Assessment of knowledge and attitude towards palliative care and associated factors among nurses working in selected Tigray hospitals, northern Ethiopia: a cross-sectional study

Introduction Palliative care is a multidisciplinary approach which is focused on both the patient and their family. Therefore the objectives of the study is to assess the knowledge and attitude towards palliative care and its associated factors among nurses in Tigray, Northern Ethiopia, 2018. Methods An institutional based cross-sectional quantitative study design was carried out using 355 nurses working in selected hospitals in Tigray region from February to March, 2018. Systematic random sampling was used to select six governmental hospitals. We used triangulation in the study method, making use of both Frommelt's Attitude Toward Care of the Dying (FATCOD) scale, and Palliative Care Quiz for Nursing (PCQN) knowledge. SPSS were applied for data entry and analysis. Statistical significance was declared at P<0.05. The goodness of fit the final logistic model was tested by using the Hosmer and Lemeshow test at a value of > 0.05. Results All the participants were able to respond. Out of the total study participants, 223 (62.8%) had good knowledge and 200 (56.3%) had a favorable attitude towards Palliative care. A medical ward had (AOR = 3.413, CI = 1.388-8.392, P = 0.019), trained Nurses [AOR = 3.488; CI = 1.735-7.015; P = 0.00) significant associated with nurses knowledge towards palliative care. Nurses working in the lemlem Karl (AOR=2.541; 95% CI; 0.013(1.106-5.835), nurses who had a 20-30 years ago had unfavorable attitude (AOR = 2.660; 95% CI; 0.002(1.386-5.106) were significant. Conclusion The nurses had poor knowledge. However, their attitude towards palliative care (PC) was favorable.


Introduction
Palliative care is a multidisciplinary approach and is focused on both the patient and their family [1]. Commonly used terms such as supportive care, best supportive care, palliative care, and hospice care were rarely and inconsistently defined in the palliative oncology literature [2]. Sixty five percent of worldwide death was reported from non-communicable diseases (NCDs), i.e. cancer, diabetic mellitus, cardiovascular disease and chronic respiratory problem in which palliative care can play significant role in bringing relief for both physical and mental symptoms of the illness [3]. Palliative care One activity authorized by this committee was a survey of nurses' knowledge of palliative care [7]. As death is an inevitable phenomenon that affects every human being; Nurses are present at both the beginning and the end of life, and play a key role; that role is seen as one of the most stressful condition of nursing [8,9]. However, there is an obvious difference between nurses' qualification, experience, and training of palliative care towards Knowledge of PC [10].
Significant advances have been achieved in African palliative care providers to manage the highly prevalent and burdensome problems experienced by those with incurable terminal disease [11]. An essential factor affecting a successful implementation of PC is nurses' knowledge, and attitudes for providing care to dying patients [12,13].Palliative care can be provided at any site including at patient's own home, health care facility, hospice unit, in hospital out-patient or daycare service [14]. There are several reports that show patients are dying in pain that could be treated, especially for patients with chronic illnesses. A consequence of pain being undertreated is that it could cost more money in health care than actually treating the pain [15].These avoidable experiences need to be improved so patients are able to live and die peacefully with in the absence of pain as much as possible [ Additional Curative and rehabilitative services are delivered by more than 500 private health facilities including hospitals, higher clinics, pharmacies, and rural drug vendors. There are three public universities and two public health science colleges in the region. There are 3864 nurses in the Region. The total population of Tigray region accounts 6,690,003.
All nurses who are working in Tigray governmental hospitals were Source population, all nurses working in randomly selected governmental hospitals in Tigray and who meet the inclusion criteria were also Study population. But nurses working in the central sterilization supply department, operating room, delivery rooms were excluded. The total sample size was allocated proportionally based on the number of nurses from each selected hospitals using simple random sampling. Then proportional allocation was done for each ward in each selected institution. Because of the sample size was less than 10,000, the sample size was determined using a Formula single population proportion. The sample size is calculated poor knowledge prevalence 30.5% in the previous study in Addis Ababa [19] with 5% marginal error, 95% and confidence interval (CI). Based on this assumption, with the none-response, rate 10% total sample size was 355.
A self-administered English questionnaire was used for data collection.
The knowledge questions adopted from the Palliative Care Quiz for  Similarly, 86.5% of nurses responded that the extent of the disease determines the method of pain treatment. In addition, Drug addiction was a major problem when morphine is used on a long-term basis for the management of pain 289(81.4%).Forty-nine percent of the subjects agreed that accumulation of losses renders burn out for those who work in PC. Of the total respondents 77.5%, 72.4%, 72.7% agreed that adjuvant therapies are important in pain management, that the patients right not to resuscitate (DNR) should be respected, and that terminally ill patients should be supported to have hope, orderly. Only two hundred twenty-three (62.8%) had good knowledge out of the whole study participants, towards PC ( Table 2).  (Table 3).

Conclusion
The result of this study suggested that the majority of respondents that have had a poor knowledge towards PC but attitude were favorable. Similarly, work institution, the age of nurses and duration of training on PC were significantly associated with knowledge; institution, duration of training in additional training on pc, on the other hand, were found to be significant finding with the PC attitude.
In conclusion, much should be done to assist nurses to perform their duties based on the knowledge they grasp in various training, workshops, formal or informal education. The curriculum designer and policymaker in Ethiopia should also integrate courses related to PC issues so as to improve their graduates' level of knowledge.
What is known about this topic  Inadequate palliative care service implementation was delivered in Ethiopia;  Although large number of patients suffer from pain in the last stage of life there is no standard palliative care service.

What this study adds
 Nurses have poor knowledge towards PC but attitude were favorable;  Work institution, the age of nurses and duration of training on PC were significantly associated with knowledge; institution, duration of training in additional training on palliative care were found to be significant.

Competing interests
The authors declare no competing interests.

Acknowledgments
We would like to acknowledge the administration of Tigray regional health bureau for their 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 selected hospitals in Tigray region, 2018