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
© 2014 MA Healthcare Ltd
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 nationally, and aside from what is provided in the primary 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 inpatients in Saudi Arabia die in hospitals, because hospice care is not available and in-home palliative 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 palliative care (Lynch et al, 2011), but insufficient palliative care knowledge among nurses is a barrier to quality provision (Paice et al, 2008). Education regarding palliative care in general nursing curricula worldwide is considered by many to be inadequate (Ahmed et al, 2004; Nakazawa et al, 2009; Choi et al, 2012). Nurses’ knowledge of and attitudes 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 interventions in experimental studies (Frommelt, 2003; Mallory, 2003; Barrere et al, 2008; ZarghamBoroujeni et al, 2011). Many countries have now adopted a systematic approach to improving palliative 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).
International Journal of Palliative Nursing 2014, Vol 20, No 9
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
KFSH&RC-Riyadh is a tertiary care facility that employs nurses of around 30 different nationalities. As palliative care is not yet integrated into the health-care system in Saudi Arabia, expatriate nurses’ knowledge of and attitudes towards palliative care probably result primarily from the education 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 systems. The criteria for the classification were based on data such as the level of public awareness, opioid availability, institutions providing palliative
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 [email protected]
435
tional 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 re
Research
Aim The aim of this study was to assess knowledge of and attitudes towards palliative care among multinational 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.
Design
Methods
This study used a descriptive cross-sectional design in which nurses completed self-administered questionnaires. The questionnaires quantified the nurses’ knowledge of and attitudes towards palliative care and included a demographic 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 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 20, with a lower score indicating poorer knowledge. The PCQN was used without modification and has been validated in similar studies (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 previously been validated (Barrere et al, 2008).
436
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 population 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&RCRiyadh 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 completion 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 inpatient oncology, surgical, medical, cardiovascular, obstetric/gynaecologic, and intensive care wards. Completed questionnaires were received from 395 respondents (54% response rate) of 19 different 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 independent t-test was used to compare knowledge and attitudes for variables categorised with two groups, such as palliative care training. A oneway 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 differences. 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 significant 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-
© 2014 MA Healthcare Ltd
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.
International Journal of Palliative Nursing 2014, Vol 20, No 9
tional 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 re
Research
tive care integration into their health-care system. 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 countries 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.
© 2014 MA Healthcare Ltd
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 highest 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 nationality. 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
Knowledge of and attitudes towards palliative care among multinational nurses in Saudi Arabia Gassan Abudari, Hassan Zahreddine, Hassan Hazeim, Mohammad Al Assi, Sania Emara
© 2014 MA Healthcare Ltd
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 nationally, and aside from what is provided in the primary 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 inpatients in Saudi Arabia die in hospitals, because hospice care is not available and in-home palliative 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 palliative care (Lynch et al, 2011), but insufficient palliative care knowledge among nurses is a barrier to quality provision (Paice et al, 2008). Education regarding palliative care in general nursing curricula worldwide is considered by many to be inadequate (Ahmed et al, 2004; Nakazawa et al, 2009; Choi et al, 2012). Nurses’ knowledge of and attitudes 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 interventions in experimental studies (Frommelt, 2003; Mallory, 2003; Barrere et al, 2008; ZarghamBoroujeni et al, 2011). Many countries have now adopted a systematic approach to improving palliative 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).
International Journal of Palliative Nursing 2014, Vol 20, No 9
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
KFSH&RC-Riyadh is a tertiary care facility that employs nurses of around 30 different nationalities. As palliative care is not yet integrated into the health-care system in Saudi Arabia, expatriate nurses’ knowledge of and attitudes towards palliative care probably result primarily from the education 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 systems. The criteria for the classification were based on data such as the level of public awareness, opioid availability, institutions providing palliative
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 [email protected]
435
tional 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 re
Research
Aim The aim of this study was to assess knowledge of and attitudes towards palliative care among multinational 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.
Design
Methods
This study used a descriptive cross-sectional design in which nurses completed self-administered questionnaires. The questionnaires quantified the nurses’ knowledge of and attitudes towards palliative care and included a demographic 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 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 20, with a lower score indicating poorer knowledge. The PCQN was used without modification and has been validated in similar studies (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 previously been validated (Barrere et al, 2008).
436
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 population 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&RCRiyadh 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 completion 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 inpatient oncology, surgical, medical, cardiovascular, obstetric/gynaecologic, and intensive care wards. Completed questionnaires were received from 395 respondents (54% response rate) of 19 different 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 independent t-test was used to compare knowledge and attitudes for variables categorised with two groups, such as palliative care training. A oneway 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 differences. 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 significant 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-
© 2014 MA Healthcare Ltd
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.
International Journal of Palliative Nursing 2014, Vol 20, No 9
tional 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 re
Research
tive care integration into their health-care system. 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 countries 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.
© 2014 MA Healthcare Ltd
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 highest 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 nationality. 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
