Research Research

Nurses’ knowledge about palliative

care services in North Lebanon
Sarah El Khatib, Ansar Khoder, Dalal Moghrabi, Mohamad Rabah and Samaa Al Tabbah

Abstract
Background: The surge in number of people needing palliative care services along with the deficit
in nursing knowledge in in this field are challenges to be addressed in order to ensure higher quality
end of life life care. Aim: The aim of this cross-sectional, exploratory pilot study was to assess
nurses’ knowledge in palliative care using the palliative care knowledge test (PCKT). Method:
Descriptive analysis and correlations were carried out. Findings: Nurses showed insufficient
knowledge in palliative care; 52% had a poor level (≤18 points) and 48% a fair level (19–28) of
knowledge. No participants scored more than 73% in the total PCKT score. Nurses scored poorest
in the management of dyspnoea and psychiatric problems. Conclusion: This pilot study
demonstrated that promoting continuous education in palliative care is needed to provide quality
care to terminally ill patients.

Key words: l knowledge l palliative care knowledge test l Lebanon l nurse l palliative care

T
he quality of care provided for patients managing symptoms, educating the patient and
struggling with serious health-related family members, and organising the patient’s
problems can strongly affect the quality environment to minimise loss of control, is critical
of life (QoL) of both patients and their loved ones to the delivery of high-quality palliative care
Sarah El Khatib
(Huijer et al, 2009a; World Health Organization, (Menekli et al, 2021).
Assistant Professor, 2018; Radbruch et al, 2020). According to However, multiple factors such as knowledge,
Faculty of Public Health,
Lebanese University,
the World Health Organization, palliative attitude, beliefs and experiences affect nurses’
Lebanon; Center for care (PC) is defined as an interdisciplinary effectiveness in providing palliative care services
Epidemiology and
Research in Population
caregiving approach aimed at optimising the (Doumit, 2021). It was reported that many nurses
Health (CERPOP), QoL of patients facing life-threatening illness often do not feel well-prepared, or have a lack of
Université de Toulouse,
Inserm, Université Paul
and their families, by alleviating physical, knowledge in caring for terminally ill patients;
Sabatier, France spiritual and psychosocial distress (World Health thus, needing further education in palliative care
Ansar Khoder Organization, 2018). It can be implemented (Vu et al, 2019).
Registered Nurse, Faculty at any time and at any stage of illness, whether Even though palliative care services in Lebanon
of Public Health, Lebanese
University; Al Youssef terminal or not, contrary to hospice care, which is have made some important strides in the last
Hospital Center, Lebanon a comfort care without curative intent offered to decade, significant challenges and barriers to
Dalal Moghrabi dying patients (Currow et al, 2020). Worldwide, it healthcare systems remain:
Registered Nurse, Faculty
of Public Health, Lebanese is estimated that 40 million people need palliative ● The rapidly ageing population
University; Al Youssef care each year, yet only 14% receive the services ● The high burden of non-communicable
Hospital Center, Lebanon
they need (World Health Organization, 2018). diseases (NCDs)
Mohamad Rabah Nurses play a key role in providing palliative ● Lack of knowledge and skills in palliative care
Registered Nurse, Faculty
of Public Health, Lebanese care for patients who need it (Rosa et al, 2022). among healthcare providers (Abu Sharour et al,
University; Nini Hospital, The nurse is the most valuable palliative care 2021; Doumit, 2021).
Lebanon
team member as they have the greatest contact
Samaa Al Tabbah
Clinical Pharmacist, with the patient (Schroeder and Lorenz, 2018; Aim
Faculty of Health Getie et al, 2021). This prolonged contact The aim of this pilot study was to assess the
© 2022 MA Healthcare Ltd

Sciences, American
University of Beirut; gives the nurse a unique opportunity to know level of palliative care knowledge among nurses
School of Pharmacy, the patient and properly address their wishes working at two different hospitals in North
Lebanese American
University, Lebanon and needs (Achora and Labrague, 2019). Lebanon using the PCKT score, as well as to
Correspondence to:
In addition, a nurse’s expertise in providing study the factors affecting nurses’ palliative
samaa.tab@hotmail.com physical and emotional care to the patient, care knowledge.

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Methods Ethical considerations

Study design and participants Approval was granted by the Institutional
This is a cross-sectional exploratory pilot study Review Board of the Lebanese university,
carried out at two hospitals located in Northern Faculty of Public Health Section III, and the
Lebanon—El Youssef Hospital Center in Halba Nursing Department at the two hospitals.
city and Nini Hospital in Tripoli—during the Oral consent was also obtained from the
month of July 2020. The study included 48 participating nurses.
registered nurses (RN) working in different
units at the two hospitals: medical/surgical and Statistical analysis
intensive care (ICU) units. Statistical Package for the Social Sciences (SPSS),
version 21.00 for Windows (SPSS Inc., Chicago,
Inclusion/exclusion criteria IL) was used to analyse the data. Descriptive
All the nurses working in the two hospitals were statistics of all the included variables was
eligible. All of those who agreed to participate done. Frequencies and percentages were used
in the study during the implementation period to describe qualitative variables, mean and
were selected. standard deviation. The level of significance was
set at 5%, with a 95% confidence level.
Procedure and data collection Bivariate analysis between the total PCKT
To assess the level of nurses’ knowledge, the score and the different variables was used to
French validated version of the self-report measure the effect of different factors on nurses’
questionnaire (PCKT), developed by Nakazawa initial total knowledge score. An independent
et al (2009) was used. The tool’s validity and t-test was used for binomial variables (sex,
reliability were established previously. hospital, current job function and if they have
This test consisted of 37 questions divided attended previous palliative care training),
into six dimensions: whereas analysis of variance (ANOVA) was
● The philosophy of care used to compare the means among multinomial
● The management of pain variables (age, educational level and years
● Dyspnoea of experience). A p-value of <0.05 indicated
● Psychiatric disorders statistical significance.
● Gastrointestinal disorders
● Communication.
The questionnaire was anonymous. The
total number of completed and returned Table 1. Sociodemographic characteristics of the study
questionnaires was 48; the response rate sample (N=48)
was 96%. All the nurses working in the two Characteristic Variable N %
hospitals were invited to participate in this
Age (years) <25 9 18.8
study; oral consent was obtained from the
25–30 21 43.8
participating nurses. The questionnaires
were distributed during different shifts to 30–35 10 20.8
cover the maximum number of nurses in the >35 8 16.7
two hospitals. Sex Male 15 31.3
Nurses’ knowledge was assessed as follows: Female 33 68.8
for each question, one point was awarded Hospital El Youssef Hospital Center 33 68.8
in case of a correct answer and zero points Nini 15 31.3
in case of ‘wrong’ or ‘don’t know’ answer. A
Years of education 2 12 25
total knowledge score was then calculated
3 17 35.4
for every nurse. Knowledge scores were
4 17 35.4
classified into ‘poor knowledge’ (≤18 points),
‘fair knowledge’ (19–28 points) and ‘good >4 2 0.2
knowledge’ (≥29 points). A subscore or one Years of experience <10 32 66.7
word depending on style subscore (JWC would 10–20 13 27.1
use subscore) score for every dimension was >20 3 6.3
© 2022 MA Healthcare Ltd

also calculated. In addition, factors that may Current function Registered nurse 41 85.4
affect nurses’ knowledge such as age, gender,
Head nurse 7 14.6
educational level, years of experience, current
Attended previous palliative care Yes 14 29.2
position, previous training in palliative care
educational session No 34 70.8
were measured.

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Results Factors affecting the knowledge in different

Sociodemographic characteristics of the study
sample are presented in Table 1. In total, 48
out of 50 questionnaires were analysed. The
questionnaires filled by nurses working in the
ER department were excluded, since the authors
considered the type of workflow and exposure
to the patient as different from regular units.
Study participants were mainly female (68.8%,
33 nurses) with almost two thirds aged <30 years
and having <10 years’ experience. Regarding
educational level, the vast majority (70.8%) had
3–4 years of education. A total of 88.5% of the
included nurses were working as regular floor
registered nurses, while around 15% were heads
of divisions. Only 14 nurses had already attended
previous palliative care educational sessions.
Prevalence of correct answers for different
questions of PCKT scores is presented in Table 2.
The mean total score of PCKT was 19.18±3.44.
All the included nurses demonstrated insufficient
knowledge in palliative care, with one half
having a poor level of knowledge (≤18 points)
and the other half a fair level of knowledge
(19–28 points). The least number of correct
answers was for two questions in the pain
management dimension and concerned the use of
opiates (Questions 11 and 14).
The item-specific responses for the subscales of
PCKT and their corresponding prevalence rates
are shown in Figure 1. The nurses’ knowledge
in palliative care was particularly low in the
dyspnea management (37.8%), followed by the
management of psychiatric problems (48, 3%).
Factors affecting the total PCKT knowledge
score are presented in Table 3. Results showed
that none of the studied factors seemed to affect
nurses’ palliative care knowledge. All correlations
were not statistically significant (p>0.05).
Figure 1: Item-specific responses for the subscales of the Palliative Care
Knowledge Test and their corresponding prevalence rates
80
70
71.5
60 63
50
50.4 52.2
40 48.4
30 37
20
10
dimensions of palliative care are presented in
Table 4. There was not any significant difference
in the different dimensions of palliative care
between nurses in term of sex, nor in term of
level of education and years of experience. A
previous formation on palliative care did not
affect nurses’ specific knowledge in different
palliative care dimensions.
Discussion
Nurses’ knowledge in palliative care is crucial
in determining the QoL of terminally ill patients
and chronically sick patients (Huijer et al,
2009a; Parveen et al, 2020). Enhancing this
knowledge in different dimensions of palliative
care will contribute to helping alleviate patients’
distress and improve healthcare outcomes (Vu et
al, 2019).
In this study, initial level of nurses’ knowledge
in different aspects of palliative care were
relatively low. This result is in agreement with
previous research conducted in Lebanon (Huijer
et al, 2009b) and in different parts of the world,
such as Vietnam (Vu et al, 2019), Switzerland
(Iori and Morin, 2015), Jordan (Al Qadire,
2014), Palestine (Ayed, 2015), the US (Vu et al,
2019) and India (Prem et al, 2012). This finding
can be explained by the fact that palliative care
is not yet recognised as a proper discipline by the
Lebanese health authorities (Huijer et al, 2009a)
and was only recently added to the curriculum
of some Lebanese nursing schools (Daher et
al, 2002).
Palliative care knowledge in this study
appeared to be particularly deficient in the
dyspnoea dimension, psychiatric dimension and
gastrointestinal dimension. These results were
concurrent with other studies that also used
the PCKT tool to measure nursing knowledge
in palliative care (Prem et al, 2012; Iori and
Morin, 2015; Vu et al, 2019). Results show that
additional efforts must be made to strengthen
the knowledge of nurses on the use of opiates
(indication, management of side-effects) to
alleviate patient pain and control dyspnoea.
In the philosophy of care dimension, only
37.5% of the responding nurses correctly
answered the question: ‘patients who receive
palliative care must accept death’; this is a stark
contrast to the article produced by Iori and
Morin (2015), in which 85% answered correctly.
© 2022 MA Healthcare Ltd

0
This can be attributed to the existing culture
ca hy

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st ro

n
oe

tio
Pa
of sop

te st
re

al
iat

in Lebanon, in which the word ‘care’ means

pn

ica
in Ga
in
ch
ilo

ys

un
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D
Ph

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‘doing everything we can to prevent the death

m
om

of the patient’, rather than ‘accompanying the

C

*p>0.05 non-significant
patient’. Only 63% of the responding nurses had

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Table 2. Prevalence of correct answers for different questions of Palliative Care Knowledge Test
(PCKT) scores
Dimension Question Correct Correct
answer response
true/false n (%)
(T/F)
Philosophy of 1. Palliative care should only be provided for patients who have no curative treatments available F 28 (58.3)
care 2. Palliative care should not be provided along with anti-cancer treatments F 31 (64.6)
3. What is important to quality of life varies from individual to individual T 44 (91.7)
4. Patients who receive palliative care must accept death F 18 (37.5)
Total 121 (63)
Pain 5. When a cancer patient has pain, opioids should be introduced first F 14 (29.2)
6. One of the goals of pain management is to get a good night’s sleep T 37 (77.1)
7. When opioids are taken on a regular basis, nonsteroidal anti-inflammatory drugs should not be used F 28 (58.3)
8. Regular use of pain relievers is effective in the management of cancer pain T 39 (81.3)
9. Antidepressants and anticonvulsants sometimes help relieve cancer pain T 28 (58.3)
10. Although severe pain occurs when opioids are used regularly, the next dose should not be given early F 25 (52.1)
11. Long-term use of opioids can often induce addiction F 8 (16.7)
12. The use of laxatives is effective in preventing opioid-induced constipation T 41 (85.4)
13. Increasing the dosage of opiates should be limited as respiratory depression can occur as a side-effect F 17 (35.4)
14. The use of opiates does not influence the patient's survival time T 5 (10.4)
Total 242 (50.4)
Dyspnea 15. Morphine should be used to relieve dyspnea in cancer patients T 23 (47.9)
16. When opioids are taken on a regular basis, respiratory depression will be common F 15 (31.3)
17. Oxygen saturation levels are correlated with dyspnoea F 12 (25)
18. Assessment of dyspnea should be based on the subjective perception of patients T 26 (54.2)
19. Anticholinergic drugs or scopolamine hydrobromide are effective for alleviating bronchial secretions T 18 (37.5)
of dying patients
20. The only effective way to reduce bronchial secretions in patients at the end of life is manual aspiration F 15 (31.3)
Total 109 (37.8)
Psychiatric 21. During the last days of life, drowsiness associated with electrolyte imbalance should decrease discomfort T 18 (37.5)
problems 22. Benzodiazepines should be effective for controlling delirium T 29 (60.4)
23. Some dying patients will require continuous sedation to alleviate suffering T 38 (79.2)
24. Morphine is often a cause of delirium in terminally ill cancer patients F 15 (31.3)
25. Delirium occurs frequently in patients who are prone to mental weakness (anxiety, anxiety) F 16 (33.3)
Total 116 (48.3)
Gastrointestinal 26. A gastric tube should be inserted to decrease symptoms caused by obstruction of the digestive tract F 8 (16.7)
problems 27. At terminal stages of cancer, higher calorie intake is needed compared to early stages F 21 (43.8)
28. A decrease in oral fluid intake associated with cancer can only be treated with an infusion F 24 (50)
29. Even though oral fluid intake is not possible due to obstruction of the digestive tract, parenteral T 40 (83.3)
high-calorie nutrition often improves quality of life if the patient's general condition is good
30. There is no route except central venous for patients unable to maintain a peripheral intravenous route F 18 (37.5)
31. When patients receive an infusion of 1000ml or more per day, pleural effusion and ascites tend to increase T 22 (45.8)
32. Steroids should improve appetite among patients with advanced cancer T 30 (62.5)
33. When patients with ileus use metoclopramide, stomach pain and vomiting may worsen T 38 (79.2)
34. Intravenous infusion will not be effective for alleviating dry mouth in dying patients T 29 (60.4)
Total 230 (53.2)
Communication 35. Communication skills and techniques can be learned T 42 (87.5)
© 2022 MA Healthcare Ltd

36. The information required by patients and families as well as the degree to which they take part in T 40 (83.3)
decisions may change depending on the course of the disease and the duration of the disease
37. Uncertain information should not be given to patients or families because it could cause additional anxiety F 21 (43.8)
Total 103 (71.5)

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Table 3. Factors affecting the total Palliative Care Knowledge Test knowledge score
Characteristic Variable n Total score Effect size Statistical
mean (Cohen’s d=) evaluation
(+/-SD)
Age (years) <25 9 20.22 (2.38) 0.041 ANOVA: F=0.681;
25–30 21 18.52 (3.65) p*=0.568

30–35 10 19.90 (4.25)

>35 8 18.87 (2.85)
Sex Male 15 18.46 (4.19) 0.256 T=0.977; p*=0.334
Female 35 19.51 (3.06)
Hospital El Youssef Hospital Center 35 19.13 (3.79) 0.000 T=-0.723;
Nini 15 19.2 (3.33) P*=0.942

Educational level (years) 2 12 18.58 (2.15) 0.010 Anova F=0.163;

3 17 19.47 (3.6) P*=0.921

4 19 19.29 (4.27)
>4 2 19.5 (0.7)
Years of experience <10 33 18.96 (3.19) 0.07 Anova F=0.246;
10–20 14 19.76 (4.24) P*=0.783

>20 3 19 (3)
Current function Registered nurse 42 19 (3.13) 0.07 T=0.791; P*=0.593
Head nurse 8 20.14 (5.11)
Attended previous Yes 15 18.07 (3.38) 0.048 T=-1.458;
palliative care No 35 19.65 (3.41) P*=0.152
educational session
*P>0.05 non-significant

Table 4. Factors affecting the knowledge in different dimensions of palliative care

Dimensions of Palliative Care Knowledge Test score p-Value*
Variables Philosophy of care Pain Dyspnea Psychiatric Gastrointestinal Communication
Sex 0.776 0.06 0.986 0.812 0.815 0.610
Previous palliative care 0.411 0.174 0.820 0.957 2.78 0.985
formation
Education (years) 0.788 0.968 0.493 0.885 0.980 0.788
Years of experience 0.241 0.598 0.703 0.312 0.515 0.422
*P>0.05 non-significant

correct answers regarding the philosophy of care
compared with 91% in Iori and Morin’s (2015)
article; this may be due to the late integration of
palliative care in the health system in Lebanon
compared with Switzerland.
In the gastrointestinal dimension, only
16.7% correctly answered the question
regarding whether or not a gastric tube should
be inserted to reduce the symptoms caused
by an obstruction of the digestive tract, in
contrast to 53% in the Swiss study (Iori and
Morin, 2015). This may be due to the fact that
nursing courses often instruct the use of gastric
Nurses’ knowledge in the communication
dimension was the highest (71.5%); this result
is not consistent with the study conducted by
Huijer et al (2009b). This result is promising,
since good communication allows nurses to
connect with their patients and understand
their priorities and wishes, which results in
better patient outcomes (Huijer et al, 2009b).
Regarding the factors affecting nurses’
palliative care knowledge, none of the studied
factors seemed to significantly affect the
nurses’ level of knowledge. The authors did
not find any statistically significant differences
© 2022 MA Healthcare Ltd

tubes as a viable solution in case of obstruction
(Roveron et al, 2018), contrary to its use in
the management of palliative care, where the
main purpose is to maintain patient comfort
(Mobily and Patel, 2015).
in palliative care knowledge between the
two sexes examined in the study, nurses who
had or had not worked in palliative care
previously, or nurses who had a different
level of experience or level of education. These

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Key points
● There is a lack in knowledge among nurses regarding palliative
care services
● Continuous education in palliative care is needed among nurses
● Education in palliative care will promote a better quality of life
and care to terminally ill patients.
CPD reflective questions
● How much did you know about the subject before reading
this paper?
● What type of support is needed for nurses to improve
their knowledge?
● What further recommendations could be included in this paper?
results did not correlate with previous studies
conducted in Lebanon (Huijer et al, 2009a;
Huijer et al, 2009b; Huijer et al, 2016). This
can be attributed to the small sample size of
this pilot study; further investigations should
be conducted in future studies.
Study limitations
A key limitation of this study is that it was
a pilot study with a small sample size. The
sample population was limited to participants
from only two medium sized hospitals in the
same region of Northern Lebanon; this may
limit the external validity of the findings.
Another important limitation was the timing
of the study, which was conducted during
the COVID-19 pandemic and the Lebanese
financial crisis. These factors increased the
workload of existent nurses and may have
made them less interested in participating in
this study. In future studies, sampling across
various hospitals, units and regions would
provide a broader sample that is more likely to
represent the palliative care knowledge base of
registered nurses in Lebanon.
Conclusion
In this pilot study, the authors found a low
level of nursing knowledge in palliative
care. This highlights the importance of
incorporating palliative care courses in all
nursing curriculum. Further studies are needed
to determine the deficient area of nursing
knowledge in palliative care to address
educational deficits and improve nurses’
practice. Analysis of the correlation of different
factors with the level of knowledge, taking
into consideration different parameters such
480
005_IJPN_28_10_474_481_Lebanon.indd 480
as sex, hospital size and previous exposure
to a palliative care formation would be
recommended. IJPN
Statement of interest: None
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