Nurses practice towards palliative care in Shire Endasilasie health facilities, Northern Ethiopia: a cross-sectional study

Introduction The public health strategy of the World Health Organization for palliative care is to increase access to palliative care services by integrating it with the healthcare systems. Therefore, the value of palliative care service provision by nurses who deliver the majority of care to chronical patients is an important issue. The objective of the study is assessing nurses' practice of palliative care. Methods A facility based cross-sectional study was carried out among 278 nurses working in governmental health facilities of Shire Endasilasie town, Tigray region, Ethiopia from February to June 2018. The questionnaire was revised based on the findings of the pre-test. The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were entered and analyzed using SPSS version 22. The final result was reported using text and tables. Results A total of 278 nurses were included in the study and the response rate was 100%. The majority of the participants (71.9%) were females and the mean age of the respondents was 32.08 years (range from 20 to 60). Approximately two-thirds (74.8%) of the respondents had poor knowledge of palliative care practice. Half of the study participants reported emotional support gained as primary psychological support. Commonly used drugs for severe pain were paracetamol or ibuprofen 202 (72.2%) and 47.8% nurses focus on quality patient pain assess. Conclusion The majority of the nurses had a poor practice of palliative care.


Introduction
Worldwide, around ten million people are suffering by life-threatening illnesses such as HIV/AIDS and cancer [1]. The majority of the cases occur in developing countries where quite often there is inadequate access to prompt and effective treatment for such problem [2]. The implementation of palliative care (PC) service using effective, low-cost approaches is the best alternative to respond to the urgent needs of the patient with a terminal illness and improve quality of life for those with chronic illnesses [1]. The goals of palliative care can and should be incorporated into everyday practice [3,4]. As currently used in America medicine, "palliative care" is becoming a widely accepted term for an approach to the management of terminally ill patients that focuses on symptom control and support rather than cure or life prolongation [5]. American quality forum is dedicated to improving the quality of care and focuses on palliative care recognizing its growing place within the broader scope of health care [6]. Discussion between the importance of clinical activities or the issue that supportive care is more important will remain a central issue [7,8]. Palliative care is a philosophy of care and therefore it can be delivered in a variety of settings, including institutions such as hospitals, inpatient hospice and home care for older people which constitutes specialty palliative care and hospice care varies both within and across a country [9,10].
Every year nearly half a million people die of cancer in sub Saharan Africa. Despite the rapid improvement of palliative care for cancer, the expansion of the service is still low [11]. The WHO public health strategy for palliative care aims to increase access to palliative care services through its integration into healthcare systems [1]. Studies of hope in palliative care, over the past ten years, have focused primarily on those individuals in the advanced stages of cancer and the human immunodeficiency virus [12]. Studies using quantitative methodology have focused on exploring hope levels across the dying trajectory and the relationship between hope and other psychosocial variables while those using qualitative methodology have focused on the meaning of hope and elucidating how terminally ill individuals maintain and engender their hope [13]. Therefore, the value of palliative care to nurses who deliver a large proportion of the care to chronically ill patients is unquestionable [14] and there is a need to help and educate nurses for the provision of palliative care service and care for terminally ill patients. So, the first step in developing a strategy to help and educate nurses about palliative care is to assess the current practice as there is limited research on palliative care [15].
The aim of this study was to assess nurses' practice towards palliative care among nurses working in governmental health facilities in Shire Endasilasie town, Tigray regional state, Ethiopia.

Study area
The study was carried out in Shire Endasilasie town which is 1084 km away from the capital city of Ethiopia, Addis Ababa and 304 km from the capital city of Tigray regional state, Mekelle. There were four government health facilities in Shire Endasilasie town (two health centers and two hospitals). The study was conducted from February to June 2018. An institution-based cross-sectional study was used to assess nurses' palliative care practice. All nurses working in governmental health facilities in Shire Endasilasie town and all sampled nurses working in medical, surgical, pediatrics, and neonatal wards, intensive care unit (ICU), outpatient and emergency departments were included. Nurses engaged in the care of patients with chronic illness and/or terminal illness, nurses deployed to sterilization department, central triage and on leave were excluded from the study.
The sample size was calculated using a single population proportion formula as follows: Where n = minimum sample size required for the study, d = margin of error = 0.05, Zα / 2 value of standard normal distribution (z = 1.96) with confidence interval of 95% and α was 0.05. Previously in a study, 76.2% had poor knowledge of palliative care practice [16], The study participants were selected proportionally from nursing staffs each of the four governmental health facilities (Omar health center, Alganesh health center, Central defense hospital and Suhul hospital) were selected proportional to a number of nurses in the selected facilities. The study participants from each health facility were selected using a systematic sampling technique using the nurses' registry in the respective health facility. The first sample was selected by lottery method.

Data collection
Data were collected by self-administering the practice questions adopted from the literature of similar studies [16][17][18][19][20]. The questionnaire was prepared in English and then translated into the local language which is Tigrigna and then back to English by different people and corrected accordingly. A pre-test was done on 10% (28) of the nurses in Kahsay Abera hospital which is nearest to Endasilasie Shire. For the purpose of validity and reliability issues, the questionnaire was revised based on the findings of the pre-test. The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were entered and analyzed using SPSS version 22. Descriptive statistics were presented using tables.

List of operational definition
Palliative care: palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with a life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual [1].
Good palliative care practice: ≥75% of total knowledge aspect of practice questions.
Poor palliative care practice: <75% of the total practice questions.

Discussion
The finding of this study showed that the majority (74.8%) had a poor This could be due to Ethiopians introducing modern medicine and the availability of health facilities near the population as well as providing great value and concern for religion. Twenty-seven percent of cultural assessment during patient care preference regarding disclosure of information. On the contrary, the study done in America reported that majority of nurses viewed that truth-telling and decision making is practiced [25]. Half of the nurses in this study addressed the psychological issues of the patient with emotional support. On the contrary, the study done in Norway reported that the majority of nurses viewed that lying to the patients about their diagnosis and prognosis as unethical [26]. Is also the difference from this Addis Ababa majority nurses were hiding the truth [16]. Nearly three fourth (72.7%) of the respondents' use paracetamol or ibuprofen for chronic pain management. This might be a result of severe side effect of opioid analgesics and/or nurses are not recommended to prescribe opioid analgesics. Similarly, in a study done in Malawi, health workers required access to pain medication and knowledge of oral morphine in order to provide appropriate patients care [27]. This is important because the treated pain has a bad feeling on the patient, limitation of activity in daily living and social interaction [28]. With estimation, half of nurses concern on the quality of pain assessment. In contrast, grade with the face is the priority of nurses [17].

Conclusion
The majority of the nurses had poor knowledge of the practical aspects of palliative care. Guidelines for nurses' palliative care practice should be developed and distributed to all health facilities.

What is known about this topic
• The majority of nurses had a poor practice of palliative care; • Palliative care was provided only to patients with cancer and HIV; • The perception of terminally ill patients concern as need of treatment.

What this study adds
• Approximately two thirds (74.8%) of the respondents had poor practice towards palliative care; • Only a few nurses initiated palliative care discussions with patients during diagnosis; • Palliative care includes the management of patient pain and family members.

Competing interests
The authors declare no competing interests.

Authors' contributions
TZ and HB developed the proposal, analyzed data, wrote the report and the manuscript. HG and TW organized the overall process. MZ contributed to proposal writing, data collection. All authors have checked and accepted the final manuscript.

Acknowledgments
We would like to acknowledge the Tigray Regional Health Bureau for the kind support and permission in getting references and data about the population's profile. We are also grateful to Aksum University Health Science College Research and Community Service Office, College of Health Sciences, Aksum University, Aksum, Ethiopia for giving us this opportunity to do this research. Table 1: socio-demographic characteristics of nurses at Shire town health facilities in Tigray region, Ethiopia, June 2018