 shows the step of drugs prescription for pain management in Rwanda.

The aim of palliative care.

The plan of palliative care is to provide excellence life to the people living with serious

illnesses and their families by preventing and taking care of the symptoms and complications

of diseases through physical, psychological, spiritual as well as social support and it can be

given directly after confirmation of the disease, during treatment, follow-up period and at the

ending of living time (WHO, 2016, para.2).

Indications for palliative care

Palliative care is for every one living with the serious disease, such as Cancer, Heart disease,

Lung diseases, Kidney failure, Dementia, ALS (amyotrophic lateral sclerosis and HIV/AIDS

(WHO, 2016, para.7). Each year, 40 million persons require palliative care, 78%of them

reside in low and middle income countries globally, while only 14% of those can access

palliative care services. The major cause for this is a lack of training on palliative care for

health providers (WHO, 2015, para.3).

Cancer is an up-and-coming community wellbeing crisis and in 2008 around 715 000 recent

cases and 542 000 deaths in Africa caused by cancer furthermore in 2030 the number will be

nearly doubled related to augmentation of residents as well as based on cancer condition the

World Health Organization improved community wellbeing approach for developing

palliative care services (Powell et al., 2014, p.7)

Palliative care and hospice providers

Palliative care can be delivery by the following people: a group of doctors, Nurses,

Registered dieticians, Social workers, Psychologists, Physiotherapists as well as Chaplains

and it is can be done at hospitals, home, cancer canters and at long -term care facilities

(WHO, 2016.para, 6).

Benefits of palliative care

It helps enough control of pain and other symptoms get an intelligence of control, reduce

burden on family members and reinforce relationships, increase understanding of the

character of the disease, the patient and family participate in decision making and it help to

get the care at home and prevent hospitalization as well as help the family cut prolonged grief

and posttraumatic stress disorder (WHO, 2016.para, 4).

The difference between palliative care and hospice

Palliative care starts at diagnosis of the condition and during time of treatment but hospice

care begins after stopping management of the illness as well as hospice care is generally

provided just when the patient is likely to survive 6 months or less, both palliative care and

hospice care give comfort to patient living with life treating disease (WHO, 2016.p.9).

In 2011 study done by Lynch et al.p.15. Showed that palliative care were well incorporated in

20 countries, despite the fact that 42% had no palliative care services at all as well as more

32% had simply cut off palliative care services.

According to Downing et al.(2010,p.5), the aim of palliative care is neither to accelerate nor

to push back passing away, add the emotional component along with other characteristics of

patient care which contribute to maintain structure in order to facilitate the patients exist once

as dynamically as possible until he/she passes away. It also involves important assisting the

family in coping with the patient’s sickness and also during passing away as well as death

counselling.

Although palliative care services are developing, there are many issues that affect the

availability of palliative care such as inconvenience of delivering, sharing, as well as

‘opiophobia’ between patients and health care suppliers, and inadequate knowledge about

how as well as when to utilize opioids for the doctors and trained nurses working in rural

areas (Powell et al., 2014, p.11). Palliative care is needed in developing countries because of

the increase in number of chronic diseases such cancer, human immunodeficiency virus

infection and sickle cell diseases (Henry, 2011, p.4).

2.2.3. Empirical Literature

In 2013 in sub-Saharan Africa, approximate 24.7million of persons were existing with

Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), 70%

of total diseases, over 700,000 recent cases of cancer and 600,000 decease related to cancer in

2007, the rate are expected to increase by 400% within next 50years (Ntizimira et

al.2014,p.18).Despite the confirmed need, recent condition of palliative care in Africa is

inadequate with most components missing, like access to important painkillers, mainly oral

morphine and there is general need of government guidelines that make out palliative care as

necessary part of wellbeing care and there is poor education for both health care experts and

the common community on palliative care (Henry, 2011, p.7).

A study was done by Fadare et al 2014,p.4, in Nigeria with the purpose of assessing the

knowledge and attitude of healthcare workers in a tertiary level hospital. A cross-sectional

study was conducted and a questionnaire was used to collect data from 400 nurses. and the

sample 135(86%) responded that PC was on the dynamic management of the dying as 70.5%

of participants equated PC to pain management and they had recognized that nurses plus

other wellbeing care specialized are poorly prepared to help the patients in palliative care

furthermore some explanation have been recognized are insufficiency in nursing learning,

lack of curriculum content linked to ache management in addition to awareness associated

with pain as well as palliative care.

Now understanding on PC is improved, the health care experts have a chance to learn right of

entry to treatment as well as we can support our hard work to share skills also make a huge

group of countries with organisational collaborators which utilize a comprehensive language

on palliative care(Powell et al 2014,p.10).A community health plan, as suggested by the

World Health Organization (WHO), recommends the most excellent approach for explaining

information as well as skills interested in evidence-based be cost-effective to facilitate access

and availability of PC for everyone in developing countries (Henry, 2011, p.8).

2.3. Attitudes toward palliative care

Business dictionary (2016, p.9) defines attitude as “a predisposition or a tendency to respond

positively or negatively towards a certain idea, object, person, or situation. Attitude

influences an individual’s choice of action, and responses to challenges, incentives, and

rewards together called stimuli”.

Ayed et al (2015,p.4) conducted a study in Palestine assessing the knowledge and attitude of

the nurses towards palliative care on the nurses working in selected hospitals in Northern

districts, Palestine by using descriptive, cross sectional study. 96 nurses participated in he

study., 59.4% had education of palliative care, and 6.2% of members had excellent attitude

to palliative care and they finish their study with those result: there are large difference

among Nurse’ qualification, experience, and training on pc and they found that the nurses had

poor knowledge but their attitude about PC is modest and they advised to make the national

health policy and curriculum of the nurse education related to palliative care in nursing

education program.

Kassa et al.,(2014,p.13) done a study in selected hospitals in Addis Ababa, Ethiopia on 341

nurses for assessment of the knowledge, skills, attitudes and associated factors with PC by

using a cross sectional quantitative study design. Systematic random sampling was utilized to

choose -two governments with two non government hospitals, they utilized triangulation in

study as methodology, palliative care quiz for Nursing (PCQN) and SPSS software statistical

packages were applied for data entry and analysis. The result showed that 365 nurses were

chosen, 341(94.2%) were registered, 104(30.5%) had fine knowledge and 259(76%) had

favourable attitude towards palliative care in medical surgical wards as well as teaching on

palliative care were completely related with knowledge of the nurses and they concluded that

the nurses had reduced knowledge but their attitude about PC was favourable and the

organization, individuals’ level of education, working in medical ward, as well as the

preparation they obtained on PC, were also considerably connected with the attitude the

nurses had, and the nurses functioning in Hayat Hospital (nongovernmental) had a 71.5%

possibility of having unfavourable attitude towards PC than those work in Black Lion

Hospital (governmental) (Kassa et al., 2014, p.6).

A study done by Abudari, Zahhreddine, Hazeim, Assi, Emara (2013,p. 11), in Saudia Arabia

on 395 nurses with the purpose to establish knowledge and attitudes of the nurses working at

King Faisal Specialist Hospital and Research Centre-Riyadh (KFSH & RC-Riyadh) by using

questionnaire with demographic data, palliative care Quiz for Nurses (PCQN), and Frommelt

Attitude Toward Care of the Dying scale (FATCOD).The results showed the nurses had

moderate attitudes about palliative care but their knowledge was a deficient.

2.4. Critical Review and Research Gap identification

As mentioned in many different studies the nurses’ knowledge about palliative care is still

poor but their attitude is moderate as the gap is to increase their knowledge as well as the

knowledge and attitude of the nurses influenced by integration of palliative care into health

care structure and nursing education (Abudari et al., 2013, p.6).

2.5. Conceptual framework

Knowledge-Attitude- Behaviour (KAB) Model

Figure 2 Conceptual framework (Madden, Ellen, Ajzen, 1992 )

The conceptual framework used in this study is the Knowledge, Attitudes, & Behaviors

(KAB) Approach developed in 1992 by Madden, Ellen and Ajzen.

Nurses’

knowledge about

palliative care

Attitude of nurses

towards palliative

care

Nurses’ behaviour for

adopting palliative care

practice

Improved patients’

quality of life

Nurses’

knowledge about

palliative care

Attitude of nurses

towards palliative

care

The aim of this model was to make improvement in the fields of education and practice

facilitates development and change. Research has shown that knowledge instruction alone is

a poor agent for influencing changes in behavior so successful outcomes of interventions in

education and performance improvement need more increased knowledge in additional

knowledge of the nurses about palliative can influence their attitude toward it and then after

their attitude change their behaviour and improve the quality of care delivery to the patients

who need palliative care as well as patient’s quality of life improved.

In this study, knowledge means nurses’ understanding and awareness of the aim, principles,

and domains of palliative care, common drugs used in pain management, indications and

benefits of palliative care; while the attitude means a feeling or way of thinking of the nurses

toward palliative care. The perception of the nurses towards palliative care and end of life

care would be influenced by the knowledge.

Conclusion: In this chapter relevant the literature review, the theoretical review, the

empirical review and the conceptual framework guiding has been discussed.

CHAPTER THREE: METHODOLOGY

3 .1 Introduction

The methodology is the ways of obtaining, organising and analysing data (Polit and Hungler,

2004, p.233).This chapter describes, research design, research approach, research setting,

study population, inclusion and exclusion, sampling, sampling strategy, sample size, data

collection instruments, data collection procedure, data analysis, data management Ethical

considerations, Data dissemination, Limitations, and challenges, them after Conclusion of

this chapter.

3. 2. Research design

The research design of a study is the vital advance that researchers utilize to respond their

research question and for the management of some challenges faced during the research

process (Polit & Beck 2010, p.49). In this study, Descriptive, cross-sectional design was

used.

Descriptive research is research study has the main objective of getting the correct

explanation of the features of people, situations or groups (Polit & Hungler 2004, p.716). A

cross-sectional study is a study done once in a given period of time to establish the state of

affairs at the particular time (Polit & Beck 2010, p.49).

3.3. Research approach

The quantitative approach occurs as of the belief that individual phenomena with variables in

human being behaviour are able to be calculated independently (Parahoo, 2006, p.5). A

quantitative approach was used in this study.

3.4. Research setting

This study was conducted in Rwanda specifically at the University Teaching Hospital of

Kigali. The setting is described through the following health care system.

3.4.1 Health care system of Rwanda

Health services in Rwanda are provided through the public sector, government-assisted health

facilities, private health facilities, and traditional healers. The health system in Rwanda is a

decentralized and it has a three levels pyramidal structure including the central, intermediary

and peripheral levels. The central level includes the Ministry of Health, Rwanda Biomedical

Center (RBC) and the national referral hospitals whose mission is to provide tertiary care to

the population. Its main responsibilities include elaborating policies and strategies, ensure

monitoring and evaluation, capacity building and resource mobilization. In addition, this

central level organizes and coordinates the other levels of the health system, and provides

them with administrative, technical and logistical support (Rwanda Ministry of Health, 2014).

The intermediary level of a health facility is constituted with one provincial hospital in each

province, with the objective to serve as an intermediate level of referral hospitals to decrease

the services demand in the national referral hospitals. The peripheral level is represented by

the health district and consists of an administrative office, a district hospital and a complex of

health centres that are either public, government assisted faith based, or private. The

responsibilities of the health district include the organization of health services in health

centres and the district hospital, administrative functioning and logistics, including the

management of health resources and supplies, and the supervision of community health

workers and there are also health posts promoted by the Ministry of Health in order to

minimize the gap of geographic accessibility (Rwanda Ministry of Health, 2014, p. 12).

According to the Rwanda Annual Health Statistics Booklet by MOH (2014, p.4), Rwanda has

five national referral hospitals (King Faisal Hospital (KFH), Rwanda Military Hospital,

University Teaching Hospital of Kigali (UTHK), University Teaching Hospital of Butare

(UTHB) and Ndera Hospital for psychiatric care).This study was conducted at one those five

national referral hospitals which are UTHK (University Teaching Hospital of Kigali) and it

was known as Kigali Hospital Centre situated in Kigali city, Nyarugenge District.UTHK is

one of the referrals of the Country that began to work as a health centre in 1928.From1965, it

started to work as hospital with the performance law N° 41/41/2000 of 7/12/2000 on the

institution and association of Kigali Hospital Centre it has been an important element and

became a civic institute with authorized personality recognized as University Teaching

Hospital of Kigali (UTHK) It has the following services: Internal medicine services,

Gynaecology and Obstetrics/Maternity services, Surgery (Urology, Neurosurgery), Paediatric

services, ENT, Ophthalmology services, Radiology, Anaesthetics and resuscitation,

Stomatology, Dermatology, Emergency services, Laboratory, Physiotherapy, Orthopaedic

services. The researcher was chose pediatric ward because she was already working in this

ward and she needs cared for cases need palliative care. She also choose surgical ward

because the children there have surgical problems such as spin cord injuries, burns, and other

physical injuries are admitted to this ward. Paediatric ward has 69 nurses and surgical ward

has 145 nurses.

(worldatlas.com, 2016)

Figure 3 Map of Rwanda

3.5. Population

The population is the full amount of units from which information can be collected. (Parahoo,

2006, p. 258). In this study, all registered nurses working in the paediatric ward and surgical

ward were chosen to participate in the study. The population of this study was 214 nurses.

3.6. Inclusion and exclusion criteria

The inclusion criteria were all registered nurses working in the pediatric ward and surgical

ward who were present and the exclusion criteria was all nurses who were not working in the

pediatric ward and surgical ward.

3. 7.Sampling

3.7.1. Sampling strategy

Convenience sampling is a type of nonprobability or nonrandom sampling where members

of the target population that meet certain practical criteria, such as easy accessibility,

geographical proximity, availability at a given time or willingness to participate are included

for the purpose of the study (Dornyei, Z, 2007, p.1).

Convenience sampling procedure was used in this study. The most probable nurses were

chosen to act as respondents and were interviewed until the sample size was reached.

Researcher asked all nurses who were present in the pediatric ward and surgical ward. If

nurse failed to participate in the study, another nurse was chosen to fill the sample size and

representativeness.

3.7.2. Sample size

Sample size in the quantitative study must be the biggest so that it is representative of the

target population (Polit & Beck, 2010, p.49). In this research the sample size was 139

registered nurses.

(According to Yamane (1967, p.886), the simple method to determine sample sizes is

following:

N 214

N=; n ═ ───────── ═ 139.413≈ 139

1+N (e) 2

1+214(0, 05) 2

N= Study population =214

n= sample size

Confidence level= 95

Morgin of errors=e=5%

Sample size needed =139

3.8. Data collection

3.8.1. Data collection instruments

Knowledge on palliative care was assessed by adapting the palliative care quiz for nursing

(PCQN).Developed by Ross, Mcdonald & Mcguinness (1996, p.126). Permission to use this

tool was obtained from authors. The original tool was in English, and was translated in

Kinyarwanda to make the instrument more understandable for the participants.

The validity of a data collection instrument is the ability of a research instrument to show

that it is measuring what you have set out to calculate and the reliability of an instrument

which refers to consistency and stability in its findings when used repeatedly under constant

conditions (Kumar, 2011,p.3).

This validity and reliability measurement for the palliative care quiz for nursing (PCQN) is

explained by the fact that these tools were developed by the Experts in research and these

tools used in many different studies( Lynch et al, 2013,p.17).

However, to ensure validity and reliability of the palliative care quiz for nursing (PCQN) in

the context of this current study in Rwanda, this tool were pre-tested in a pilot study using 16

bedside nurses.

A pilot study is a smaller version of a proposed study conducted to refine the methodology. It

is developed much like the proposed study, using similar subjects, the same settings, the same

treatment, the same data collection and analysis techniques (Polit & Beck, 2010, p.49).

The researcher determined that it would take fifteen (15) minutes to complete the

questionnaire and internal consistency among the questionnaire items was 0.71 Cronbach's

alpha (α) and it was considered within the acceptable range according to Goforth, 2015.

The tool used in this study had three sections. Section one; includes 5 variables describing

social demographic and characteristics of the participants but without names for

confidentiality issue. Section two includes 46 questions described the knowledge regarding

palliative care. It comprises 20 questions with possible responses of ‘true’, ‘false’, and ‘I do

not know and 26 questions options which included multiple choices and “Yes” or “No. The

questions measure understanding of the philosophy and principles of palliative 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 46, with a lower score indicating poorer knowledge and the

knowledge scores were classified into Poor knowledge (>50%), Fair knowledge (50- 69%),

and (≥70%) considered Good knowledge (Kim et al, 2011, p.19).

Sections three had 11 items described the nurses’ attitude regarding palliative care with five

levels of scale ranging from strongly agree to strongly disagree (strongly agree=5, agree=4,

Uncertain=3 disagree=2 and strongly disagree=1). The highest score of 5 for each option and

the total possible score was 55. Possible overall scores range from 11 to 55, with higher

scores reflecting more positive attitudes. The scale contains both negative and positive

statements, with reversed scores assigned to negative statements. The tool was designed as

Likert-Scale with 11 items and the scale was used without modification and has previously

been validated (Barrere et al, 2008, p .211).

The attitude scores were categorized into good (≥70%), moderate (50-69%), and poor

(<50%) ( Abudari, Zahhreddine, Hazeim, Assi, Emara,2013,p. 435).

3.8.2 Data collection procedure

After getting the ethical approval from the Institutional Review Board (IRB) of UR/CMHS,

and the permission from the Director General of UTHK, the researcher went to the study

setting to provide explanation about the study. The participants were targeted in staff meeting

where the explanations about the research were provided, the researcher explained the

objectives of the study to the participants, also explained about the consent form insisting on

their rights, the confidentiality and anonymity, then participants who accepted to participate

in the study were requested to put their names and signature on the consent form.

Participants after accepting to participate in the study were met with the researcher in

prepared room with privacy. Method of self administered structured questionnaire was used,

questionnaires were provided to the participants the same day of data collection. Before

filling the questionnaire, the researcher gave clear and homogenous instructions to the

participants to remove all difficulties related to the study, then after the participants were

requested to complete the questionnaire using information given by the researcher. After

completing the questionnaire the researcher collected the filled questionnaire by going to the

place where the participants were given a sit. Data collection took two months from 13 th

February /2017 to 12 th

/ April/ 2017.

3.9. Data analysis

Data were analysed using computer SPSS version 20. Descriptive statistics of the results was

presented in the tables and the charts and the chi-square test was used to determine the

association between socio- demographic characteristics and knowledge and attitude level of

nurses towards palliative care.

3.10. Ethical considerations

Ethical approval was obtained from IRB the College of Medicine and Health Sciences,

University of Rwanda. After obtaining ethical approval, written permission was obtained

from UTHK. The participants were explained with respect to the study and those who

accepted, contributed to the study after getting their written informed consent. There was

confidentiality of participants through using anonymity during data collection, by avoiding

putting their names on the questionnaire. Informed consent was obtained from participants on

the day of data collection. First, the researcher explained to the participants who she was, and

then the researcher told the participant the purpose of the study, the reason why they had been

chosen as participants. Also, they were explained about the tool that was used to make it

understandable. Moreover, participants were explained how the confidentiality and privacy of

the study were guaranteed as well as how the information provided by them could be

beneficial for the following days. Furthermore, they were explained how the participation

was voluntary and without any reword; they were also explained that they had right to accept

or refuse to participate or to withdraw any time without any punishment. At the end, the

participants were requested to put their names and signature on consent form if they accepted

to participate in the study.

Risk protection

In order to defend the nurse’s privileges who decided to contribute in this schoolwork, a

researcher was used some approach like verbal permission given by the nurses before the

questionnaire administration, the reason for the study was well explained to the nurses as well

as they had the right to refuse to contribute.

3.11. Data management

At the end of the day data collected were entered and stored in the computer that had the

password to secure information collected from participants. The data were controlled every

time to prevent errors. Data entry and data manipulation were highly checked for regular

errors until the researcher finished doing analysis and reporting the findings. Data will be

kept for 5 years then after they will be burnt.

3.12. Data dissemination

Data will be disseminated through the presentation of findings in the college of medicine and

health sciences, the results findings will also be disseminated in the area of research. The

findings of the research will be disseminated in different conferences, meetings, and seminars

as well as in other institutions. Data will be also published in a peer reviewed journals.

Conclusion

This study used quantitative, cross sectional design. UTHK were chosen, the data collection

was done using structured questionnaire which was translated into Kinyarwanda to make it

understandable and participants were given the information about the ethical concern. In

addition, the questionnaires were completed after getting instructions; the researcher

collected the filled questionnaire and checked for their completeness. Then the data was

entered into the computer where the regular checking of error was performed and the

computer was protected using a password. Moreover, the data analysis was performed by

using descriptive statistics and the chi-square test was used to determine the association

between socio- demographic characteristics and knowledge and attitude and data will be

disseminated through meetings, conferences and data will be published.

CHAPTER FOUR: RESULTS

4.1. Introduction

This chapter presents the results and its discussion. It includes data obtained from the nurses

who work at CHUK/UTHK in the pediatric ward and in the surgical ward on knowledge and

attitude that they have toward palliative care, using the self-administrative questionnaires. A

total number of participants responded to the questionnaire were 139, the majority of the

respondents were females which were 106 and 33 were males. Their ages ranged from 20 to

61years and above, majority 36% of the respondents were in the group aged 31-35 years and

the lowest number of participants were in the group aged 20-25 years was 2.9%. About

educational level, the majority of participants were prepared up to Nursing Diploma 86.33%

and 13.67% of participents were prepared to Bachorer’s degree. The majority of respondants

38.85% had 2- 5 years of experience at work and only 8.63% of the sample size had obtained

in service education and 91.37% had not obtained it.

Table .4.1.Demographic and characteristics of the sample

Variables Frequency Percent

Age

20-25years 4 2.9

26-30 years 45 32.4

31-35 years 50 36

36-40 years 29 20.9

41-45 years 5 3.6

45-50 years 6 4.3

Total 139 100

Gender

Female 106 76.3

Male 33 23.7

Total 139 100

Work experience Less than 2 years 9 6.5

2-5 years 54 38.8

5-10 years 41 29.5

11 years and above 34 24.5

Total 139 100.0

Education level DiplomaA1 120 86.3

DegreeA0 19 13.7

Total 139 100.0

In service-education yes 12 8.6

No 127 91.4

Total 139 100.0

Table .4.1. showed the results related to demographic variable where the majority of

respondents (35.97%) were within the age 31 – 35 years, based on gender the result showed

that the majority of the respondents were females 106 (76.26%), regarding educational level,

the results showed that the majority of participants were prepared to Nursing Diploma

86.33%, while the majority of respondants 38.85% had 2- 5 years of experience at work and

only 8.63% of the sample size had obtained in service education and 91.37% did not have

obtained it.

Table .4.2. The association between the level of knowledge on palliative care and socio-

demographic variables.

Variable Level of knowledge p-

value Good knowledge Fair knowledge Poor knowledge

Frequenc

percentag

Frequenc

percentag

Frequenc

Percentage

2.8%

0.856

Chi

squar

e 4.90

Age

20-25years 0 0.0% 3 3.3% 1

26-30

years

4 30.8% 29 32.2% 12 33.3%

31-35

years

5 38.5% 31 34.4% 14 38.9%

36-40

years

3 23.1% 21 23.3% 5 13.9%

41-45

years

0 0.0% 2 2.2% 3 8.3%

45-50

years

1 7.7% 4 4.4% 1 2.8%

Gender

Female 11 84.6% 68 75.6% 27 75.0%

0.757 Male

2 15.4% 22 24.4% 9 25.0%

Educatio

n level

DiplomaA

6 46.2% 80 88.9% 34 94.4%

DegreeA0 7 53.8% 10 11.1% 2 5.6% 0.000

Work

experienc

Less than

2 years

1 7.7% 5 5.6% 3 8.3%

0.270 2-5 years 5 38.5% 30 33.3% 19 52.8%

5-10 years 4 30.8% 32 35.6% 6 16.7%

11 years

and above

3 23.1% 23 25.6% 8 22.2%

service-

education

palliative

care

yes 0 0.0% 7 7.8% 5 13.9%

13 100.0% 83 92.2% 31 86.1%

Total 13 100% 90 100% 36 100%

Table 4.2 showed that respondents’ knowledge was associated with their increased level of

education (p=0.000).Based on the results, the researcher concluded that increased level of

education could improve knowledge of the participants.

Table 1. Table4.3. the association between the level of attitude on palliative care and

socio- demographic variables.

Variable

Level of attitude p-value

Moderate attitude Poor attitude

Frequency percentage Frequency percentage

Age

20-25 1 2.2% 2 2.4%

0.629

26-30 16 35.6% 21 25.6%

31-40 16 35.6% 33 40.2%

41-45 9 20.0% 19 23.2%

46-50 1 2.2% 4 4.9%

50 and

above

2 4.4% 3 3.7%

Sex male 11 24.4% 17 20.7% 0.629

female 34 75.6% 65 79.3%

Education

level

Diploma 29 64.4% 81 98.8% 0.000

Degree 16 35.6% 1 1.2%

Work

experience

less than 2

years

3 6.7% 6 7.3%

0.908

2-5 years 24 53.3% 44 53.7%

5-10 years 6 13.3% 14 17.1%

11 years

and above

12 26.7% 18 22.0%

In service-

education in

palliative

care

yes 6 13.3% 6 7.3%

0.268

51 86.7% 76 92.7%

Table 4.3 showed that respondents ‘attitude was associated with their increased level of

education (p=0.000). Based on result well educated participants had good knowledge as well

as the knowledge can influence attitude.

Table 4.4 Nurse’s knowledge about palliative care.

Table 4.4.1.Section a: answering the questions by using true/ false / don’t know.

Statements Wrong answer Correct answer

Frequency Percentage Frequency Percentage

1. Palliative care is only appropriate in

situations where there is evidence of a simple

route.

75 54.0% 64 46.0%

2. Morphine is the standard used to compare

the analgesics effect of other opioids.

82 59.0% 57 41.0%

3. The degree of the disease determines the

method of pain treatment.

76 54.7% 63 45.3%

4. Adjuvant therapies are important in

managing pain.

87 62.6% 52 37.4%

5. It is important for the family members to

stay at the bedside until death occurs.

106 76.3% 33 23.7%

6. During the last days of life, lethargy

associated with electrolyte imbalance may

decrease the need for sedation.

76 54.7% 63 45.3%

7. Drugs dependence is a major problem

when morphine is used on a long-term.

108 77.7% 31 22.3%

8. Individuals who are taking opioids should

also follow a bowel regime.

91 65.5% 48 34.5%

9.The condition of palliative care requires

emotional detachment

92 66.2% 47 33.8%

10. During the terminal stages of an illness,

drugs that can cause respiratory depression

are appropriate for the treatment of severe

dyspnoea.

73 52.5% 66 47.5%

11. Men generally resolve their grief more

quickly than women.

95 68.3% 44 31.7%

12.The philosophy of palliative care is

compatible with that of aggressive treatment

95 68.3% 44 31.7%

Table 4.4.2. Continuation of section a: answering the questions by using true/ false / don’t know.

Statements Wrong answer Correct answer

Frequenc

Percentage Frequency Frequency

13. The use of placebos is appropriate in the

treatment of some types of pain.

71 51.1% 68 48.9%

14. In high doses, codeine causes more nausea and

vomiting than morphine.

86 61.9% 53 38.1%

15. Suffering and physical pain are the same. 83 59.7% 56 40.3%

16. Demerol is not an effective analgesic for the

control of chronic pain.

105 75.5% 34 24.5%

17. The accumulation of losses renders burnout

inevitable for those who work in palliative care.

97 69.8% 42 30.2%

18. Manifestations of chronic pain are different from

those of acute pain.

92 66.2% 47 33.8%

19. The loss of an isolated or contentious relationship

is easier to resolve than the loss of one that is close or

intimate.

105 75.5% 34 24.5%

20. Pain point (entry) is lowered by fatigue or

anxiety.

85 61.2% 54 38.8%

The resultats showed that Only 24.5% had correct answers on the Demerol is not an effective analgesic for the control of chronic pain.

Table 4.4.3.Section b: answering the questions by using yes / no.

Statements Wrong answer Correct answer Frequency Percentage Frequency Frequency

1. Palliative care is planned to delay or to

prolonged death.

92 66.2% 47 33.8%

2. Palliative care is only about pain. 83 59.7% 56 40.3%

3. A patient suffering from cancer needs

palliative care.

5 3.6% 134 96.4%

4. A patient suffering from the HIV/ AIDS

needs palliative care.

40 28.8% 99 71.2%

5. A patient suffering from the chronic heart

disease needs palliative care.

37 26.6% 102 73.4%

6. A patient suffering from the chronic renal

failure needs palliative care.

36 25.9% 103 74.1%

7. Only pharmacological treatments are the kind

of the care should be given to the patient with

cancer.

58 41.7% 81 58.3%

8. The both pharmacological and non

pharmacological treatments are the kind of the

care should be given to the patient with cancer

46 33.1% 93 66.9%

9. Only pain management is the kind of the care

should be given to the patient with cancer.

74 53.2% 65 46.8%

10. Palliative care is given at hospitals only. 87 62.6% 52 37.4%

11. Palliative care is given at home. 77 55.4% 62 44.6%

12. Palliative care is given at community. 70 50.4% 69 49.6%

13.The nurses only can provide PC 58 41.7% 81 58.3%

Many participants 92(66.2%) they didn’t know the plan of palliative care where they

responded that the plan of palliative care is to prolong the death but the majority 96.4% of

participants knew that the patient suffering from cancer needs palliative care.

Table 4.4.4. Continuation of section b: answering the questions by using yes / no,

Statements Wrong answer Correct answer

Frequency Percentage Frequency Frequency

14. The doctors only can provide PC. 40 28.8% 99 71.2%

15. The social workers only can provide PC. 39 28.1% 100 71.9%

16. A team of health providers such as

Physicians, Nurses, Social workers,

Dieticians, Physical therapists, mental health

counsellors and Chaplains.

35 25.2% 104 74.8%

17. The pain management is a program of PC. 49 35.3% 90 64.7%

18. The spiritual support is a program of PC. 79 56.8% 60 43.2%

19. The social support is a program of PC. 69 49.6% 70 50.4%

20. To prolong death is a program of PC. 77 55.4% 62 44.6%

21. The benefits of PC are to reduce anxiety,

depression, and pain.

67 48.2% 72 51.8%

22. The benefits of PC are to increase

confidence in navigating their care.

46 33.1% 93 66.9%

23. The benefits of PC are to increase

satisfaction with the care received.

73 52.5% 66 47.5%

24.The time you stop to provide PC is

immediately after diagnosing incurable

diseases

40 28.8% 99 71.2%

25. The time you stop to provide PC is after

five years living with chronic disease.

31 22.3% 108 77.7%

26. The time you stop to provide PC is when

the patient dies.

31 22.3% 108 77.7%

The resultats showed that(22.3%) they didn’t know the time you stop to provide palliative

care where they responded that the time you stop to provide palliative care is after five years

living with chronic disease.

Figure 4 . The nurses' knowledge levels of palliative care

The findings showed that only 13(9.3%) had good knowledge, 90(64.7%) had the fair

knowledge and 36(25.8%) had poor knowledge.

Table.4.5 Nurses ‘attitude towards palliative care.

Statements Strongly

agree

Agree Uncertain Disagree Strongly

disagree

As a patient nears passing away, the nurse

must leave from his /her interest with the

patient.

(6.5%)

(7.9%)

(2.9%)

(27.3%)

(55.4%)

It is helpful for the chronically ill person to

express his/her feeling.

(45.3 %)

(43.2%)

(5.8%)

(5.0%)

(0.7%)

The length of time required to give nursing

care to a dying person would frustrate me.

(30.9%)

(34.5%)

(15.8%)

13(9.4%) 13

(9.4%)

The family should maintain as normal an

environment as possible for their dying

member.

(11.5%)

(37.4%)

(12.9)

(20.9)

(17.3)

The family should be involved in the

physical care of the dying person.

(47.5%)

(2.9%)

(2.2%)

(0.0%)

It is difficult to form a close relationship

with the family of a dying member.

(21.6%)

(38.8)

(16.5%)

(14.4%)

(8.6%)

Nursing care for the patient's family should

continue during the period of grief and

bereavement.

(42.4%)

(37.4%)

(12.9%)

(2.9%)

(4.3%)

Nursing care should extend to the family of

the dying person.

(36.7%)

(48.9%)

(5.0%)

(3.6%)

(5.8%)

When a patient asks, “Nurse am I dying?"I

think it is best to change the subject to

something cheerful.

(17.3%)

(19.4%)

(25.2%)

(20.1%)

(18.0%)

I am afraid to become friends with

chronically sick and dying patients.

(41.0%)

(41.7%)

(7.9%)

(5.8%)

(3.6%)

I would be uncomfortable if I entered the

room of a terminally ill person and found

(48.9%)

(35.3%)

(10.8%)

(2.9%)

(2.2%)

her/him crying.

In assessing the attitude of the nurses toward PC 11 items were requested the participants to

response as strongly agree, agree, uncertain, disagree and strongly disagree.

Table4. 5 summarized the attitude of the nurses toward PC. More than half (55.4%) of the

nurses were more likely to strongly disagree of as a patient nears passing away; the nurse

must leave from his /her interest with the patient, as well as (45.3 %) of the nurses strongly

agree with beneficial for the chronically sick person to verbalize his/her feelings. Unexpected

(19.4%) agreed that when a patient asks, “Nurse am I dying?'I think it is best to change the

subject to something cheerful.

Figure 5 .The nurses' attitude of palliative care

Figure 6.2. showed that the most respondents' attitudes levels towards palliative care were

poor attitude 106(76.3%), 33 (23.7%) moderate attitude, and there were no one who had good

attitude level on palliative care.

CHAPTER FIVE: DISCUSSION

This study assessed knowledge and attitude toward palliative care among nurses at University

Teaching Hospital of Kigali. This chapter discusses the major findings of the study according

to the objectives of the study which were to assess the existing level of knowledge and

attitude of the nurses working at University Teaching Hospital of Kigali about palliative care.

5.1. Socio-demographic information

The socio demographic information showed that the majority of the respondents were

females 106 (76.26%).A low number of the male nurses due to three main problems facing

the men in a nursing profession such as understanding like nursing as a feminine profession,

male nurses’ donation to heavy manual work and the male nurses has advantages of getting

other position like leadership (Zamanzadeh et al., 2013,p. 54). The majority of respondents

(35.97%) were within the age 31 – 35 years.

Regarding education level, the majority of participants were prepared to Nursing

Diploma(86.33%) and Bachorer’s degree were only (13.67%) , these findings agrees with the

rusalts of (Ayed, 2015, p.17) and regarding work experience, many participants 54(38.85%)

had 2- 5 years of experience so it can cause the issue of low knowledge thi resalts agrees with

Fadare et al (2014), while regarding in service- education in palliative care only 12(8.63%) of

the sample size had obtained training, these findings were similar with the rusalts of

(Uwimana & Struthers 2012, p.16)

5.2. Knowledge about palliative care

This study is the first of its type conducted in Rwanda to document the knowledge and

attitude toward palliative care among nurses at a referral hospital. The findings showed that

only 13(9.3%) had good knowledge. These findings are similar to the study done by Kassa et

al., (2014, p.13), Ayed et al (2015, p.4) where the nurses had good knowledge were 30% of

the participants.

According to the findings, showed that ,Only (41.0%) of the participants had correct answers

on the morphine is the standard used to compare the analgesics effect of other opioids and it

supported with results of (Powell et al.2014, p.11), while many participants 92(66.2%) they

didn’t know the plan of palliative care where the participants responded that the plan of

palliative care is to prolong the death. (WHO, 2016) stated that the plan of palliative care is to

get better excellence life of the people living with serious illnesses and their families by

avoiding and take care of the symptoms and complications of diseases through physical,

psychological, spiritual as well as social support. Many participants (59.7%) had an incorrect

answer where they know that palliative care is only about pain and it supported with a study

done by Fadare et al 2014, p.4.

5.3. Attitude about palliative care

The attitude was assessed using a 5-items scale (ranging from strongly agree 5 to strongly

disagree, 1). It had 11 item ranking scale with the highest score of 5 for each option and the

total possible score was 55.The attitude scores were categorized into good (≥70%), moderate

(50-69%), and poor (<50%) .

The description of attitude scores shows that 76.3% of respondents ‘had a poor attitude

towards palliative care. This finding was in disagreement with the findings of Kassa et

al.,(2014,p.13) and many results of other studies found the data contrary to this research

(Ayed et al 2015, p.4; Zahhreddine, Hazeim, Assi, Emara 2013,p. 11,

5.4. Limitations of the study

As few similar research done in Rwanda about the assessment of nurses ‘knowledge and

attitude toward palliative care, it was difficult to compare and to discussion the results from

this study to other studies. Lack of a standard tool for practice and unavailability of PC unit in

the hospitals involved were challenges of this study to assess the real practice of nurses on

PC. Since the study was conducted in one hospital, the results cannot be generalised to the

other hospital.

5.5. Summary

The findings from this study highlighted that the nurses had a poor attitude but their

knowledge are moderate.

CHAPTER SIX: CONCLUSIONS AND RECOMMENDATION

The purpose of this study was to assess knowledge and attitude toward palliative care among

nurses at University Teaching Hospital of Kigali. From the research that has been carried out,

it is possible to conclude that nurses are not knowledgeable regarding palliative care in

UTHK as this study has shown that the nurses had moderate knowledge but their attitude

were poor and some explanation have shown that there are insufficiency in learning, lack of

curriculum content related to palliative care, palliative care experience and training and the

level of palliative care integration in the health facilities.

6. 1. Recommendations

6.1.1. Nursing practice

In order to improve palliative care in Rwanda will require multi-institutional strategies.

Such strategies should focus on establishing palliative care services at all levels of the

healthcare system and organize the training of the nurses about palliative care.

6. 1. 2 Nursing education

Palliative care needs to become an integral part of all nursing school curricula and medical

education program for undergraduate and postgraduate nurses that cover all aspects of

palliative care, such as its principles and philosophy, communication, psychosocial support,

pain and symptom management, and cultural views.

6.1.3. Nursing research

More studies are needed in this area to clearly understand the problems met in the practice

setting and to show the acceptance of a PC delivery model that is culturally sensitive and

meets the needs of the Rwandan population.

REFERENCE LIST

Angela, L. & David, S., 2011. Hospice without borders.Rwanda Trip,

Ayed, A., 2015. The Nurses ’ Knowledge and Attitudes towards the Palliative Care. , 6(4),

pp.91–100.

Barrere CC, Durkin A, LaCoursiere S , 2008 The influence of end-of-life education on

attitudes of nursing students. Int J Nurs Educ Scholarsh 5:11. doi: 10.2202/1548-

923X.1494

Dornyei, Z.,2007.Rsearch methods in applied linguistics.New York:Oxford University Press.

Downing, J. et al., 2016. A palliative care link nurse programme in Mulago Hospital,

Uganda : an evaluation using mixed methods. BMC Palliative Care, pp.1–13. Available

at: http://dx.doi.org/10.1186/s12904-016-0115-6.

Downing, J.D. et al., 2013. Developing children ’ s palliative care in Africa through beacon

centres : lessons learnt.

Kassa H., Murugan R., Zewdu F., Hailu M. And Woldeyohannes D.,2014. Assessment of

knowledge, attitude and practice and associated factors towards palliative care among

nurses working in selected hospitals, Addis Ababa, Ethiopia. BMC Palliative Care. Vol

13 NO 6

Kim HS, Kim BH, Yu SJ et al ,2011. The Effect of an End-of- Life Nursing Education

Consortium Course on nurses’ knowledge of hospice and palliative care in Korea. /

Hospice Palliat Nurs 13(4): 222-9

Kumar, R., 2011. Research Methodology: a step-by-step guide for beginners 3rd Editio.,

SAGE Publications Ltd.

Lawless Kimberly A, P.G.S., 2004. The knowledge, attitudes, & behaviors approach how to

evaluate performance and learning in complex environments. , (September), pp.1–15.

Loscalzo, M.J., 2008. Palliative Care : A Historical Perspective,

McCusker, M. et al., 2013. Health Care Guideline. Palliative Care for Adults, Available at

www.icsi.org.

Lynch T, Connor S, Clark D ,2013. Mapping levels of palliative care development: a global

update. J Pain Symptom Manage 45(6): 1094-106. doi: 10.1016/j.jpainsym-

man.2012.05.011

Ministry of Health Rwanda, 2012. Pain management guidelines. , (September), pp.1–62.

Ministry of Health Rwanda, 2011. REPUBLIC OF RWANDA Rwanda National Palliative

Care Policy,

Ntizimira, C.R. et al., 2014. Palliative care in Africa : a global challenge. , pp.1–4.

Parahoo K. ,2006 Nursing Research: Principles, Process and Issues, 2nd edn. Palgrave

Macmillan, Houndsmill.

Polit D.F. & Beck C.T.,2010 Essentials of Nursing Research: Appraising Evidence for

Nursing Practice, 7th edn. Wolters Kluwer Health / Lippincott Williams & Wilkins,

Philadelphia.

Rwanda Ministry of Health, 2014. Health Sector Policy.

Ryan Karen, M.L.P.-K. et . a., 2014. Palliative Care Needs Assessment Guidance. , pp.1–13.

Uwimana, J. & Struthers, P., 2012. Met and unmet palliative care needs of people living with

HIV / AIDS in Rwanda. Journal of Social Aspects of HIV/AIDS, 4(1).

World Health Organization (WHO): WHO definition of palliative care. 2006. Available

from: http://www.who.int/cancer/palliative/definition/en/. Retrieved date: 5 th

September,

2016

Zamanzadeh, V. et al., 2013. Factors Influencing Men Entering the Nursing Profession, and

Understanding the Challenges Faced by Them : Iranian and Developed Countries ’

Perspectives. , 2(14), pp.49–56.

Dictionary.com (2016)

Thefreedictionary.com(2016)

Dictionary.combridge.org/dictionary/English/attitude.

http://www.merriam-webster.com/dictionary/hospice

http://en.oxforddictionaries.com/difinition/attitide

http://www.who.int/mediacentre/factsheets/fs402/en/

http://www.investopedia.com/terms/s/sampling.asp#ixzz4Lk0t2drH

http://www.raosoft.com/samplesize.html

https://medlineplus.gov/ency/patientinstructions/000536.htm

http://www.worldatlas.com/webimage/countrys/africa/rw.htm

http://en.oxforddictionaries.com/difinition/attitide

http://www.investopedia.com/terms/s/sampling.asp#ixzz4Lk0t2drH

http://www.raosoft.com/samplesize.html

https://medlineplus.gov/ency/patientinstructions/000536.htm

http://www.worldatlas.com/webimage/countrys/africa/rw.htm

APPENDIX I

QUESTIONNAIRE

QUESTIONS ABOUT PALLIATIVE CARE CONCERNING THE NURSES WORKING

IN PEADIATRIC AND SURGICAL WARD AT UTHK.

I am MARIE CLAIRE KARIKWERA; student at CMHS in Masters’ program especially in

Pediatric track. I will conduct a research project about the nurses’ knowledge and attitude

toward palliative care among the nurses working at UTHK.

I. INSTRUCTIONS

 These questions will be related to knowledge and attitude of the nurses working in

pediatric and surgical ward at UTHK about palliative care.

 Your name will not be mentioned anywhere.

 Choose the appropriate answer or fell in the blank if necessary.

 Feel free while answering.

 Please respond carefully.

 I thank you for participation in my research.

II. DEMOGRAPHIC DATA

1. Age

20-25years old 26- 30years old 31-35 year old

36-40 years old 41-45 years old 46 -50 years old

51 years and above

2. Gender: Male Female

3. Education level:

Diploma A1 Degree (A0) Masters

4. Professional experience in pediatric or in surgical ward:

Less than 2years 2- 5years 5-10 years 11 years and above

In service-education in palliative

III.QUESTION ABOUT KNOWLEDGE ON PALLIATIVE CARE

SECTION A: ANSWERING THE FOLLOWING QUESTIONS BY USING TRUE/

FALSE / DON’T KNOW.

Statements TRUE FALSE DON’T

KNOW

1. Palliative care is only appropriate in situations where there is

evidence of a simple route.

2. Morphine is the standard used to compare the analgesics effect

of other opioids.

3. The degree of the disease determines the method of pain

treatment.

4. Adjuvant therapies are important in managing pain.

5. It is important for family members to stay at the bedside until

death occurs.

6. During the last days of life, lethargy (sleepiness) associated with

electrolyte imbalance may decrease the need for sedation.

7. Drug dependence is a major problem when morphine is used on

a long-term source for the management of pain.

8. Individuals who are taking opioids should also follow a bowel

regime.

9. The condition of palliative care requires emotional detachment

(disconnection).

10. During the terminal stages of an illness, drugs that can cause

respiratory depression are appropriate for the treatment of severe

dyspnoea.

11. Men generally resolve their grief (unhappiness) more quickly

than women.

12. The philosophy of palliative care is compatible with that of

aggressive treatment.

13. The use of placebos is appropriate in the treatment of some

types of pain.

14. In high doses codeine causes more nausea and vomiting than

morphine.

15. Suffering and physical pain are the same.

16. Demerol is not an effective analgesic for the control of chronic

pain.

17. The accumulation of losses renders burnout inevitable for

those who work in palliative care.

18. Manifestations of chronic pain are different from those of acute

pain.

19. The loss of an isolated or contentious relationship is easier to

resolve than the loss of one that is close or intimate.

20. Pain point (entry) is lowered by fatigue or anxiety.

SECTION B: ANSWER THE FOLLOWING QUESTIONS BY USING YES / NO.

Statements Yes No

1. Palliative care is planned to delay or to prolonged death? Yes No

2. Palliative care is only about pain? Yes No

3. The patient suffering with cancer needs palliative care? Yes No

4. The patient suffering with HIV/AIDS needs palliative care?

Yes No

5. The patient suffering with chronic heart disease needs palliative care? Yes No

6. The patient suffering with chronic renal failure needs palliative care? Yes No

7. Only pharmacological treatments are the kind of the care should be given

to the patient with cancer.

Yes No

8. Both pharmacological and non pharmacological treatments are the kind

of the care should be given to the patient with cancer.

Yes No

9. Only pain management is the kind of the care should be given to the

patient with cancer.

Yes No

10. Palliative care is given at hospitals only. Yes No

11. Palliative care is given at home. Yes No

12. Palliative care is given at community. Yes No

13. The nurses only can provide palliative care. Yes No

14. The doctors only can provide palliative care. Yes No

15. The social workers only can provide palliative care. Yes No

16. A team of health providers such as Physicians, Nurses, Social workers,

Dieticians, Physical therapists, mental health counsellors and Chaplains. Yes No

17. The pain management is program of palliative care. Yes No

18. The spiritual support is program of palliative care Yes No

19. The social support is program of palliative care Yes No

20. To prolong death is program of palliative care Yes No

21. The benefits of PC are to reduce anxiety, depression and pain. Yes No

22. The benefits of PC are to increase confidence in navigating their care. Yes No

23. The benefits of PC are to increase satisfaction with the care received. Yes No

24.The time you stop to provide PC is immediately after diagnosing

incurable diseases

Yes No

25. The time you stop to provide PC is after five years living with chronic

disease. Yes No

26. The time you stop to provide PC is when the patient dies. Yes No

III.QUESTIONS ABOUT ATTITUDE ON PALLIATIVE CARE

What are you think about these following statements?

Statements

Strongly

agree

Agree

Uncertain

Disagree

Strongly

disagree

1. As a patient nears passing away; the nurse

must leave from his/her interest with the

patient.

2. It is helpful for the chronically ill person to

express his/her feeling or opinion.

3. The length of time required to give nursing

care to a dying person would frustrate me.

4. Family should maintain as normal an

environment as possible for their dying

member.

5. The family should be involved in the

physical care of the dying person.

6. It is difficult to form a close relationship

with the family of a dying member.

7. Nursing care for the patient's family should

continue during the period of grief and

bereavement.

8. Nursing care should extend to the family of

the dying person.

9. When a patient asks, “Nurse am I dying?'I

think it is best to change the Subject to

something cheerful.

10. I am afraid to become friends with

chronically sick and dying patients.

11. I would be uncomfortable if I entered the

room of a terminally ill person and found

him/her crying.

APPENDIX II

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

TITLE OF STUDY: ASSESSMENT OF NURSES’ KNOWLEDGE AND ATTITUDE

ABOUT PALLIATIVE CARE AMONG NURSES AT UNIVERSITY TEACHING

HOSPITAL OF KIGALI.

Researcher’s Name: MARIE CLAIRE KARIKWERA

Phone number: 0783269347

email: [email protected]

Introduction: You are being asked to be in a research study regarding the NURSES’

KNOWLEDGE AND ATTITUDE ABOUT PALLIATIVE CARE AMONG NURSES AT

UNIVERSITY TEACHING HOSPITAL OF KIGALI. You were selected as a possible

participant because you are a registered nurse working AT UNIVERSITY TEACHING

HOSPITAL OF KIGALI in pediatric and surgical wards.

We ask that you read this form and ask any questions that you may have before agreeing to

be in the study.

Purpose of Study

The purpose of the study is to assess nurses ‘knowledge and attitude about palliative care

among nurses at University Teaching Hospital of Kigali.

Description of the Study Procedures

If you agree to be in this study, you will be asked to sign this consent form, take this a

questionnaire read it and fill it. You will be required to submit it back to the researcher with

in the period of 3 days.

Risks/Discomforts of Being in this Study

There may be unknown risks.

There are no reasonable foreseeable (or expected) risks.

Benefits of Being in the Study

This study will express real information to the policy maker, about the knowledge and the

attitude that Nurses working at UTHK in that wards have on palliative care and then act

consequently.

Confidentiality

The researcher will not be collecting or retaining any information about your identity.

The records of this study will be kept strictly confidential. Research records will be kept in a

locked file and all electronic information will be coded and secured using a password

protected file.

The researcher will not include any information in any report he may publish that would

make it possible to identify you.

Payments

There will be no payment

Right to Refuse or Withdraw

The decision to participate in this study is entirely up to you. You may refuse to take part in

the study at any time without affecting your relationship with the researcher.

You have the right not to answer any single question, as well as to withdraw completely from

this research study at any point during the process.

Right to Ask Questions and Report Concerns

You have the right to ask questions about this research study and to have those questions

answered by me before, during or after the research. If you have any further questions about

the study, at any time feel free to contact me, my name is KARIKWERA MARIE CLAIRE, at

email:[email protected] or by telephone at phone number:0783269347. If

you like, a summary of the results of the study will be sent to you. If you have any other

concerns about your rights as a research participant that have not been answered by the

investigators, you may contact Phil Peake, Co-chair of the Smith College Institutional

Review Board at (413) 585-3914.

If you have any problems or concerns that occur as a result of your participation, you can

report them to the Phil Peake at the number above. Alternatively, concerns can be reported by

completing a Participant Complaint Form, which can found on the IRB website at

http://www.smith.edu/irb/

Consent

Your signature below indicates that you have decided to volunteer as a research participant

for this study and that you have read and understood the information provided above. You

will be given a signed and dated copy of this form to keep, along with any other printed

materials deemed necessary by the researcher.

Subject's Name (print):

Subject's Signature: ……………………….. Date:……………………………..

Researcher’s Signature: ……………………….. Date:……………………………..

APPENDIX III

PERMISSION OF USING PCQN AS TOOL

Hello Marie Claire. Yes, you are welcome to use the PCQN. I have looked after Dr. Ross

correspondence for many years. Good luck with your important project. Frances 04:31 AM

11/27/2016, you wrote:

Content-Type: application/vnd.openxmlformats-officedocument.wordprocessingml.document;

name="KARIKWERA UBWE.docx"

Content-Disposition: attachment; filename="KARIKWERA UBWE.docx"

X-Attachment-Id: f_iw0g44qn0

Frances Fothergill Bourbonnais, RN PhD

Emeritus Professor

School of Nursing

University of Ottawa

451 Smyth Road

Ottawa, Ont. K1H 8M5

(613) 562-5800 ext 8423.

KARIKWERA COVER PAGE - Copy (3).pdf
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