The Practice of Palliative Care amongst Nurses in Selected Hospitals in Eastern Nigeria

In recent times, palliative care nursing has caught the attention of nurse re-searchers in Africa as more individuals are being diagnosed with chronic diseases of the aged like cancer, cardiac and cerebrovascular conditions. This study examined the influence of knowledge and attitude on the practice of palliative care among practicing nurses in eastern part of Nigeria. A descriptive cross-sectional research design was used for the study. The population of the study is all registered, licensed and practicing nurses working in the named public and private hospitals where palliative care is supposedly well established. Proportionate sampling technique was used to select 289 respondents. Three commercial instruments that were modified were used for data collection. Level of significance was set at 5%. The study was conducted from October 2018 to June 2019. Results revealed that 52.7% of the respondents had satisfactory practice of palliative care, 73.7% of the respondents had adequate knowledge of palliative care (mean 2.64 (1.06) and 77.5% of the respondents had positive attitude towards palliative care (Mean 2.81 (1.14)). There was also a significant weak positive association between nurses’ educational level and their knowledge of palliative care with an effect size of 21.9% (P = 0.003). There was also a significant association between nurses’ years of experience and their attitude to palliative care with an effect size of 35.6% (P < 0.001). There was no significant association between type of hospital facility nurses work in and their practice of palliative care (P = 0.343). Recommenda-tions were made on how to improve the practice of palliative care among professional nurses.


Introduction
Throughout the past decade, the world has experienced growing health enhancing technology that has had a significant influence on medical science and practice. The average life expectancy at birth worldwide had increased from 58.7 years in 2009 to 71.4 years in 2015 [1]. With this increasing global life expectancy more individuals are being diagnosed with chronic diseases of the aged like cancer, cardiac and cerebrovascular conditions. The increased global life expectancy implies that individuals with chronic and debilitating illnesses must be provided comfort to maintain the highest possible Quality of Life (Qol) for as long as life remains. This is palliative care.
The concept of palliative care has been defined by several authors. World Health Organization defined palliative care as an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness through the relief of suffering by means of early identification, impeccable assessment and treatment of pain and other problems like physical, psychological and spiritual [2]. [3] defined palliative care as the care that is primarily directed at providing relief to a terminally ill person through symptom management and pain management. Similarly [4] explained that palliative care is alleviating symptoms, whether or not there is hope of a cure. The above definitions imply that palliative care is improving the functionality of the terminally ill. [3] argued that people near the end of life do not only want to live life as fully as they can, they also want to be respected by healthcare providers who will in turn assist them in maintaining their dignity and independence while relieving symptoms and ensuring their comfort. Thus, nursing strategies and interventions must be geared towards managing individual's symptoms, and reducing the burden of pain. It therefore becomes paramount for nurses to possess adequate knowledge, the right attitudes and interpersonal competence to provide comfort and maintain the highest possible QoL. Knowledge of palliative is rudimentary to nursing care. Similarly, the attitude of nurses towards death and dying patients may influence the care nurses are able to provide. [3] asserted that not all nurses are comfortable with caring for the dying. Ideal attitude to palliative care is described as flexibility in interpersonal relations, desire for open communication about critical issues, and psychological mindedness in relation to patients and families of dying patients [4].
Palliative care was introduced into Nigeria in 1993 by Fatunmbi and Merriman [5]. In 2008, the Nigerian Federal Ministry of Health not only included elements of palliative care into the National Cancer Control Plan (2008-2013) as well as the National Guidelines for HIV and AIDS treatment and care in adolescents and adults [6], they also established palliative care units in 15 tertiary and secondary health institutions in Nigeria. Despite the presence of palliative care in Nigeria since a decade ago, it is observed that Nigeria is lagging behind in palliative care provision. It is pertinent to ask some basic questions. Is this situation related to the way palliative nursing is practiced in Nigeria?
Practice of palliative care refers to the quality of end-of-life care provided to patients. The core of nursing intervention in this regard should focus on communication, pain and symptoms relief, knowledge of available resources, and fostering involvement in and control of decision making by the patient as long as possible. Other questions are, are practicing nurses in Nigeria knowledgeable about palliative care, what is their attitude towards it, and how exactly do they practice it? The premise is that based on the nurses' position within the healthcare system, they ought to play a significant role in palliative and end-of-life care. In search of answers to the above questions, this study was justified.
There are several factors that influence a successful practice of palliative care. These include healthcare professionals' knowledge, attitude, beliefs, and previous experiences. [7] asserted that these factors may influence the health professionals' behaviour during evaluation and treatment of patients. According to [8] nurses are a crucial component of palliative care delivery teams, developing plans of care, providing leadership for staff and guidance or support for patients and families Thus, to achieve a successful delivery of palliative care, nurses must not only possess the knowledge and skills to provide effective end-of-life care, but must also have the right attitudes and interpersonal competence to provide compassionate care [4].
Fourteen empirical studies were reviewed in this study. Majority of the studies found favourable positive attitude towards palliative care among nurses [2] [3] [9] [10]. At the time of reporting this study, two studies [4] [11] found poor practice of palliative care and no known published studies examined the relationship between practice of palliative care among nurses and the type of hospital facility in which they work in. The researcher hopes that a study of this nature will fill this identified gap. [4] found inadequate practice of palliative care which was inconsistent with [11]. Few studies have examined the association between practice of palliative care and demographic characteristics such as marital status, type of ward, level of education, and job experience. The researcher believes that the identified gap in practice underscores a need for an empirical investigation to assess the knowledge, attitude and practice of palliative care among nurses from selected hospitals in eastern part of Nigeria.

Scope of the Study
This study is expected to unravel the knowledge, attitude, practice of palliative care and the associations between knowledge of palliative care among nurses and their educational level, years of experience, type of ward, and type of hospital facility (public and private).

Objective of the Study
To identify the extent to the variables; knowledge and attitude of practicing nurses in eastern part of Nigeria influence their practice of palliative care.

Hypothesis
 There is no significant relationship between nurses' educational level and their knowledge of palliative care.  There is no significant relationship between nurses' years of experience and their attitude to palliative care.

Research Methodology
The research design adopted for this study was descriptive cross sectional design.
The study was set in eastern part of Nigeria.

Ethical Clearance
Due ethical clearance was obtained.

Findings
Demographic profile of respondents The population was 989. Taro Yamane formula was used to determine the sample size which is 285. To account for potential attrition, a non-response adjustment formula for cross-sectional survey was applied, thus, a final sample size of 317 was established. Table 1 showed that the mean age of the respondents was 34.27 (8.58) years. Majority (43.6%) of the respondents were aged 30 -39 years. Most (92.7%) of the respondents were females. Majority (40.1%) of the respondents had RN/RM as their highest educational qualification. 87.9% of the respondents served in public hospitals. Majority of the respondents had 4 -7 years of clinical experience.
Knowledge of palliative care Items 8 -21 were analyzed to answer research question 1. Table 2 summarized responses to Knowledge of palliative care among nurses.
Generally, majority (73.7%) of the respondents had adequate knowledge of palliative care (mean 2.64 (1.06)). Meanwhile, the respondents had inadequate knowledge on palliative care being appropriate in situations of deteriorating condition, palliative care not requiring emotional detachment, drugs that can cause respiratory depression not being appropriate for dyspnoa, the philosophy of palliative care being compatible with aggressive treatment, the use of placebos not appropriate, and the risk of burnout (mean < 2.5). The respondents were most knowledgeable on palliative care being provided for individuals who cannot benefit from curative therapy (mean 3.2 (0.96)). They were least knowledgeable on palliative care being appropriate care to individuals with deteriorating condition (mean 2.05 (0.98)).
Attitude to palliative care Items 22 -45 were analyzed to answer research question 2. Table 3 summarized responses on attitude to palliative care among nurses.
Overall, majority (77.5%) of the respondents had positive attitude towards palliative care (Mean 2.81 (1.14)). Meanwhile, the respondents had felt that giving care to a dying patient is not a worthwhile learning experience, nursing care for patients' family should not continue throughout the period of grief, scary to Open Journal of Nursing      On the whole there was significant association between nurses' educational level and their knowledge of palliative care (P = 0.003). The nature of this relationship is weak positive such that as educational qualification increases, there follows a mild increase in knowledge of palliative care (φ = +0.219).
Hypothesis 2: There is no significant relationship between nurses' years of experience and their attitude to palliative care.

Discussions
Knowledge of palliative care Similar findings were recorded in studies by [17] and earlier study by [10]. [17] found that Paediatric nurses in Florida USA, had a good level of baseline   [18].
In contrast, this finding was in conflict with [19] study in South-East Iran.
These authors found that, nurse have negative to neutral attitudes toward palliative care (2.99 ± 0.29 out of 5). The difference in findings could be related to the demography of nurses in the separate studies. While the present study sampled nurses irrespective of their clinical location, [19] samples were nurses working in oncology and intensive care. Thus, the findings of [19] study are limited and cannot be generalized for nurses in Iran.
Practice of palliative care This study found that about half (52.7%) of the respondents had satisfactory practice of palliative care. This finding was not in agreement with [2] who is in a study on assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in Addis-Ababa Ethiopia, found that 76.2% of nurses had poor practice of palliative care. The difference in findings could be liked to differences in sampling technique used in the separate studies. [2] utilized multistage sampling method, whereas the present study uti-Open Journal of Nursing lized proportionate sampling technique. Multistage sampling tends to be less accurate than proportionate sampling but practicable when the population is large and widely dispersed as was the case in [2] who sampled out of about 10,000 nurses. On the other hand, proportionate sampling may result in insufficient numbers for making comparisons among strata and conclusions [18]. As obtainable in the present study, nurses serving in private hospitals made up 12.1% of the study sample. This could introduce some degree of bias to the results and conclusions of the study. This study supports [10] study on palliative care among nurses in Lebanon. Both the present study and [10] utilized a cross-section of nurses irrespective of the ward that these nurse work.
Relationship between nurses' educational level and their knowledge of palliative care This study showed a significant weak positive association between nurses' educational level and their knowledge of palliative care (P = 0.003) with an effect size of 21.9%. This means that this association will hold true in about one in every five of the respondents. This finding was not supported by [2] who found no significant association between educational level of nurses and their knowledge of palliative care. The difference in findings could be due to the proportion of degree and diploma holders in the sample used in the separate studies.
Relationship between nurses' years of experience and their attitude to palliative care This study found significant weak positive association between nurses' years of experience and their attitude to palliative care (P = 0.000*) with an effect size of 35.6%. This finding was supported by [19] who is in a study on nurses' attitudes toward palliative care in south-east Iran. The similarity in findings could be linked to the level of significance used in the separate studies. Both [19] and the present study utilized 5% level of significance to control for the risk of a Type 1 error [18].
In contrast, the finding of this study was not in agreement with [2] [4] that found that no significant relationship between attitude toward palliative care and nurses' years of experience at the P values of (P > 0.05) and (P = 0.27) respectively. The divergence in findings could be connected to differences in methods of data analysis used in the studies. [4] utilized t-test parametric statistical method, whereas the present study utilized chi square non-parametric statistical method. Parametric tests are more powerful than non-parametric tests, but non-parametric are used instead when a normal distribution cannot be assumed [18]. [2] utilized a class interval of 5 (i.e. <5 years, 5 -10 years, 11 -15 years, and >20 years), whereas the present study utilized a class interval of 4 (i.e. 0 -3 years, 4 -7 years, 8 -11 years, and 12 -15 years). Purists agree that class intervals used in the classification of ordinal data can affect the external conclusion of validity of test of hypothesis [18].
Relationship between type of hospital nurses work in and their practice of palliative care This study found that there was no significant association between type of

Limitations of the Study
The weakness to the external conclusion validity of this study includes:

Conclusion
This study concluded that the respondents had a satisfactory (borderline) prac-  Palliative care is only appropriate in situations of a downhill trajectory or deterioration in conditions.

10
Method of Pain management in Palliative care is not determined by the severity of pain in disease.

11
Adjuvant therapies are important in managing pain as pain is not only relieved by drugs 12 Drug addiction is a major problem when morphine is used on a long-term basis for the management of pain.

13
The provision of palliative care requires emotional detachment.
14 During the terminal stages of an illness, drugs that can cause respiratory depression are appropriate for the treatment of severe dyspnoea.

15
The philosophy of palliative care is compatible with that of aggressive treatment. 16 The use of placebos is appropriate in the treatment of some types of pain.

17
Morphine instead of Pethidine is the standard used to compare the analgesic effect of other analgesics.

18
The accumulation of losses renders burnout Inevitable for those who work in palliative care.

19
Manifestations of chronic pain are different from those of acute pain.

20
Terminally ill patients have the right to choose "Do not resuscitate" (DNR).

21
It is not very crucial for family members to remain at bedside until death occurs. Family members who stay close to a dying person often interfere with a professionals' job with the patient.

27
The length of time required to give nursing care to a dying person would frustrate me.

28
Families should not be concerned about helping their dying member make the best of his/her remaining life.

29
Family should not maintain as normal an environment as possible for their dying member.

30
The nurse should not be the one to talk about death with the dying person.

31
The family should not be involved in the physical care of the dying person.

32
It is difficult to form a close relationship with the family of a dying member.

33
There are no times when death is welcomed by the dying person.

34
Nursing care for the patient's family should not continue throughout the period of grief and bereavement.

35
The dying person and his/her family should not be the in-charge decision makers. Open Journal of Nursing