The knowledge, attitudes, and beliefs of registered nurses about end-of-life care in the Kingdom of Saudi Arabia

Abstract

Background: End-of-life care is currently not well integrated into health care services in the Kingdom of Saudi Arabia (KSA) (Aboshaiqah, 2019; Alshammaray et al., 2019). Patients frequently receive end-of-life care in non-specialist palliative care settings with care provided by generalist registered nurses (RNs) rather than specialist palliative care nurses (MOH, 2022). Evidence indicates that end-of-life care provided in specialist palliative care settings differs significantly from that offered in non-specialist palliative care settings (Achora & Labrague, 2019; Karbasi et al., 2018;). This has been attributed, in part, to the fact that generalist RNs may not be well prepared to provide effective end-of-life care due to inadequate knowledge and poor attitudes and beliefs about end-of-life care (Aboshaiqah, 2019; Abudari et al., 2014). Therefore, exploring and understanding knowledge, attitudes and beliefs about end-of-life care of RNs working in KSA Ministry of Health (MOH) hospitals is an important step to better inform policy and practice. Aims: This thesis sought to examine the knowledge, attitudes and beliefs about end-of-life care among RNs working in MOH hospitals in the KSA. The barriers and facilitators that influence the quality of end-of-life care provided to patients in MOH hospitals in the KSA has also been explored. Methods: A sequential explanatory, mixed-methods study was conducted. In the quantitative phase, an online cross‐sectional survey was distributed to 1,293 registered nurses working in five different hospitals in the KSA. The Palliative Care Quiz for Nursing (PCQN) was used to gather information about registered nurses’ knowledge of end-of-life care, the Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) was used to assess nurses’ attitudes towards end-of-life care. Beliefs about end-of-life care were examined using the Care for Terminally Ill Patient (CTIP) tool. Following the survey, a subset of registered nurses participated in online individual semi-structured interviews. These interviews were audio- recorded and transcribed verbatim before being analysed using thematic analysis. The integration of the results was guided by the Theory of Reasoned Action (TRA) and used joint display tables to provide a comprehensive understanding of the factors that influence the knowledge, attitudes and beliefs about end-of-life care of RNs working in the KSA. Results: Out of the 1,293 registered nurses who were eligible to participate, 415 (34.90%) completed the entire online survey. The results showed that participants had poor knowledge about end-of-life care, with a mean score of 8.50 out of 20. Participants held mostly positive attitudes toward caring for dying patients and their families, but they also expressed some negative attitudes towards talking with patients about death, their relationship with patients’ families and controlling their emotions. More than half of the participants held the belief that a combination of curative and palliative care, provided by an interdisciplinary team, was the most effective approach for end-of-life patients. The majority of participants also believed that discussing end-of-life care with patients or families leads to feelings of hopelessness. Notably, RNs' knowledge, attitudes and beliefs were significantly associated with their age, religion, ward type, level of education, and frequency of providing end-of-life care. Sixteen participants were interviewed. The individual interview data identified the barriers and facilitators that registered nurses experience when providing end-of-life care. Barriers included a lack of communication skills, family, cultural and religious resistance to end-of-life care, and the dynamic of truth-telling. In addition, RNs also identified a lack of knowledge in pain management, the cultural and religious needs of patients, as well as psychological, psychosocial, and emotional needs. The factors that facilitated the provision of quality end-of-life care included gaining support from colleagues and patients’ families. Other facilitators included prior experience and education in end-of-life care, willingness to provide culturally and religiously appropriate care, and the involvement of a multidisciplinary team. The integration highlighted that RNs’ past experiences, prior education, age, gender, religion, culture, and workplace settings impact on their knowledge, attitudes and beliefs towards end-of-life care. The integration also revealed that RNs’ knowledge, and the subjective norms of patients, families, and their colleagues can influence an RN’s attitudes and beliefs, and thus their behaviours toward providing end-of-life care. Conclusion: This project has generated new knowledge about RNs’ knowledge, attitudes and beliefs about end-of-life care. RNs require additional education and training to provide high-quality end-of-life care for patients in general hospital settings. To achieve this, RNs should be supported through the development of protocols and policies about end-of-life care decision-making and training to enhance communication skills. A multidisciplinary approach to coordinating and providing end-of life care should be funded and implemented. Education providers and leaders in healthcare settings should consider developing programs for undergraduate nurses and nurses in clinical practice to enable RNs to provide high-quality and effective end-of-life care to patients in generalist and specialist end-of-life care settings.