Revista Enfermería Herediana

Knowledge of palliative care among nursing professionals at a hospital in Lima

Aurora Isabel Vargas Cotarma¹ , Jackeline Melissa Jurado Felix¹ , Diana Elizabeth Calle Jacinto de Guillen^{1, 2}

¹ Universidad Peruana Cayetano Heredia, Facultad de Enfermería. Lima, Peru.
² Hospital Santa Rosa. Lima, Peru.

ABSTRACT

Objective: To determine the level of knowledge about palliative care among nursing professionals working at a hospital in Lima. Materials and methods: A quantitative study with a non-experimental, cross-sectional, and descriptive design. The population consisted of 66 nursing professionals from medicine, oncology, and intensive care services. For data collection, the survey technique was used, and a questionnaire was employed as an instrument, where psychometric tests showed its validity and reliability for its application. The instrument was adapted from the book Cuidados paliativos (Palliative Care) by Nuria Trujillo Garrido. Results: Knowledge about palliative care was at a medium level (57.6%). In terms of dimensions, a high level of knowledge on pain management (59.1%), a medium level of knowledge on dyspnea control (65.2%), a medium level of knowledge on palliative sedation (59.1%), and a high level of knowledge on skin care (57.6%) were observed. Conclusion: It was demonstrated that the level of knowledge about palliative care among nursing professionals is medium.

Keywords: palliative care; knowledge; nursing.

INTRODUCTION

The nursing profession focuses on patient care, which involves both professional skills and a personal commitment oriented to self-care and the preservation of life. However, everyday factors can divert professionals from their essential mission: human care and respect for life (1). Among the tasks of nursing staff, palliative care stands out, as it not only covers oncological diseases but also irreversible and terminal pathologies such as heart failure, dementia, multiple sclerosis, and other neurological diseases (2). This type of care is essential to alleviate the multiple symptoms experienced by terminal patients, ensuring a dignified death (3).

Globally, only 20 out of 234 countries have these services integrated into their healthcare systems, while 42% lack them entirely and 32% offer isolated palliative care. Each year, more than 40 million people require palliative care, primarily due to cardiovascular diseases (38.5%), cancer (34%), and other chronic conditions (4).

In addition, the aging of the Peruvian population presents another challenge for palliative care. In 2024, older adults accounted for 13.9% of the population, and their growth rate (2.7%) surpassed that of young individuals, increasing vulnerability to chronic diseases (5).

Despite the importance of palliative care, its implementation faces significant challenges. Galindo-Huerta et al. (3) state that nursing professionals often lack the necessary training to provide this type of care, which affects the quality of services. Bush et al. (6) highlight that proper training is essential to ensure high-quality care. On the other hand, Guillén (7) emphasizes the importance of this type of care in the advanced stages of the disease, both for the patient and their family.

International studies reflect limitations in this field. Hiciano et al. (8) found that 89.6% of Spanish nurses considered their education in palliative care to be insufficient, while Ulloa et al. (9) in Mexico revealed that, although 99% of staff had poor knowledge, 52% achieved medium-high performance thanks to empirical experience. Hernández-Sánchez and Aguilar-García (10) reported that, in Mexico, 80.49% of healthcare personnel had sufficient knowledge in this area, whereas 19.51% lacked it.

Similarly, Guevara-Valtier et al. (11) stressed the need to optimize professional skills through continuous training. Chover-Sierra et al. (12) emphasized the usefulness of specific educational programs to enhance knowledge in palliative care. Achora and Labrague (13) concluded that this care should be provided gradually according to the needs of the patient and their family, and they recommend strengthening training in psychosocial and spiritual aspects.

As established by the Council of Europe Recommendation 1418 (1999) on the protection of human rights and dignity of the terminally ill and the dying: "Every person has the right to receive high-quality care during a serious illness and to die with dignity, free from severe suffering, and with respect for their spiritual and religious needs." Although palliative care was initially developed for cancer patients, ethical considerations regarding justice, equality, and equity demand that this level of care be extended to all individuals with similar needs (14).

Non-oncological diseases encompass a wide range of conditions affecting different organs and systems. They are primarily characterized by their chronic nature, potential to cause disability, progressive course, and the significant negative impact they have on patients' quality of life (4).

In a hospital in Lima, it was observed that a large proportion of the nursing staff in the Medicine and Intensive Care Units associated palliative care exclusively with the oncology department. Although these forms of care have traditionally been associated with the treatment of oncological patients, it is crucial to recognize that they are also essential in other medical contexts, such as chronic non-oncological diseases. In this regard, palliative care for non-oncological patients is not only a necessity but also an obligation.

This misconception that palliative care is exclusive to the field of oncology could limit its application in other healthcare services where it is also essential, thereby affecting the quality and continuity of the comprehensive care required by patients at different stages of their illness. Therefore, the objective of this study was to determine the level of knowledge regarding palliative care among nursing professionals at a hospital in Lima.

MATERIALS AND METHODS

A quantitative study was conducted with a non-experimental, cross-sectional, observational, and descriptive level (15). A total of 66 nursing professionals working at a hospital located in the district of Pueblo Libre in Lima, Peru, participated from June 2023 to January 2024. All professionals in the population who met the inclusion criteria were included. Nursing professionals working in the medical, oncology, and intensive care unit (ICU) departments were included, with a minimum of two years of work experience, hired under any modality, and who voluntarily agreed to participate in the study. Those on leave or vacation and those performing administrative duties were excluded from the study.

A survey was used as the data collection technique, and the instrument applied was the "Questionnaire to Measure the Level of Knowledge of Nursing Professionals on Palliative Care," adapted from the book Cuidados paliativos by Nuria Trujillo Garrido (16).

The instrument was validated by the expert judgment of ten professionals. The binomial test was used to evaluate agreement regarding content validity (p = 0.0028), construct validity (p = 0.0022), and criterion validity (p = 0.0101). In addition, the Kuder-Richardson statistical test was used, with a result of 0.718, which means that the instrument is reliable. To this end, a pilot test was conducted on 15 nursing professionals in a hospital with characteristics similar to those of the study population.

The questionnaire was divided into four dimensions: pain management, dyspnea control, palliative sedation, and skin care. The alternatives were multiple choice, with 1 point awarded for each correct answer and 0 points for incorrect answers. The classification was based on the Stanine technique.

The classification of knowledge levels was established in different specific areas. In terms of pain management, the levels were categorized as high for those who scored between 15 and 11 correct answers, medium for those with 10 to 6 correct answers, and low for those who scored between 5 and 0 correct answers. Regarding dyspnea control, a high level was 10 to 8 correct answers, a medium level was 7 to 4, and a low level was 3 to 0 correct answers. In the dimension of knowledge about palliative sedation, high levels were between 11 and 8 correct answers, medium levels between 7 and 4, and low levels between 3 and 0. In terms of skin care, a high level was assigned to those who scored between 9 and 7 correct answers, a medium level between 6 and 4, and a low level between 3 and 0. Finally, the overall knowledge score was classified into three categories: high, ranging from 31 to 45 correct answers; medium, from 16 and 30; and low, from 0 to 15.

The research was approved by the Ethics Committee of the Universidad Peruana Cayetano Heredia and subsequently authorized by the hospital itself through its Office of Teaching and Research. After obtaining authorization, coordination was made with the head nurses of each department to explain the study and obtain the informed consent of the clinical nursing staff, respecting the bioethical principles governing research. This data collection process was carried out between June 2023 and January 2024. The questionnaire was administered in person and individually in the designated break areas, lasting approximately 15 to 20 minutes, and ensuring that the nursing staff's duties were not interrupted.

The collected data were coded and subsequently entered into a database created in Microsoft Excel for further analysis using the STATA statistical software, version 16. A descriptive analysis of the data obtained was performed, and the results were presented in a frequency and percentage table.

RESULTS

Table 1 shows that the study found that 90.9% were female. Regarding the type of contract, 54.5% were appointed staff, while special administrative contracts (CAS) accounted for 25.8%, and third-party hires represented 19.7%. In terms of work experience, 37.9% of the participants had been working in their service area for 11 to 15 years. Medical and ICU services account for 36.4% of the population, while oncology accounts for only 27.3%. On the other hand, 72.7% reported having a specialty certification. Finally, regarding courses or workshops on palliative care, 63.6% of the participants reported not having attended any.

Table 1. Sociodemographic characteristics of nursing professionals at a hospital in Lima.

Table 2 shows the knowledge of the dimensions of palliative care. Pain management reached a high level (59.1%); dyspnea control reached a medium level (65.2%); palliative sedation reached a medium level (59.1%); and skin care reached a high level (57.6%).

Table 2. Knowledge levels by dimension of palliative care among nursing professionals at a hospital in Lima

In Table 3, the overall knowledge level regarding palliative care showed a medium level at 57.6%, a high level at 37.9%, and a low level at 4.5%.

Table 3. Overall knowledge level on palliative care among nursing professionals at a hospital in Lima.

Table 4 shows the frequency of responses given for each dimension. In the pain management dimension, the questions with the highest frequency of errors were those related to identifying the type of pain (53.0%) and psychological treatments (50.0%). The rest of the questions obtained correct answers above 50%.

Table 4. Knowledge of the pain management dimension by items among nursing professionals at a hospital in Lima.

In Table 5, regarding the dimension on knowledge of dyspnea control, the items with the highest error rates (56–60 %) were those related to reversible dyspnea and treatments for patients with airway obstruction caused by a tumor, while the other questions had more than 50 % correct responses.

Table 5. Knowledge of dyspnea control dimension according to items among nursing professionals at a hospital in Lima.

Table 6 shows that the palliative sedation dimension obtained a medium level. Therefore, regarding this treatment, the items most frequently answered incorrectly were those related to classification according to purpose (75.8%) and the documentation to be completed in the medical record of a patient treated with this technique (72.7 %). On the other hand, the other items were answered correctly by more than 50 %.

Table 6. Knowledge of dyspnea control dimension according to items among nursing professionals at a hospital in Lima.

Table 7 shows that the questions in the skin care dimension answered incorrectly corresponded to the recommended position for keeping palliative patients bedridden (37.9%) and to the monitoring signs of edema in palliative patients (39.4%).

Table 7. Knowledge of the skin care dimension according to items among nursing professionals at a hospital in Lima

DISCUSSION

The level of knowledge about palliative care, in relation to the dimensions of the study variable, found that the dimension of pain management has high levels of knowledge. The results obtained in this dimension would be related to the fact that participants have professional experience in the areas of medicine and ICU. The data found is similar to the study by Kim et al. (17), who reported that nursing professionals demonstrate skill in managing pain and associated symptoms. Similarly, the study by Zubairi et al. (18) focused on the knowledge and perceptions of healthcare professionals regarding pain management in palliative care, reporting a high percentage of knowledge. However, these results differ from those of Sesma-Mendaza et al. (19), who stated that nursing professionals only have a basic level of knowledge in pain management. Therefore, it is considered essential to incorporate the accurate and timely identification of the corresponding assessment into nursing practice in order to improve the control of symptoms associated with pain.

On the other hand, a medium level of knowledge regarding palliative care was observed in the dimension of dyspnea control. The lack of skills in this dimension would be due to a lack of appropriate training; this is reflected in the higher percentage of nursing professionals who have not taken courses based on palliative care. The results obtained are consistent with the research conducted by Hackner et al. (20), who aimed to evaluate the diagnostic approach and level of knowledge of palliative care regarding dyspnea control, which determined a medium level of knowledge. Conversely, the results differ from the study by Medina et al. (21), who reported insufficient knowledge among nurses about palliative care and respiratory techniques for dyspnea control. Consequently, nursing professionals need to strengthen their knowledge regarding dyspnea management, as respiratory difficulty is a common symptom in patients receiving palliative care (22). Therefore, having knowledge and skills related to this symptom will enable them to provide better care for these patients.

On the other hand, a medium level of knowledge in palliative care was observed in relation to the dimension of palliative sedation. The results found, as previously mentioned, are associated with limited training in the area explored. These findings are consistent with the study by Sastre et al. (23), whose aim was to examine the range of knowledge regarding palliative care concepts, such as palliative sedation, and reported a medium level of knowledge. In contrast, the findings differ from the study by Zuleta-Benjumea et al. (24), who found a high level of knowledge about palliative sedation. Therefore, it should be considered that the participation of nursing professionals is fundamental in palliative sedation, as they are responsible for administering medications and performing the necessary follow-up to evaluate the effectiveness of the intervention. For this reason, professional training and competence in palliative sedation are key factors for providing high-quality care to the population requiring this type of care.

Regarding the level of knowledge on palliative care in skin care, high levels of knowledge were observed. It should be mentioned that the results show that most participants have several years of work experience. Furthermore, when comparing all findings, it is observed that they differ from the study by Cazorla and Pacheco (25), who reported that the dimension of skin care—specifically pressure ulcers—shows a moderate level of knowledge. On the other hand, the research by Kaçmaz et al. (26) indicates that nurses’ knowledge regarding skin care is low. Similarly, the study by Gedamu et al. (27) reports that the overall knowledge of nurses about skin care is low. For this reason, based on the findings, it is important to highlight the relevant knowledge about proper skin care among nursing professionals working in the institution. Besides, it is essential to continuously raise awareness about maintaining skin integrity for patients requiring these nursing activities, since skin injuries often lead to a considerable deterioration in the individual’s health condition (28).

Regarding the overall level of knowledge about palliative care among the participants, a medium level of knowledge was found. This result differs from the study by Guevara-Valtier et al. (11), who reported that nursing professionals’ knowledge regarding palliative care is considered low, consistent with the findings of Chover-Sierra et al. (12), who demonstrated that the level of knowledge among nursing professionals in the field of palliative care is basic. Similarly, Hiciano et al. (8) showed that nurses in Area VII of the Region of Murcia have a low range of knowledge related to the basic concepts of palliative care. On the other hand, the results of this research differ from the study by Guillén (7), who reported that most nurses in the medical service recognize the importance of palliative care. Similarly, the study by Hernández-Sánchez and Aguilar-García (10) observed a high level of knowledge about palliative care.

Finally, as this analysis was developed, it was possible to identify that both male and female nurses who participated in the study have professional experience in the areas where they work. This has been observed in the highest percentage of the indicator, which corresponds to 11 to 15 years of service. Moreover, it is relevant to highlight that 72.7% of participants reported having a professional specialty. The professional characteristics described have allowed nurses to acquire competencies and general knowledge regarding nursing care for patients who require this type of attention. Nevertheless, it is important to emphasize that 63.6% have not participated in courses or workshops focused on palliative care. Furthermore, a study conducted in 2021 in Turkey, published in the journal Nurse Education in Practice, demonstrated a statistically significant difference (p < 0.001) between the medium scores of nurses before and after an educational intervention on palliative care. The authors determined that the development of educational interventions is an effective way to improve nursing professionals' knowledge of palliative care (29). Therefore, it is worth mentioning that nursing professionals and the health facility where the study was conducted have the responsibility to enhance knowledge related to palliative care, in a way that staff not only have basic general knowledge about the management of this issue but also acquire greater expertise through educational training for effective and relevant care.

CONCLUSIONS

The knowledge of palliative care among nursing professionals at a hospital in Lima is at a medium level. However, this result varies according to the different dimensions evaluated: pain management stands out with a high level, while dyspnea control, palliative sedation, and skin care show mixed levels. Specifically, both palliative sedation and dyspnea control show a medium level of knowledge, while skin care ranks at a high level.

Researchers are encouraged to continue conducting research studies focused on palliative care in services where the prevalence of terminal patients is recurrent, rather than focusing solely on the field of oncology. Similarly, we invite others to conduct similar studies to identify the level of knowledge among nursing professionals in various institutions, using our instrument as a stepping stone for future research.

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