Assessment of the knowledge, attitude and practice towards palliative care amongst the 4th year nursing degree students at Windhoek Campus, University of Namibia

INTRODUCTION

World Health Organization (WHO) defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems such as physical, psychological and spiritual. Palliative care involves a range of services delivered by a range of professionals that all have quality important roles to play; including physicians, nursing, support workers, paramedics, pharmacists, physiotherapists and volunteers in support of the patient and their family. Palliative care is also required for the wide range of diseases as majority of adults in need of palliative care have chronic diseases such as cardiovascular disease (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%). Besides this, each year estimated 40 million people need palliative care; 78% of them live in low-and middle-income countries, worldwide, only about 14% of people who need palliative care currently receive it.^1,2

Based on the review of palliative care in Africa, the African Palliative Care Association (APCA), a non-profit organization with its head office currently based in Kampala, Uganda, was provisionally established in November 2002. APCA’s vision is to ensure access to palliative care for all in need across Africa, whilst its mission is to ensure palliative care is widely understood, underpinned by evidence and integrated into all health systems to reduce pain and suffering across Africa. Africa is characterised by an increase rate of communicable diseases such as HIV and AIDS and a high burden of non-communicable diseases such cancers, cardio vascular diseases, diabetes and respiratory diseases. This creates an increased need for a well-developed understanding of and integration of palliative care.³

APCA brought an office for Palliative Care to Namibia in 2004. In 2011, a full semester of Palliative Care was established at the University of Namibia. However, the country with the total population of 2 456 830 in 2015, was reported to have only 2 numbers of hospitals with inpatient palliative care unit out of 45 hospitals across the country. The density of palliative care services per population (per million inhabitant) according to population data from the World Bank is 0.81 hospice or palliative care services/ million inhabitant. In addition to this, Namibia only has 1 number of houses based palliative care services offered. The estimated number of patients cared for palliative care in 2016 was 600. Undeniably, Windhoek Central Hospital had some aspects of PC while Catholic AIDS Action has satellites with active PC with staff trained in community/ home based palliative care. However, the country has no palliative care programme specific to paediatric. This creates a huge burden of suffering for the Namibian people with extremely limited access to pain medications and other palliative care intervention.⁴

As a matter of that, nurses play a central role in palliative and end-of-life care which include developing plans of care, providing leadership for staff and support for patient and families. Insufficient knowledge may make nursing students feel unprepared and stressful regarding palliative care providing, which perhaps leads to the developments of negative attitude towards caring for the dying. Thus, a deep understanding and assessment of nursing student’s knowledge, attitude and practice is needed.^5,6

Lack of assessment and proper investment in research is one the biggest challenges facing palliative care in African countries including Namibia. Therefore, confirming adequate knowledge, positive attitude and good practice towards palliative care are vital educational features when training undergraduate nursing students to act on difficulties of care for people affected by progressive, life limiting illness. To this end, the researcher is not aware of any study conducted in Namibia particularly at University of Namibia, School of Nursing that assessed and determined the knowledge, attitude and practice of the nursing students regarding palliative care. Therefore, this study was aimed at assessing the knowledge, attitude and practice towards palliative care amongst the 4th year nursing degree students at Windhoek Campus, University of Namibia.^4,7

METHODS

Study design

A non-experimental cross sectional survey was conducted using a quantitative approach on 104, 4th year nursing degree students at UNAM. A probabilistic sampling technique using a simple random sampling method was used in selecting the students.

Study place

The study took place at Wanaheda, Hakahana, Maxwilili, Okuryangava, Otjomuise, Khomasdal, Katuture Health Center and Donkerhoek clinic in Windhoek, Khomas region were 4th year nursing degree students were placed for their clinicals.

Study period

The study was conducted over the period of 8 days, from 23 June 2021 till 30 June 2021.

Study population

The study target population was all nursing students. This is because they have been allocated to various departments of health (Health Centre, General Wards, ICU, NICU) during their clinical allocation since 1st year and palliative care or end of life care is most likely to happen in this departments.

In this study the target population was all nursing students, registered for Bachelor of Nursing Clinical Honours, in 4th year at Windhoek campus, University of Namibia. This is because, it was the suitable population to the research topic as the 4th year nursing students have been taught about palliative care during their 3rd year as indicated in (School of Nursing Prospectus, 2019) the module content for General Nursing Science 3. Additionally, they have been allocated to various departments of health (Health Centre, General Wards, ICU, NICU) during their clinical allocation since 1st year as a requirement for completing the course where palliative care or end of life care is most likely to happen. This was as well as the same population which the researcher used to access and obtain data (accessible population).⁸

Sample size

A sample size of eighty three, fourth year nursing degree students was determined using a formula. Calculation was done as follows:

where; n = sample size

N = population size

e = margin of error

n=104÷(1+0.26)

n=104÷1.26

n=82.53

n=83

Data collection

Research instrument

A self-administered English questionnaire, with open ended questions was used for data collection. It included 4 sections. Section A: A socio-demographic variable included (age, gender, highest level of education and if they have ever cared for a terminally/ dying patient). Section B; consisted of statements with possible responses of ‘true’, ‘false’, and ‘I don’t know’ describing knowledge regarding palliative care which measured the understanding of the philosophy and principles of palliative care, pain, symptoms management and psychological care. Section C; used a Likert scale with five level of scale ranging from strongly agree to strongly disagree (strongly agree=5, agree=4, uncertain=3, disagree=2, and strongly disagree=1) to assess the attitudes regarding nursing students’ practices towards palliative care with ‘yes’ or ‘no’ statements.

Procedure for data collection

The researcher targeted the participants during lunch time 13h00-14h00, where each participant was randomly selected and had an equal chance of being selected. Before handing out the questionnaires, the researcher explained the study’s aims and objectives and participants were given clear and homogenous instruction regarding the problems seen in the questionnaire during pilot study. Data collection from the participants also strictly followed the ethical principles of the study. After obtaining permission from the students, the researcher distributed the questionnaires. The researcher then collected the completed questionnaires and thanked the participants. The whole procedure of completing the questionnaire took 3-7 minutes.

Data analysis

The study employed descriptive statistics to summarise the study’s variables into tables and charts presenting frequencies and percentages. Data were analysed using computer Statistical package for social sciences (SPSS) version 27.

RESULTS

Demographic information

Age

Majority of the participants 84.15% were between the age of 20-25 years. While participants between the age 26-31 years were 10.98% (11) and participants between the age 32-37 years were 4.88% (4).

Gender

A total 92.68% (76) were females and males 7.32 % were males.

Highest level of education

The sum 92.68% (76) of students obtained their NSSC/NSSCH, with 7.32% students having who obtained Certificate in nursing and it shows that they were enrolled in nursing before.

Ever care for terminally ill/ dying patient

A total 82.93% of students have cared for a terminally ill/ dying patient. While 17.07% (14) of students have never cared for a terminally ill/ dying patient.

Results on knowledge, attitude and practice towards palliative care

A good number of participants know the aim of palliative care as 98%. Nearly all participants 91% understands that drug addiction is the major problem when morphine is administered on a long term in managing pain. On the other hand, majority of the participants have zero knowledge on whether the extend of the disease determines the methods of pain treatment. In contrast 35% participants do not knowing the importance of adjuvant (non-opioids).

More than half of the participants 63% answered correctly that provision of palliative care does not require emotional detachment. Like-wise, a large number of participants 73% know that manifestation of chronic pain is different from that of acute pain and 54% participants know that; suffering and physical pain are synonymous. In general, 46% participants responded that as much as the family members need to be along the bedside of their patient, it is not so crucial for them to be there until death occur, which is correct. Half of the participants 50% knows that the pain measuring tool used mostly in children is face scale and 45% of participants did not know the key concepts of administering analgesics.

Nearly half of the participants 48% participants have strongly agreed that they would want to care for a dying patient. Unfortunately, only 33% strongly agreed that giving care to a terminally ill patient is a worthwhile experience. However, majority of participants 62% participants strongly agree that they are not afraid to go in the room of a terminally ill/ dying patient alone. In contrast, 30% participants strongly disagreed “the length of time required to give nursing care to a terminally ill patient would frustrate me”. Surprisingly, 28% participants strongly agree that they are confident enough to face the family members of a terminally ill/ dying patient. On the other hand, majority of the participants 77% strongly agree that terminally ill/ dying patient should be given honest answers about their conditions. Half of the participants 51% strongly agreed that nursing care of the patient’s family should continue during the period of grief and bereavement. In contrast 73% participants strongly disagreed that it would be best if a terminally ill or dying patient is left alone until he/ she actually dies with 73% strongly disagree “I would not care if a terminally ill/ dying patient gave up hope of getting better” while 43% strongly disagreeing “I would hope the person I am caring for dies when I am not around”.

Majority of the participants 95% responded ‘no’ that as a nurse is near death, the nurse should withdraw from his/her involvement with the patient, and 89% of the students responded “yes” the family should be involved in the care of a dying patient as much as possible. Incredibly, all participants 100% responded ‘yes’ the terminally ill/ dying patient should be treated equal and with dignity the same as other patients while a good number of participants 90% answered “no” the terminally ill or dying patient should not be allowed to make decisions about his/her own physical care. On the other hand, 85% participants indicated “no” if medical equipment and materials are few in the ward, they should not be used on terminally ill/dying patient, rather the be reserve for a healthier patient. And majority of participants 98% responded that “yes” families need emotional support to accept the behaviour changes of a dying person. Surprisingly, 95% answered “no” that terminally ill patient should not know about their condition as this will stress them more. A good number 70% of participants indicated “no” when addressing spiritual issues, the nurse should impose his or her own views while 95% participants have practically agreed that yes, decision making of the patient should involve the patient.

The overall results on the level of knowledge, attitude and practice towards palliative care amongst the 4th years nursing degree students

Data obtained from the participant’s knowledge, attitude and practice were added all together and divided by the total number of statements measuring knowledge. The final score was categorised as good knowledge and poor knowledge; positive attitude and negative attitude; good practice and bad practice. The results are summarised below.

The study gained 54.9% of participants who had good knowledge towards palliative care. While 45.1% participants had poor knowledge on palliative care. This means, more than half of the participants had good knowledge on palliative care.

The participants 76.8% who have positive attitudes towards palliative care. Whilst the least number of participants 23.2% had negative attitudes towards palliative care.

The study had majorities of participants 91.5% with good practice towards palliative care, whilst a least number of participants 8.5% with bad practice towards palliative care.

DISCUSSION

Knowledge towards palliative amongst the 4th year nursing degree students

Assessing nursing student’s knowledge is important because knowledge plays a crucial role in attitude or behavioural consistence. Firstly, in this study 98% of the participants were correctly able to identify the primary aim of palliative care. This is promising finding as students appear to understand and have an idea of what palliative care. This finding is not supported by the study done in Georgia by who’s findings were (86.1%). In contrast, a study done in Arab American only 58.6% of students could get this statement correct. Besides this, in this study, the highest number of incorrect answers on knowledge towards palliative were on the following statements: the extent of the disease determines the method of pain treatment 5%; suffering and physical pain are synonymous 24% and the results on key concepts of administering analgesics are by mouth, by clock and by ladder 37%. This can be due to inadequate palliative care education in nursing programme.^7,5,9

In addition, this study’s level of knowledge score shows that 54.9% of students had good knowledge on palliative care which was classified as suboptimal level of knowledge while 45.1% nursing students had poor knowledge towards palliative care. To contrary this study’s findings the following studies had poor knowledge on palliative care among nursing students: a study done in Rwanda only 9.3% nursing students had good knowledge, a study done in Arab American only 40.58% nursing students had good knowledge and another study done in Indonesia shows that only 24.3% students nurses had good level of knowledge towards palliative care.^7,9,10

Attitude towards palliative care amongst the 4th year nursing degree students

Assessment of attitude towards palliative care in this study looked at factors such as: giving care to a dying patient; whether care should be extended care to the family of a dying person; and whether a dying patient should be given honest answers about their condition were observed. Adding to this, students were also asked how confident they are in facing family members of a dying patient and if the time required to care for a terminally ill patient would frustrate them. Surprisingly, not less than 60% was obtained from the results these results contradict with the study done in Ethiopia by Kassa, Woldenyohannes and Muragan. Reasons could be that the nursing students have nursed quite a number of terminally ill and dying patients thus their attitudes being influenced by the experience. The attitude scale of this study was scored and categorised into positive and negative attitude. Thus, providing description of attitude score which shows 76.8% of students had positive attitude towards palliative care. On the other hand, 23.2% nursing students had negative attitude towards palliative care. These results are dissimilar to a study done in Saudi Arabia by Youssef, attained 83% positive attitude towards palliative care among nursing students.^11,12

Practice towards palliative care amongst the 4th year nursing degree students

It is interesting that the findings from this study indicates that students have good practices towards palliative care and none of the statements scored less than 70%. This shows that student’s actions and implementations towards caring for a terminally ill/ dying patient are acceptable. These results disprove with the study done in Ethiopia by Kassa, Woldenyohannes and Muragan, that got 20.2%. The study revealed that there is good level of practice of 91.5% nursing students towards palliative care. On the other hand, only 8.5% of students shows bad practice towards palliative care. These results slightly differ from the results of previous study conducted in Indonesia by Agustini that obtained 85.2% good practice among nursing students. Other previous studies also indicated a high mean score on palliative care practices.^11,7,13,14

Limitations

Firstly, this study was conducted on undergraduate 4th year nursing degree students at Windhoek campus, UNAM, without additional data or other provinces. Hence the results cannot be generalized to all undergraduate nursing students in Namibia. Secondly, this study was a cross-sectional study without longitudinal observation of the participants and it did not involve any intervention and the associations between these variables were not measured.

CONCLUSION

Integrating palliative care education is required as a pillar to improve student’s knowledge, attitude and practice. Therefore, nursing educators should not only design the proper teaching content but also, they need to use various teaching strategies to promote active and experimental learning regarding palliative care.

ACKNOWLEDGEMENTS

I wish to express my heart felt appreciation to the School of Nursing Ethical Committee for granting me with the permission. My colleagues, 4th year nursing students, Unam, Windhoek Campus for the enormous support and input during the data collection stage. And all my family members and friends, thank you so much for your moral support, education and encouragement. Lastly my two seniors who facilitated the process of the entire manuscript, thank you.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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