One of the important factors influencing a successful delivery of palliative healthcare is the health care professionals’ knowledge, attitudes, beliefs, and experiences, which determine not only their procedure but also their behavior during evaluation and treatment of patients.[¹] After physicians, the nurses are the most valuable palliative care team members who address the physical, functional, social, and spiritual dimensions of care.[²] Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in pain. Several reasons have been identified including inadequacies education, absence of curriculum content related to pain management, and faculty attitudes and beliefs related to pain.[³]

A public health strategy, as recommended by the World Health Organization (WHO), offers the best approach for translating knowledge and skills into evidence-based, cost-effective interventions that can reach everyone in need of palliative care in developing countries.[⁴] The World Health Organization (WHO) pioneered a public health strategy (PHS) for integrating palliative care into a country's health care system. The WHO PHS addresses 1) appropriate policies; 2) adequate drug availability; 3) education of policy makers, health care workers, and the public; and 4) implementation of palliative care services at all levels throughout the society.[⁵] Education of health care workers has a great influence on their knowledge, which acts as a foundation for better clinical practice.[⁶] The role of multidisciplinary collaborative team work cannot be over-emphasized in the provision of palliative nursing care services.[²] Nurses considered next only to physicians, for their important role in providing palliative care and for being responsible for patients with life-limiting and/or life-threatening.[⁷] However, various factors affect nurses’ effective role as a health care provider, in a palliative care setting. The most important factor amongst them is knowledge about palliative care.

The knowledge and understanding about pain had undergone a paradigm shift from a biomedical dimension to a behavioral dimension.[^{8, 9}] In other words, an anatomical or pathological understanding is now replaced with biopsychosocial perspective for pain.[¹⁰] One such recent biopsychosocial explanation of pain is the mechanism-based classification, used by physical therapists’ management in palliative care.[¹¹] A recent survey found that nurses had a biomedical orientation to chronic pain rather than a behavioral one.[¹²] Such attitudes and beliefs not only result from inadequate knowledge per se, but also vice versa.

Knowing the present levels of professionals’ knowledge facilitate appropriate training programs[^{13, 14}] to address identified deficits and thereby to improve the quality of provided care.

There were many studies that previously reported levels of knowledge about palliative care amongst nurses,[¹⁵–²⁵] but none of the earlier studies provide information on knowledge about distinct aspects of palliative care such as philosophy, pain, dyspnea, psychiatric problems, and gastro-intestinal problems. Nakazawa et al.[²⁶] developed and validated the palliative care knowledge test (PCKT) for evaluating knowledge on palliative care amongst health care professionals. PCKT has 5 distinct subscales for each of the above-mentioned issues in palliative care practice. To our knowledge, there is no study that evaluated the knowledge of nurses using the PCKT. The objective of the present study was to evaluate the nurses on knowledge about palliative care using the PCKT.

The study was conducted at a multispecialty tertiary care hospital where the participants included those who attended a continuing professional development program exclusively for staff nurses. The study's ethical approval was obtained from the institutional ethics committee, and all participants were required to provide their written informed consent prior to their participation. Consented participants were then given the survey questionnaire.

The study utilized a self-report questionnaire originally used by Nakazawa et al.[²⁶] The scale had 20 items (statements about pain) for each of which the person had to answer ‘correct,’ ‘incorrect,’ or ‘unsure.’ Items 1 and 2 indicate philosophy (2 points), 3 to 8 for pain (6 points), 9 to 12 for dyspnea (4 points), 13 to 16 for psychiatric problems (4 points), and 17 to 20 for gastro-intestinal problems (4 points). Total score for an all-correct response is 20.

The received questionnaires were then screened for their suitability of responses to get the final number of included participants’ questionnaires. Thus, we arrived at the response rate for our survey.

Comparison across individual and professional variables for both dimensions were done using one-way ANOVA (post-hoc analysis using Bonferonni test), and correlations were done using Karl-Pearson's co-efficient using SPSS version 11.5 for Windows (SPSS Inc, IL).

Out of total 392 questionnaires distributed and collected, 363 valid questionnaires were included for analysis, with a response rate of 92.6%. The overall descriptive data of the study participants is provided in Table 1. The item-specific responses for the subscales of PCKT and their corresponding prevalence rates are shown in Table 2 and Figure 1, respectively.

Previous systematic review identified PCKT as a single quantitative assessment tool yet to be studied and reported in healthcare professionals, be it nurses which was done in this study for the first time in Indian professional population. The principal focus for previous palliative care studies evaluating knowledge was on a website,[²⁷] telephone advice,[²⁸] a disease condition,[²⁹] questionnaire development,[^{30, 31}] research,[^{32, 33}] and theory[³⁴–³⁶] of palliative care. Although this study did not evaluate interventions to improve palliative care knowledge amongst nurses, some recommendations on improving the same could be considered both for practice and for future research: Fundamental changes in nursing curriculum that includes a comprehensive information on palliative care; training programs on palliative care; and, telephone/online (web- based) advice.

This study's findings are in agreement with previous reports of inadequacies in knowledge in various issues related to palliative care such as pain management, opioid usage, and adverse drug events. However, direct comparison of this study's findings with earlier studies is not possible since this study is the first quantitative study that explored the 5 aspects of philosophy, pain, dyspnea, psychiatric problems, and gastro-intestinal problems. Future studies can evaluate palliative care knowledge across a curriculum, comparison between nurses from different work settings or educational background, in different countries across the globe.

This study included biopsychosocial factors related to nursing staff such as age, gender, work experience, and work setting. Education and clinical experience influence nurses’ knowledge, attitudes, and beliefs about palliative care. However, it would appear that the specialist nurses’ working environment and knowledge base engenders a practice theory divide, resulting in desensitization to patients’ physical pain.[³⁷]

Inadequacies in the pain management process may not be tied to myth and bias originating from general attitudes and beliefs, but may reflect an inadequate pain knowledge.[³⁸] This study also found that knowledge about pain was low, only less than 35% of nurses had correct responses for knowledge subscale. Future studies may assess such relationship between knowledge, attitudes, beliefs, and behaviors of nurses in real life palliative care situations.[³⁹] The study findings are of utmost significance since individual’ own knowledge largely determines inter-individual and inter-disciplinary communication in a multidisciplinary care framework for pain and palliative care.[⁴⁰] Knowledge-practice[⁴¹] translation depends upon behaviors are essential to answer inadequacies of nursing care, which directly then would facilitate appropriate educational interventions by integrating research, practice, and education in knowledge about palliative care.[⁴²–⁴⁴]

Being knowledgeable about palliative care assessment and management can help nurses and other healthcare providers overcome many of the barriers to successful pain control and palliative care.[⁴⁵] Future studies could focus on different ways of knowing,[⁴⁶] and the methods of knowledge constructions,[⁴⁷] the inter-relationship with practice and research,[⁴⁸] and the influence of evidence-base,[⁴⁹] and cultural competence[⁵⁰] in evidence-based palliative care nursing.[⁵¹]

Overall level of knowledge about palliative care was poor, and nurses had a greater knowledge about psychiatric problems and philosophy than the other aspects as indicated in PCKT. The study findings have important curricular implications for nurses and practical implications in palliative care.

Source of Support: Nil.

Conflict of Interest: None declared.

The authors wish to thank nurses who participated in the study for taking their valuable time and sharing their knowledge, views, and opinions in the survey.