Nurses practice towards palliative care in shire Endasilasie health facilities

Nurses practice towards palliative care in shire Endasilasie health facilities, northern Ethiopia, A cross-sectional study
Teklay Zeru1*, Hagos Berihu1, Hadgu Gerensea1, Mebrahtom Zeru2
1Department of Nursing, College of Health Sciences, Aksum University, Aksum, Ethiopia
2Department of Biomedical Science, College of Health Sciences, Adigrat University, Adigrat, Ethiopia
*Corresponding author: [email protected]
HB: [email protected]: [email protected]: [email protected]
Background: The WHO public health strategy for palliative care aims to increase access to services through its integration into health-care systems. Therefore, the value of Palliative Care to nurses who deliver a majority of care to chronically patients is unquestionable, and there is a need to support and educate nurses for the provision of standard palliative care practice.
Objectives: assessment nurses practice towards palliative care in governmental health facilities, in shire Endasilasie town Tigray, Northern Ethiopia, 2018.

Methodology: A facility based cross-sectional quantitative study design was carried out using 278 nurses working in governmental health facilities in Tigray region from February 2018 to June 2018. Samples were selected based on a proportion of nurses in the health facilities this led to the enhanced validity of the data. SPSS version 22 was applied for data entry and analysis.

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Result: a total number of participants were 278 and the response rate was 100%.

The majority of the participants 200 (71.9%) were female and the mean age of the respondents was 32.08 years ± 6.25 SD (range from 20 to 60).
Approximately Two-thirds of 208 (74.8%) of the respondents had poor knowledge towards PC practice. one hundred thirty-nine 139(50.0%) of the respondents reported Emotional support gained as a primary psychological support. Commonly used for severe pain were paracetamol or ibuprofen 202 (72.2%) and 47.8%) nurses focus on quality patient pain assess.

Conclusion and recommendation: The nurses had poor knowledge of the practical aspect of palliative care. incorporate courses related to palliative care issues into the in-service training program nurses should engage in research and education that demand to improve practices of palliative care.
Keywords: shire Endasilasie, Palliative care, practice
BackgroundTens of millions of people worldwide are suffer by life-threatening illnesses such as HIV/AIDS and cancer, which cause them and their family’s great suffering and economic problem. The majority of the cases occur in the developing world where quite often there is inadequate accessibility to prompt and effective treatment for these diseases. The development of palliative care through effective, low-cost approaches is usually the only possible alternative to respond to the immediate needs of the sick and improve their quality of life ADDIN EN.CITE ;EndNote;;Cite;;Author;Sepúlveda;/Author;;Year;2002;/Year;;RecNum;102;/RecNum;;DisplayText;(1);/DisplayText;;record;;rec-number;102;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;102;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Sepúlveda, Cecilia;/author;;author;Marlin, Amanda;/author;;author;Yoshida, Tokuo;/author;;author;Ullrich, Andreas;/author;;/authors;;/contributors;;titles;;title;Palliative care: the World Health Organization;apos;s global perspective;/title;;secondary-title;Journal of pain and symptom management;/secondary-title;;/titles;;pages;91-96;/pages;;volume;24;/volume;;number;2;/number;;dates;;year;2002;/year;;/dates;;isbn;0885-3924;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(1)
The quality of life for patients and their families who have life-threatening and incurable illnesses is considered the gold standard of care for all aspects of a patient our suffering.

The goals of palliative care can and should be incorporated into everyday practice ADDIN EN.CITE ;EndNote;;Cite;;Author;Soparattanapaisarn;/Author;;RecNum;355;/RecNum;;DisplayText;(2, 3);/DisplayText;;record;;rec-number;355;/rec-number;;foreign-keys;;key app=”EN” db-id=”xst0fvfxdrz995e5fz9v2takwp00zatvrrw0″;355;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Soparattanapaisarn, Noppadol;/author;;/authors;;/contributors;;titles;;title;What is Palliative Care?;/title;;secondary-title;Siriraj Medical Journal;/secondary-title;;/titles;;pages;211-212;/pages;;volume;59;/volume;;number;5;/number;;dates;;/dates;;isbn;2228-8082;/isbn;;urls;;/urls;;/record;;/Cite;;Cite;;Author;Sahler;/Author;;Year;2000;/Year;;RecNum;113;/RecNum;;record;;rec-number;113;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;113;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Sahler, Olle Jane Z;/author;;author;Frager, Gerri;/author;;author;Levetown, Marcia;/author;;author;Cohn, Felicia G;/author;;author;Lipson, Michael A;/author;;/authors;;/contributors;;titles;;title;Medical education about end-of-life care in the pediatric setting: principles, challenges, and opportunities;/title;;secondary-title;Pediatrics;/secondary-title;;/titles;;pages;575-584;/pages;;volume;105;/volume;;number;3;/number;;dates;;year;2000;/year;;/dates;;isbn;0031-4005;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(2, 3).

To palliate, of course, literally means ”to cloak” ‘Palliation can be viewed disapprovingly as merely covering up problems. However, as currently used in America medicine, ”palliative care” is becoming a widely accepted term for an approach to the management of terminal ill that focuses on symptom control and support rather than cure or life prolongation ADDIN EN.CITE <EndNote><Cite><Author>O&apos;Brien</Author><Year>2003</Year><RecNum>356</RecNum><DisplayText>(4)</DisplayText><record><rec-number>356</rec-number><foreign-keys><key app=”EN” db-id=”xst0fvfxdrz995e5fz9v2takwp00zatvrrw0″>356</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>O&apos;Brien, Tony</author></authors></contributors><titles><title>What is palliative care</title><secondary-title>Ethical Eye: Euthanasia</secondary-title></titles><pages>73-82</pages><volume>1</volume><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>(4). American health care dedicated to improving the quality the national quality, and their focus on palliative care recognizes its growing place within the broader scope of health care ADDIN EN.CITE <EndNote><Cite><Author>Ferrell</Author><Year>2007</Year><RecNum>357</RecNum><DisplayText>(5)</DisplayText><record><rec-number>357</rec-number><foreign-keys><key app=”EN” db-id=”xst0fvfxdrz995e5fz9v2takwp00zatvrrw0″>357</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Ferrell, Betty</author><author>Connor, Stephen R</author><author>Cordes, Anne</author><author>Dahlin, Constance M</author><author>Fine, Perry G</author><author>Hutton, Nancy</author><author>Leenay, Mark</author><author>Lentz, Judy</author><author>Person, Judi Lund</author><author>Meier, Diane E</author></authors></contributors><titles><title>The national agenda for quality palliative care: the National Consensus Project and the National Quality Forum</title><secondary-title>Journal of pain and symptom management</secondary-title></titles><pages>737-744</pages><volume>33</volume><number>6</number><dates><year>2007</year></dates><isbn>0885-3924</isbn><urls></urls></record></Cite></EndNote>(5).
There are a lot of challenges regarding practicing of palliative care evidence-based key intervention and outcome indicators are important and difficult issues within palliative care. Discussion between the importance of clinical activities or the issue that supportive care is more important will remain a central issue ADDIN EN.CITE <EndNote><Cite><Author>Payne</Author><Year>2008</Year><RecNum>96</RecNum><DisplayText>(6, 7)</DisplayText><record><rec-number>96</rec-number><foreign-keys><key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”>96</key></foreign-keys><ref-type name=”Book”>6</ref-type><contributors><authors><author>Payne, Sheila</author><author>Seymour, Jane</author><author>Ingleton, Christine</author></authors></contributors><titles><title>Palliative Care Nursing: Principles And Evidence For Practice: principles and evidence for practice</title></titles><dates><year>2008</year></dates><publisher>McGraw-Hill Education (UK)</publisher><isbn>0335221815</isbn><urls></urls></record></Cite><Cite><Author>Haley</Author><Year>2003</Year><RecNum>114</RecNum><record><rec-number>114</rec-number><foreign-keys><key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”>114</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Haley, William E</author><author>Larson, Dale G</author><author>Kasl-Godley, Julia</author><author>Neimeyer, Robert A</author><author>Kwilosz, Donna M</author></authors></contributors><titles><title>Roles for Psychologists in End-of-Life Care: Emerging Models of Practice</title><secondary-title>Professional Psychology: Research and Practice</secondary-title></titles><pages>626</pages><volume>34</volume><number>6</number><dates><year>2003</year></dates><isbn>1939-1323</isbn><urls></urls></record></Cite></EndNote>(6, 7).

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ADDIN EN.CITE.DATA (8-11)
Every year nearly half a million people die of cancer in sub-Saharan Africa. Despite rapid improvement of palliative care for cancer, outcome remains no as such ADDIN EN.CITE ;EndNote;;Cite;;Author;Patel;/Author;;Year;2011;/Year;;RecNum;125;/RecNum;;DisplayText;(12);/DisplayText;;record;;rec-number;125;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;125;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Patel, Jyoti D;/author;;author;Galsky, Matthew D;/author;;author;Chagpar, Anees B;/author;;author;Pyle, Doug;/author;;author;Loehrer Sr, Patrick J;/author;;/authors;;/contributors;;titles;;title;Role of American Society of Clinical Oncology in low-and middle-income countries;/title;;secondary-title;J Clin Oncol;/secondary-title;;/titles;;pages;3097-102;/pages;;volume;29;/volume;;number;22;/number;;dates;;year;2011;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(12). The WHO public health strategy for palliative care aims to increase access to palliative care services through its integration into health-care systems ADDIN EN.CITE ;EndNote;;Cite;;Author;Harding;/Author;;Year;2013;/Year;;RecNum;98;/RecNum;;DisplayText;(13);/DisplayText;;record;;rec-number;98;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;98;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Harding, Richard;/author;;author;Selman, Lucy;/author;;author;Powell, Richard A;/author;;author;Namisango, Eve;/author;;author;Downing, Julia;/author;;author;Merriman, Anne;/author;;author;Ali, Zipporah;/author;;author;Gikaara, Nancy;/author;;author;Gwyther, Liz;/author;;author;Higginson, Irene;/author;;/authors;;/contributors;;titles;;title;Research into palliative care in sub-Saharan Africa;/title;;secondary-title;The Lancet Oncology;/secondary-title;;/titles;;pages;e183-e188;/pages;;volume;14;/volume;;number;4;/number;;dates;;year;2013;/year;;/dates;;isbn;1470-2045;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(13). Studies of hope in palliative care, over the past decade, have focused primarily on those individuals in the advanced stages of cancer and the human immunodeficiency virus. 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 ADDIN EN.CITE ;EndNote;;Cite;;Author;Georges;/Author;;Year;2002;/Year;;RecNum;99;/RecNum;;DisplayText;(14);/DisplayText;;record;;rec-number;99;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;99;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Georges, Jean?Jacques;/author;;author;Grypdonck, Mieke;/author;;author;De Casterle, Bernadette Dierckx;/author;;/authors;;/contributors;;titles;;title;Being a palliative care nurse in an academic hospital: a qualitative study about nurses;apos; perceptions of palliative care nursing;/title;;secondary-title;Journal of clinical nursing;/secondary-title;;/titles;;pages;785-793;/pages;;volume;11;/volume;;number;6;/number;;dates;;year;2002;/year;;/dates;;isbn;1365-2702;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(14). There are serious deficits in this field in many countries, and the need for PC will further increase as a result of demographic development with increasing numbers of older people with an incurable chronic disease and multiple morbidities ADDIN EN.CITE ;EndNote;;Cite;;Author;Schneider;/Author;;Year;2010;/Year;;RecNum;100;/RecNum;;DisplayText;(15);/DisplayText;;record;;rec-number;100;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;100;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Schneider, Nils;/author;;author;Lueckmann, Sara L;/author;;author;Kuehne, Franziska;/author;;author;Klindtworth, Katharina;/author;;author;Behmann, Mareike;/author;;/authors;;/contributors;;titles;;title;Developing targets for public health initiatives to improve palliative care;/title;;secondary-title;BMC public health;/secondary-title;;/titles;;pages;222;/pages;;volume;10;/volume;;number;1;/number;;dates;;year;2010;/year;;/dates;;isbn;1471-2458;/isbn;;urls;;/urls;;/record;;/Cite;;Cite;;Author;Schneider;/Author;;Year;2010;/Year;;RecNum;100;/RecNum;;record;;rec-number;100;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;100;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Schneider, Nils;/author;;author;Lueckmann, Sara L;/author;;author;Kuehne, Franziska;/author;;author;Klindtworth, Katharina;/author;;author;Behmann, Mareike;/author;;/authors;;/contributors;;titles;;title;Developing targets for public health initiatives to improve palliative care;/title;;secondary-title;BMC public health;/secondary-title;;/titles;;pages;222;/pages;;volume;10;/volume;;number;1;/number;;dates;;year;2010;/year;;/dates;;isbn;1471-2458;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(15)
Therefore, the value of PC to nurses who deliver a large number of care to chronically patients is unquestionable ADDIN EN.CITE ;EndNote;;Cite;;Author;Cassel;/Author;;Year;1997;/Year;;RecNum;123;/RecNum;;DisplayText;(16);/DisplayText;;record;;rec-number;123;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;123;/key;;/foreign-keys;;ref-type name=”Book”;6;/ref-type;;contributors;;authors;;author;Cassel, Christine K;/author;;author;Field, Marilyn J;/author;;/authors;;/contributors;;titles;;title;Approaching death: improving care at the end of life;/title;;/titles;;dates;;year;1997;/year;;/dates;;publisher;National Academies Press;/publisher;;isbn;0309063728;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(16), and there is a need to support and educate nurses for the provision of standard palliative and terminally ill care. So, the first step in developing a strategy to support and educate nurses about PC is to assess their current practice as there is limited research on PC with nurses ADDIN EN.CITE ;EndNote;;Cite;;Author;Gillan;/Author;;Year;2014;/Year;;RecNum;124;/RecNum;;DisplayText;(17);/DisplayText;;record;;rec-number;124;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;124;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Gillan, Pauline C;/author;;author;van der Riet, Pamela J;/author;;author;Jeong, Sarah;/author;;/authors;;/contributors;;titles;;title;End of life care education, past and present: a review of the literature;/title;;secondary-title;Nurse Education Today;/secondary-title;;/titles;;pages;331-342;/pages;;volume;34;/volume;;number;3;/number;;dates;;year;2014;/year;;/dates;;isbn;0260-6917;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(17). Let’s conclude that the aim of this study is to assess nurse’s practice towards PC among nurses working in shire Endasilasie town. Methods
Study area
The study was conducted in Shire Endasilasie town which is located 1084 and 304 km far from the capital city of Ethiopia, Addis Ababa and the capital city of Tigray, Mekelle, respectively.

Study period
The study was conducted from February to June in 2018 in shire Endasilasie town, Tigray regional state, north Ethiopia.

Study design
The institution-based cross-sectional study design was used to address the objective Nurses palliative care practice from primary data.
Source population
All Nurses working in governmental health facilities shire Endasilasie town
Study population
All sampled Nurses working in a medical ward, surgical ward, pediatrics ward, neonatology ward, ICU, OPD, emergency room and other.

Inclusion criteria
Nurses present at the time of data collection.

Exclusion criteria
Nurses on annual rest and seriously ill on the time of data collection were excluded
Sample size determination
The sample size will be calculated using a single population proportion formula based on the following assumptions
n = (Z ? /2) 2 p (1 ? p)/ (d) 2
Where n = minimum sample size required for the study, d = margin of error = 0.05, Z?/2 value of standard normal distribution (z = 1.96) with confidence interval of 95% and ? is 0.05. P is taking by 76.2% taking from palliative care practice study conducted in Addis Ababa 2014 ADDIN EN.CITE ;EndNote;;Cite;;Author;Kassa;/Author;;Year;2014;/Year;;RecNum;12;/RecNum;;DisplayText;(18);/DisplayText;;record;;rec-number;12;/rec-number;;foreign-keys;;key app=”EN” db-id=”swvz0ded7sdsawedrz4vp2069v0tv2xspaaa”;12;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Kassa, Hiwot;/author;;author;Murugan, Rajalakshmi;/author;;author;Zewdu, Fissiha;/author;;author;Hailu, Mignote;/author;;author;Woldeyohannes, Desalegn;/author;;/authors;;/contributors;;titles;;title;Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia;/title;;secondary-title;BMC palliative care;/secondary-title;;/titles;;pages;6;/pages;;volume;13;/volume;;number;1;/number;;dates;;year;2014;/year;;/dates;;isbn;1472-684X;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(18).

n = (z ? /2) 2 p (1 ? p) / (d) 2
(1.96)2 0.762(1 ? 0.762)/ (0.05)2 = 278
Sampling procedures
To get the total sample we have used a systematic sampling technique from the nurse’s staff registration every 10th interval was taken from the government health facilities of shire Endasilasie town. But the first sample was selected by simple random sampling (lottery method).

Data collection procedures (instrument, personnel, data quality control)
Data were collected by self-administered questionnaire using adopted from the literature of similar studies
Data quality management
To assure high quality of the data, the emphasis was given to designing data collection instrument and training on data collectors. Similarly, the questionnaire format was pretested before the actual data collection period to modify the tool.
Operational definition
Knowledge aspect of practice = the nurse must have a knowledge on PC regarding the application of practice.
Good knowledge aspect of practice = ?75% of total knowledge aspect of practice questions.

Poor knowledge aspect of practice = < 75% of the total knowledge aspect of practice questions.
Data analysis procedures
The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were analyzed and interpreted using SPSS version 22.

Ethical considerations
Institution review board (IRB) of Aksum University, college of health science reviews the protocol to ensure full protection of the rights study subjects. Following the approval by IRB, an official letter of co-operation will write to the respected study area. Data will be treated confidentially and identify the subject by number only.

Result
A Socio-demographic characteristic of nurses the total number of participants was 278 and the response rate was 100%. The number of participants by health facilities was from Umer health center 35(12.58%), Alganesh health center 40(14.28%), central defense hospital 82(29.49%) and Suhul hospital 130(46.7%). The majority of the participants 200 (71.9%) were female and the mean age of the respondents was 32.08 years ± 6.25 SD (range from 20 to 60). The respondents were working medical ward 55(19.8%), surgical ward 68(24.46%), pediatrics ward 45(16.18%). Neonatology ward 18(6.4%), ICU 20(7.1%), OPD 50(18%), emergency room 14(5.03%) and other 8(2.87%) (table1)
Knowledge aspect of the practice of nurses towards PC
Approximately Two thirds 208 (74.8%) of the respondents had poor knowledge towards PC.

Only 92(33.1%) of them initiating PC discussions with patients during diagnosis while 100 (36.0%) of nurses when the disease progress and 86(30.9%) inform terminally ill patients about their diagnosis.

Concerning addressing psychological support, 139(50.0%) of the respondents reported Emotional support gained and 57(20.5%) hiding the reality. Regarding medications, the commonly used for severe pain were paracetamol or ibuprofen 202 (72.2%), codeine 39 (14.0%) and morphine 37 (13.3%), regarding patient pain assess 133(47.8%) of them focuses on quality (See Table 2)
Discussion
The result of this study showed that the majority 74.8% had a poor practice which similar to the result from New Heaven ADDIN EN.CITE <EndNote><Cite><Author>Gott</Author><Year>2012</Year><RecNum>8</RecNum><DisplayText>(19)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app=”EN” db-id=”swvz0ded7sdsawedrz4vp2069v0tv2xspaaa”>8</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Gott, Merryn</author><author>Seymour, Jane</author><author>Ingleton, Christine</author><author>Gardiner, Clare</author><author>Bellamy, Gary</author></authors></contributors><titles><title>’That’s part of everybody’s job’: the perspectives of health care staff in England and New Zealand on the meaning and remit of palliative care</title><secondary-title>Palliative Medicine</secondary-title></titles><pages>232-241</pages><volume>26</volume><number>3</number><dates><year>2012</year></dates><isbn>0269-2163</isbn><urls></urls></record></Cite></EndNote>(19). Poor knowledge on the aspect of practice in this finding could be related with respondents’ poor knowledge on the aspect of PC practice and it might also be due to the study subjects who had to doubt on professionalism affect the pc practice habit. Nearly One fourth of participated nurses did not inform terminally ill patients about their diagnosis which was lower compared to studies done in Lebanon, United States, England and Addis AbabaPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXJhbTwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (18, 20-22) and lower from study in Norway ADDIN EN.CITE ;EndNote;;Cite;;Author;Zewdu;/Author;;Year;2017;/Year;;RecNum;104;/RecNum;;DisplayText;(18, 23);/DisplayText;;record;;rec-number;104;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;104;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Zewdu, F;/author;;author;Kassa, H;/author;;author;Hailu, M;/author;;author;Murugan, R;/author;;author;Woldeyohannes, D;/author;;/authors;;/contributors;;titles;;title;Knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia;/title;;secondary-title;European Journal of Cancer;/secondary-title;;/titles;;pages;S161;/pages;;volume;72;/volume;;dates;;year;2017;/year;;/dates;;isbn;0959-8049;/isbn;;urls;;/urls;;/record;;/Cite;;Cite;;Author;Kassa;/Author;;Year;2014;/Year;;RecNum;12;/RecNum;;record;;rec-number;12;/rec-number;;foreign-keys;;key app=”EN” db-id=”swvz0ded7sdsawedrz4vp2069v0tv2xspaaa”;12;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Kassa, Hiwot;/author;;author;Murugan, Rajalakshmi;/author;;author;Zewdu, Fissiha;/author;;author;Hailu, Mignote;/author;;author;Woldeyohannes, Desalegn;/author;;/authors;;/contributors;;titles;;title;Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia;/title;;secondary-title;BMC palliative care;/secondary-title;;/titles;;pages;6;/pages;;volume;13;/volume;;number;1;/number;;dates;;year;2014;/year;;/dates;;isbn;1472-684X;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(18, 23) Since nowadays diagnosis of patients used to be expressed by nurses may not challenge to disclose to patients in the case of Ethiopia.
The finding of this study reveals that more than one-third of the respondents consider medical treatments and 30.6% prefer spiritual other than cultural and psychological beliefs when treating end of life patients. This finding is similar to the study in Lebanon study ADDIN EN.CITE ;EndNote;;Cite;;Author;Abu-Saad;/Author;;Year;2007;/Year;;RecNum;106;/RecNum;;DisplayText;(24);/DisplayText;;record;;rec-number;106;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;106;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Abu-Saad, H Huijer;/author;;author;Dimassi, Hani;/author;;/authors;;/contributors;;titles;;title;Palliative care in Lebanon: knowledge, attitudes and practices of physicians and nurses;/title;;secondary-title;Le Journal medical libanais. The Lebanese medical journal;/secondary-title;;/titles;;pages;121-128;/pages;;volume;55;/volume;;number;3;/number;;dates;;year;2007;/year;;/dates;;isbn;0023-9852;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(24). 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. In contrary, the study done in America reported that majority of nurses viewed that truth-telling and decision making
is practiced ADDIN EN.CITE ;EndNote;;Cite;;Author;Kim;/Author;;Year;2011;/Year;;RecNum;126;/RecNum;;DisplayText;(25);/DisplayText;;record;;rec-number;126;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;126;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Kim, Hyun Sook;/author;;author;Kim, Boon Han;/author;;author;Yu, Su Jeong;/author;;author;Kim, Sanghee;/author;;author;Park, Sook Hyun;/author;;author;Choi, Sungeun;/author;;author;Jung, Yun;/author;;/authors;;/contributors;;titles;;title;The effect of an end-of-life nursing education consortium course on nurses;apos; knowledge of hospice and palliative care in Korea;/title;;secondary-title;Journal of Hospice ;amp; Palliative Nursing;/secondary-title;;/titles;;pages;222-229;/pages;;volume;13;/volume;;number;4;/number;;dates;;year;2011;/year;;/dates;;isbn;1522-2179;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(25)
Half of the nurses in this study addressed the Psychological issues of the patient by emotional support. In 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 ADDIN EN.CITE ;EndNote;;Cite;;Author;Lorensen;/Author;;Year;2003;/Year;;RecNum;112;/RecNum;;DisplayText;(26);/DisplayText;;record;;rec-number;112;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;112;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Lorensen, Margarethe;/author;;author;Davis, Anne J;/author;;author;Konishi, Emiko;/author;;author;Bunch, Eli H;/author;;/authors;;/contributors;;titles;;title;Ethical issues after the disclosure of a terminal illness: Danish and Norwegian hospice nurses’ reflections</title><secondary-title>Nursing Ethics</secondary-title></titles><pages>175-185</pages><volume>10</volume><number>2</number><dates><year>2003</year></dates><isbn>0969-7330</isbn><urls></urls></record></Cite></EndNote>(26)
Is also the difference from this Addis Ababa majority nurses were hiding the truth ADDIN EN.CITE <EndNote><Cite><Author>Kassa</Author><Year>2014</Year><RecNum>12</RecNum><DisplayText>(18)</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app=”EN” db-id=”swvz0ded7sdsawedrz4vp2069v0tv2xspaaa”>12</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Kassa, Hiwot</author><author>Murugan, Rajalakshmi</author><author>Zewdu, Fissiha</author><author>Hailu, Mignote</author><author>Woldeyohannes, Desalegn</author></authors></contributors><titles><title>Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia</title><secondary-title>BMC palliative care</secondary-title></titles><pages>6</pages><volume>13</volume><number>1</number><dates><year>2014</year></dates><isbn>1472-684X</isbn><urls></urls></record></Cite></EndNote>(18). 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, a study done in Malawi, health workers required access to pain medication and knowledge of oral morphine in order to provide appropriate patients care ADDIN EN.CITE ;EndNote;;Cite;;Author;Harding;/Author;;Year;2010;/Year;;RecNum;109;/RecNum;;DisplayText;(27);/DisplayText;;record;;rec-number;109;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;109;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Harding, Richard;/author;;author;Powell, Richard A;/author;;author;Kiyange, Fatia;/author;;author;Downing, Julia;/author;;author;Mwangi-Powell, Faith;/author;;/authors;;/contributors;;titles;;title;Provision of pain-and symptom-relieving drugs for HIV/AIDS in sub-Saharan Africa;/title;;secondary-title;Journal of pain and symptom management;/secondary-title;;/titles;;pages;405-415;/pages;;volume;40;/volume;;number;3;/number;;dates;;year;2010;/year;;/dates;;isbn;0885-3924;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(27). This is important because the treated pain has a bad feeling on the patient, limitation of activity daily living and social interaction ADDIN EN.CITE ;EndNote;;Cite;;Author;Goldsmith;/Author;;Year;2008;/Year;;RecNum;110;/RecNum;;DisplayText;(28);/DisplayText;;record;;rec-number;110;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;110;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Goldsmith, Benjamin;/author;;author;Dietrich, Jessica;/author;;author;Du, Qingling;/author;;author;Morrison, R Sean;/author;;/authors;;/contributors;;titles;;title;Variability in access to hospital palliative care in the United States;/title;;secondary-title;Journal of palliative medicine;/secondary-title;;/titles;;pages;1094-1102;/pages;;volume;11;/volume;;number;8;/number;;dates;;year;2008;/year;;/dates;;isbn;1096-6218;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(28) With estimation half of nurses concern on the quality of pain assessment. In contrast Grade with the face is the priority of nurses ADDIN EN.CITE ;EndNote;;Cite;;Author;Shea;/Author;;Year;2010;/Year;;RecNum;111;/RecNum;;DisplayText;(29);/DisplayText;;record;;rec-number;111;/rec-number;;foreign-keys;;key app=”EN” db-id=”50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp”;111;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Shea, Joyce;/author;;author;Grossman, Sheila;/author;;author;Wallace, Meredith;/author;;author;Lange, Jean;/author;;/authors;;/contributors;;titles;;title;Assessment of advanced practice palliative care nursing competencies in nurse practitioner students: implications for the integration of ELNEC curricular modules;/title;;secondary-title;Journal of Nursing Education;/secondary-title;;/titles;;pages;183-189;/pages;;volume;49;/volume;;number;4;/number;;dates;;year;2010;/year;;/dates;;isbn;0148-4834;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(29).

Conclusion
The literature suggests that nurses can have the important role in terminal ill. Hence it is important to assess nurses’ practice to help them handle such critical condition. The result of this study suggested that the majority of respondents that have had poor knowledge of the aspect of practice towards PC.
Obviously, there are a lot of benefits to considering a health promotion perspective in palliative care practice. Yet the ways in which health promotion, and specifically, the concept of empowerment, have been interpreted and applied within health facility care practice can be problematic for caregivers. A critical, and more than superficial, understanding of both the opportunities and potentially harmful implications of ‘family empowerment’ as a form of health-promoting homecare nursing services is required. Unless this occurs, we jeopardize our ability to create and develop policies and services that effectively promote the well-being of not only the dying individual but also the family caregivers who provide support during end-of-life.
The departments of Nursing in higher education institutions in Ethiopia should also incorporate courses related to PC issues so as to strengthen their graduates’ level of understanding.

Recommendations
The regional health bureau should prepare a guideline for nurse’s palliative and distribute to all staffs of health facilities through the responsible personnel.
The departments of Nursing in higher education institutions in Ethiopia should incorporate courses related to palliative care issues into the in-service training program
Nurses should engage in research and education that demand to improve practices about palliative care.
Abbreviations
AIDs Acquired Immune Deficiency Syndrome
CCNs Critical care nurses
CI Confidence Interval
ER Emergency Room
ETB Ethiopian Birr
ICU Intensive care unit
OPD Outpatient department
PC Palliative Care
RN Registered nurse
SPSS Statistical Program for Social Sciences
WHO World Health Organization
Declarations
Ethical approval and consent to participate
Ethics approval and consent to participate Ethical clearance was secured from the Aksum University, College of Health Science Institution Review Board (IRB) with IRB Number 21/02/2017. Since the data is from staff Nurses permission from Tigray Regional health bureau (TRHB) and woreda offices was taken. Furthermore, written consent was taken from TRHB officer and verbal consent was agreed by all participants. However, data were recorded anonymously and confidentially.

Consent for publication
Not applicable, no individual detail presented.

Availability of data and materials
All pertinent data was in the manuscript. The datasets investigated during this study was available from the corresponding author on reasonable request.

Competing Interests
The authors state that they have no opposing interests.

Funding
There was no specific funding received for this study.

Authors’ contributions
TZ and HB: Developed the proposal, analyzed data, and wrote the report and the manuscript. HG: Organized the overall process. MZ: Contributed to proposal writing, data collection, and analysis. All authors have checked and accepted the final manuscript.

Acknowledgment
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.
Authors’ Information
TZ: Msc, Department of Nursing, College of Health Sciences, Aksum University, Aksum, Ethiopia. Email: [email protected]: Msc, Department of Nursing, College of Health Sciences, Aksum University, Aksum, Ethiopia. Email: [email protected]: Msc, Assistant Professor, Department of Nursing, College of Health Sciences, Aksum University, Aksum, Ethiopia. Email: [email protected]: Msc, Department Biomedical science, College of Health Sciences, Adigrat University, Adigrat, Ethiopia. Email: [email protected]
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Journal of pain and symptom management. 2010;40(3):405-15.28. Goldsmith B, Dietrich J, Du Q, Morrison RS. Variability in access to hospital palliative care in the United States. Journal of palliative medicine. 2008;11(8):1094-102.29. Shea J, Grossman S, Wallace M, Lange J. Assessment of advanced practice palliative care nursing competencies in nurse practitioner students: implications for the integration of ELNEC curricular modules. Journal of Nursing Education. 2010;49(4):183-9. Table 1 Socio-demographic characteristics of nurses at shire town health facilities in Tigray region, Ethiopia, June 2018
Characteristics Frequency Percentage
No (278) % (100)
work institution
Omar health center
Alganesh health center
Central defense hospital
Suhul hospital 35
40
82
130 12.58
14.28
29.49
46.7
age of nurses
20-30
31-40
41-50
50+ 129
76
61
12 46.4
27.33
21.94
4.3
Educational level
diploma
degree 120
158 43.1
57.9
ward/work area
medical ward
surgical ward
pediatrics
neonatology
ICU
OPD
emergency
other 55
68
45
18
20
50
14
8 19.8
24.46
16.18
6.4
7.1
18
5.03
2.87
work experience
less than 5 years
5-10 years
10-15
greater than 15 years 120
75
64
19 43.1
27
23
6.8
Experience in caring terminally ill patient
Daily
Once per week
Never
Few times per year
Once per month 115
62
54
25
22 41.3
22.3
19.4
8.99
8
Table 2 Practice of nurses towards palliative care at shire Endasilasie governmental hospitals, June 2018(n=278)
No Characteristics Multiple responses Frequency Percentage
Yes n (%) No n (%)
1 palliative care discussion: During diagnosis Initiate
When the disease progress
At the end of life 25(27.2%)
27(27.0%)
18(20.9%) 67(72.8%)
73(73.0%)
68(79.1%)
2 Do you inform a terminally ill patient about their diagnosis Yes
No
Depending on a family’s wish
Inapplicable 16(27.1%)
25(32.9%)
14(18.9%)
15(21.7%) 43(72.9%)
51(67.1%)
60(81.1%)
54(78.3%)
3 Factors considered when dealing with a terminally ill patient: Spiritual
Medical situation
Cultural
Psychological 23(27.1%)
27(27.0%)
12(19.7%)
8(25.0%) 62(72.9%)
73(73.0%)
49(80.3%)
24(75.0%)
4 Address spiritual issue: Connect with spiritual
counselor Listen with empathy
Impose your own view
Understand patient reaction 19(23.8%)
15(26.8%)
24(26.1%)
12(24.0%) 61(76.3%)
41(73.2%)
68(73.9%)
38(76.0%)
5 Cultural assessment during patient care should include: Truth-telling and decision making
Preference regarding disclosure of information
Dietary preference
Language, family communication
Perspective on death, suffering ; grieving 11(20.8%)
21(28.0%)
19(31.7%)
15(23.8%)
4(15.4%)
0(0.0%) 42(79.2%)
54(72.0%)
41(68.3%)
48(76.2%)
22(84.6%)
1(100.0%)
6 Addressing psychological: Emotional support
Counseling the patient
Hiding the truth 36(25.9%)
21(25.6%)
13(22.8%) 103(74.1%)
61(74.4%)
44(77.2%)
7 Do you involve in decision making? Whom Patient
Family
My own
Another health professional 24(21.2%)
16(23.9%)
26(31.3%)
4(26.7%) 89(78.8%)
51(76.1%)
57(68.7%)
11(73.3%)
8 How do you perceive terminally ill patient concern or question? Patient right
Treat
Doubting your professionalism
Attention seeking behavior 17(24.6%)
18(26.9%)
26(25.7%)
9(22.0%) 52(75.4%)
49(73.1%)
75(74.3%)
32(78.0%)
9 Communication with the family of the terminally ill patient depends on: Family’s ability to assimilate
Their involvement in decision making
Your willingness to disclose information 25(26.0%)
30(23.3%)
15(28.3%) 71(74.0%)
99(76.7%)
38(71.7%)
10 Commonly use the medication in your practice for severe pain? Paracetamol/Ibuprofen
Codeine
Morphine 55(27.2%)
10(25.6%)
5(13.5%) 147(86.5%)
29(74.4%)
32(72.8%)
11 How do you assess patient pain? Grade with face
Intensity
Location
Quality 15(29.4%)
21(36.2%)
3(8.3%)
31(23.3%) 36(70.6%)
37(63.8%)
33(91.7%)
102(76.7%)

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