Knowledge and perception of nurses on palliative care. A case study at Agogo Presbyterian Hospital Linda Akuamoah Sarfo* 1, Mary Opare 2, Dorothy Awuah-Peasah 1, Florence Asamoah 1 1 Ghana Christian University College of Ghana, Department of Nursing, PO Box AF919, Adenta, Accra, Ghana 2 Central University College of Ghana, Department of Nursing, PO Box 2305, Tema, Ghana *Corresponding author: linda.sarfo@presbyuniversity.edu.gh Abstract Lack of specialist education has been identified as a major barrier to providing quality palliative care to patients. The aim of the study was to assess theknowledge and perception of nurses on palliative care delivery at Agogo Presbyterian Hospital. Structured questionnaires were developed and administered to 92 nurses from different wards where purposive sampling technique was used. The results revealed that the nurses understandingabout palliative care was different (p=001). Despite nurses knowledge about palliative care, it was found that most of the nurses at the hospital knew their specific roles in providing palliative care to patients who came to the hospital even though they had little training in providing palliative services. The consequences of knowledge deficiencies and lack of formal education in palliative care had therefore significantly translated into poor quality service among the nurses at Agogo Presbyterian Hospital. The study therefore recommended for an effective training for nurses on palliative care delivery. Key words: palliative care, terminally ill, knowledge and perception, and Agogo Presbyterian Hospital 1. Introduction Palliative care is a healthcare approach that improves the quality of life for 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, physical, psychological and spiritual [1} The World Health Organization ( WHO) also defines palliative care as the active total care of a patient whose disease is not responsive to curative treatment [1]. In addition, WHO [1] states that palliative care aims to achieve the best possible quality of life for patients and their families, affirms life and regards dying as a normal process, neither hastens nor postpones death, provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of patient care and offers a support system to help the family cope during the patient s illness and in subsequent bereavement. Nurses spend more time with patients at the end-of-life than any other health discipline. Health care education has been widely criticized for not providing professional education within palliativecare, resulting in anxiety, interpersonal conflict and ineffective pain management in palliative care [2]. Millions of people die each year, and the majority of deaths occur in hospitals, medical centers, and/or skilled facilities where nurses provide the majority of care [3]. As the population ages, nurses will be required to provide palliative care for an increasing number of patients. Given these extremely important responsibilities, nurses must be adequately prepared to provide sensitive quality care for patients at the end of life because nurses have an ethical and moral obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. 39
2. Statement of the Problem It has been estimated that about 54 percent global mortality cases occur in hospital [4]. The challenge for health care professionals such as nurses working in hospitals is to ensure that all those who require palliative care have access to it at the time they require the services. Palliative care has been identified as one of the important areas in reducing mortality cases at hospitals. Quality health care has been linked with the level of knowledge and perception of palliative care workers. Hospitals and health workers achieves this goal by providing specialist advice and treatment and educating non-specialist clinical staff in how to provide a basic level of palliative care and when to call for specialist support. Agogo Presbyterian Hospital is one of the renowned hospitals in the Ashanti region of Ghana, however the hospital still lack palliative care specialist to care for terminally ill patients.despite this challenge, every year the hospital record high number of patients that require palliative careservices such as cancer, HIV, malaria, cardiac arrest, and road traffic accidents [5].Notwithstanding the high number of patients recorded, it is still unclear the knowledge and perception among nurses about palliative care even though they care for such special patients. This study aimed at identifying the knowledge and perception of palliative care among nurses at Agogo Hospital. 3. Objectives of the Study The main objective of the study was to assess nurses knowledge and perception on palliative care in Agogo Presbyterian Hospital. 4. Methodology Research Setting This research was conducted in Agogo Presbyterian Hospital which was established on 21st March, 1931 as the first missionary hospital in Ghana. It is the second largest hospital in the Ashanti Region (after Komfo Anokye Teaching Hospital), but also a leading hospital in Ghana for ophthalmic surgery. It is situated at Agogo, in the Asante Akyem North district of the Ashanti region of Ghana and has a bed capacity of 250 and a staff population of 400, out of which 120 are nurses [6]. The hospital provides specialty care in ophthalmology, pediatrics, general surgery and internal medicine which attracts patients from all parts of the country as well as neighboring countries of Burkina Faso, Togo and Cote d lvoire. The departments of the hospital include: outpatient, laboratory, pharmaceutical, radiography, physiotherapy, casualty, and the two operating theatres. There are currently a total of seven wards comprising maternity, medical, two surgical units, intensive care unit, pediatric ward, and ophthalmic ward [6]. Agogo Presbyterian Hospital is a teaching hospital for nurses and medical students. Research Design The research design was aquantitative descriptive study. Study population and sample size The study population consisted of Registered nurses, as well as enrolled nurses at Agogo Presbyterian Hospital. The total population of nurses at Agogo Presbyterian Hospital is 120 nurses. The study employed the use of Slovin s formula study used a confidence level of 95 percent which gave a margin error of 0.05. in finding out the sample size for the study. The Where N = total population (120) n = sample size 40
a= Alpha (margin of error or error of tolerance) = confidence level (0.05) n= 120 1 + 120(0.05) 2 = 92 Therefore the sample size for the research study was 92 staff nurses out of a total population of 120 nurses where purposive sampling technique was used [7]. The 92 nurses worked closely with patients, while the remaining 28 nurses worked in administration. Thus, 100% of the population took part in the study. Data collection and Data Analysis Both primary and secondary data were collected. Primary data were collected using a research questionnaire and the researcher personally administered the questionnaires.the questionnaires consisted of series of structured questions which were related to the research work and directed to respondents with the aim of gaining firsthand information. The questionnaire consisted of both open-ended and close-ended questions. Secondary data was collected from documents and existing journals on knowledge and perception of palliative care. Data analysis was done using Statistical Package for Social Scientist version 16.0 (SPSS16.0) software and the results were displayed in the form of frequency tables, percentages and charts Ethical consideration The research received approval from the hospital administration prior to the conduct of the study. In addition, verbal consent was obtained from the respondents prior to the administration of the questionnaires. 5. Findings and Analysis Demographic Characteristics of Respondents Results indicated that 67% of respondents were females and 33% of respondents were males. In addition, the majority (76%) of respondents were not married while the minority (2 4%) of respondents was married. The study also found that most of the respondents were between the ages of 20 and 30 years representing 71% of total respondents, 18% were above 30 years, while 11% reported being less than 20 years. Furthermore, majority of respondents (65%) had attained diploma level of nursing education, while 25% were found to be enrolled nurses, and 10% had attained a Bachelor s of Science Degree and there was no record of any nurses having a Master s Degree in Nursing or PhD in Nursing. Respondents were asked their employment status and majority of respondents, 64% were Staff Nurses (SN), and followed by 24 % who were Senior Staff Nurses (SSN), 10% were Nursing Officers (NO), with only 2% drawn from Principal Nursing Officers (PNO). Also, respondents were asked the number of years they have worked with Agogo Presbyterian Hospital, and 40% indicated that they had worked more than 5 years, 34% said they have worked for Agogo Presbyterian Hospital for less than 3 years, while the remaining 26% said they have worked for Agogo PresbyterianHospital between 3 and 5 years. Knowledge Level of Nurses on Palliative Care Respondents knowledge levels about palliative care were assessed and 69% level of knowledge about palliative care was good, 23% knowledge level about palliative care was average, and 8% knowledge 41
level was excellent. The results revealed that there was no significance between the educational level of respondents and their knowledge level on palliative care. Perception and Understanding on Palliative Care Respondents were asked to indicate their main understanding and perception of palliative care. The majority of respondents representing 78% mentioned that it was an approach for nurses to improve quality of life of patients and their families who are facing a life threatening illness, while 22% said palliative care was a type of care when one is approaching death. The result indicates a difference in the understanding on the roles nurses on palliative care among the respondents interviewed. The data contradict the position of Schlairet (2009) [8] who implied that nurses who are working in hospitals, clinics, and community setting are without knowledge of how best to assist patients and families facing end-oflife care. Roles Performed by nurses during Palliative Care Respondents were asked their specific roles in the care of palliative patients at Agogo PresbyterianHospital, in which 49% indicated they provide personal care, observation and reporting of symptoms, another 44% stated they assist in medical care, while5% stated they have not experienced the opportunity to engage in palliative care yet. A minimum of 2% indicated they provide symptom control (Table 1).This analysis confirms [9] the position that nurses assume primary responsibility for providing personal care and assisting patients with activities of daily living during end of life. They further explained that nurses practice within a variety of palliative care settings including long-term care, acute care, and patients homes. Table 1:Roles performed by nurses caring forpalliative patients Indicators Percentage (%) Assist in medical care 44 Provide symptom control 2 Provide personal care, observation and 49 reporting of symptoms Enhance patient contact 0 Never had the opportunity to engage in 5 palliative care Total 100 Source: Field survey, 2014 Impact of low Knowledge level on Palliative Care to Quality Health Care Respondent were asked whether knowledge deficiencies and lack of specialist education in palliative care settings significantly inhibit quality end-of-life-care, and all the respondents (100%) agreed. Mallory(2003) [10] confirmed this position by investigating pivotal components for nurses to deliver quality palliative care and concluded that it was significant to increase their knowledge and perception during end-of-life. Respondents were asked whether there are specific end-of-life curricula developed to educate nurses at Agogo Presbyterian Hospital on palliative care, and 59% of respondents indicated that they were aware of the end-of-life curricula developed to educate nurses at Agogo Presbyterian Hospital, 39% said they were not aware, whilst 3% of respondents disclosed that they were not sure (figure 1). The findings show that specific end-of-life curricula have been developed to educate nurses at Agogo hospital but not to the awareness of the general nursing population. 42
Educational Programs Enrolled to Educate Nurses on Palliative Care Figure 1:Are there specific end-of-life curricula developed to educate nurses at Agogo hospital on palliative care 6. Conclusions and Recommendations In conclusion, nurses at Agogo Presbyterian Hospital have knowledge and perception about palliative care as well as the basic care to provide to terminally ill patients. As the population of dying patients increases, nurses will be required to provide palliative care for an increasing number of patients. Given these extremely important responsibilities, nurses must be adequately prepared to provide sensitive quality care for patients at the end of life because nurses have an ethical and moral obligation to relieve pain and suffering and to promote the dignity and autonomy to dying patients. It is therefore recommended that management and authorities of Agogo Presbyterian Hospital and other health institutions, periodically and continuously provide in-service training for nurses regarding palliative care. In addition, palliative care services should be highly developed, well-coordinated and always available to patients in hospitals, care homes and patient s personal homes. Furthermore, an adequately wellresourced palliative care services should support hospitals to achieve their goals in terms of addressing challenges such as lack of continuity and coordination of care and ineffective professional education leading to lack of knowledge of staff. Acknowledgements We are grateful to the Ghana Christian University College for funding the study. In addition, we thank Lucy Adjanor Akoto for her active role in the data collection. We are indebted to the respondents/nurses who work at Agogo Presbyterian Hospital. 43
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