Attitudes of registered nurses about the end – of – life care in multi-profile hospitals: a cross sectional survey

In Lithuania, palliative care is provided in an institution, a day centre, or at the patient’s home. Palliative care is the comprehensive care of patients with incurable, progressive diseases. Depending on the needs of the patient and his or her family members, necessary assistance is provided to the patient by a doctor, nurse, social worker, psychologist, and other staff. Palliative care was introduced as a concept in 2006 under the National Cancer Control and Prevention Programme. Legal regulation of EOL issues in Lithuania started in 2007; the procedure for providing palliative care was approved. Regulatory arrangements for palliative care provision under contracts with the National Health Insurance Fund (NHIF) were introduced in 2007. The contract terms included a description of indications for referral, relevant procedures and provision standards (e.g., a team of at least three professionals, including a physician, nurse, and social worker; a list of equipment for health-care facilities; minimum duration of consultations at a patient’s home) [18].

Subsequently, in 2012 a description of the requirements for the provision of supportive treatment and nursing services was approved. Following these descriptions, EOL care was provided. However, writing a last will and testament of the future is still not standard practice, and discussion with the patient and his or her relatives about EOL care priorities remains a forbidden topic. In most cases, health care professionals must take moral responsibility for decisions related to EOL care. Also, the reality is that intersectoral collaboration for health still remains a delicate issue in Lithuania [19, 20]. Regardless of the general acceptance that other sectors of society are important for the health of the population, no effective mechanisms to implement this intersectoral collaboration have been in place until recently [19‐21]. And cross-sectoral and multidisciplinary collaboration in the provision of not only life care services but also all other health care services is essential to ensure quality and safe services for the patient. The aim of this study was to describe nurses’ attitudes in providing EOL care and exploring barriers and facilitating behaviors of nurses in multi-profile hospitals in Eastern Europe.

A descriptive, cross-sectional, correlational design was applied in this study.

Registered nurses (RNs) were recruited from all unit types and specialities (surgical, therapeutic, and intensive care), working in the seven large municipal multi-profile hospitals representing Lithuania. In Lithuania, there are approximately 22,500 RNs, and 2560 work in these hospitals in all unit types. According to a sample calculation formula, 378 nurses (22,500 nurses in Lithuania, 95% probability, and 0.05 error percentage) were needed for the study [22]. To account for not all voluntarily consenting to participate, a higher sample size was targeted to be adequately powered. For this study, 1310 RNs were selected to participate. This population of RNs served as the same pool from which a different sample was drawn for another study [23]. Nurses who worked day, night, or mixed shifts during the study were invited to participate in the study. The study did not include nurses who were on maternity or annual leave and had a certificate of incapacity for work.

Nurses’ readiness to care for patients at the EOL and attitudes toward their care were assessed using the Questionnaire of Helps and Obstacles in Providing End-of-Life Care to Dying Patients and Their Families [24]. The questionnaire was validated and verified in a previous study conducted by the authors [25]. Respondents were able to choose an option according to a Likert scale with 1 = no help/not an obstacle to 5 = extremely intense help/extremely large obstacle. Socio-demographic characteristics, such as age, gender, employment, current workplace, and length of current employment were also collected.

Cronbach’s alpha for the questionnaire was established at 0.86, meeting the requirement for acceptance. Similar questionnaires have been used in studies with oncology departments in Lithuania and intensive care departments in Spain and the United States [25‐27].

Questionnaires were distributed to nurses (face-to-face) by one of the authors at the hospitals during the months of September to November 2017. During the study, 1320 questionnaires were distributed; 1180 questionnaires were returned, of which 1055 were satisfactorily completed (response rate 79.9%).

Survey data were analyzed using SPSS for Windows 19.0 (SPSS Statistics for Windows) [28]. Only fully completed questionnaires were used for analysis. The level of significance selected for testing data points was established at p ≤ 0.05. Descriptive statistics were used to calculate the average values of the variables within a 95% confidence interval; standard deviation of the scores were also calculated.

The study was approved by the Bioethics Committee at the Lithuanian University of Health Sciences (No. BE- 2-27). Hospital administrations were informed of the research goals. Verbal informed consent was obtained from each participant following an explanation of the research study goals during the face-to-face recruitment process. This process was approved by the ethics committee. Nurses had the right to refuse participating in the study or withdraw at any time without penalty. The confidentiality of participants was assured, and anonymity was maintained. All data were summarized and reported only in the aggregate.

Sociodemographic characteristics of 1055 RNs are described in Table 1. The average age of RNs participating in the study was 45.8 ± 9.9 years, and the average length of service was 23.4 ± 11.1 years. The majority of respondents were married (n = 668, 63.3%) and worked part-time (n = 786, 74.5%) in mixed shifts (n = 716, 67.9%). Almost half had completed medical college (n = 495, 46.9%). Of all RNs, 49% (n = 516) worked in the internal medicine department, with 32.6% (n = 344) in the surgery department, and 18.4% (n = 195) in the intensive care department.

According to the study, RNs working in the three different profiles emphasized safe and effective care for patients at the EOL. RNs also emphasized the importance of meeting the patient’s spiritual needs in EOL care, i.e., the patient should have the right to a dignified and painless death. The survey revealed a statistically significant difference between RNs in the three departments in attitudes about working with seriously ill patients who frequently died. RNs in the surgical department more than those in the intensive care and internal medicine departments felt these nurses required the help of a psychologist (M = 4.20, p = .009). The RNs in the surgical departments also indicated stronger attitudes that family and relatives should not be limited in time and duration of the patient visit (M = 4.16, p < .001). Meanwhile, RNs working in the internal medicine departments were more likely to say that patients should not be permanently suppressed by sedation drugs (M = 3.69, p = < .001). And RNs working in intensive care departments felt most psychologically prepared to deal with the problems at the EOL (M = 3.67, p = .011) (Table 2).

Analyzing the most common barriers to EOL care, the survey data indicated that for the first block of barriers, with a comparable average of more than 4 points, the respondents in all departments attributed dealing with angry family members as a barrier (p = .004) and inadequate understanding of the nursing care by the patient’s relatives (NS). RNs working in intensive care departments were more likely to identify the barrier of family and friends who regularly called the nurse to find out about the patient’s condition rather than listening to informed family members (M = 4.02, p = .034). Also, for intensive care RNs, family members disagreeing on the kind of care that was most adequate for the patient was perceived as a barrier (M = 3.90, p = .046).

For the second block of barriers, with a mean score of 4 to 3.5, RNs assigned family members’ inadequate knowledge about the situation and lack of time to talk to patients about their wishes for EOL problems as barriers. And in the third block of barriers, with scores of less than 3.5, RNs attributed the lack of knowledge to communicate with the bereaved patient’s family, the lack of evaluation of nurses’ opinions, and the evasion of physicains to talk about diagnosis and their over-optimistic view of the situation as barriers (Table 3). Group differences were not statistically significant.

Data for analyzing factors that would facilitate EOL care are presented in Table 4. RNs across all departments indicated that patient family education on how to deal with the seriously ill would facilitate the work of nurses. Similarly, nurses working in all three departments said that EOL training, volunteering, and family involvement would facilitate EOL care. Group differences were not statistically significant.

The results of this study draw attention to the need for family education and inclusion in the patient’s EOL care. Collaboration between physicians and nurses related to EOL decisions for patients is important. And creating an appropriate work environment that relieves the psychological burden of both relatives and care givers should be implemented in clinical practice; this change might ensure improved quality and safety of care for patients.

A number of studies have been conducted that analyzed the attitudes of nurses working in oncology or palliative care departments towards death and their readiness to provide care to patients at the end of life. However, very few studies have evaluated the attitudes of RNs working in various clinical units towards death and readiness to provide EOL care. The current study allows nurse researchers to anticipate the prevailing trend in multi-profile hospitals in Eastern Europe and to form further, in-depth research in this area. There were limitations of the study. Prior training on EOL issues of the RNs who participated in the study was not evaluated. It is not known whether as part of their undergraduate or postgraduate courses, any or all healthcare professionals receive training on EOL care and related factors in order to provide patients with quality services not only in oncology or palliative care units but also in the multi-profile hospitals. Only RNs working in the seven hospitals were invited to participate in this study. The attitudes and experiences of nurses working in community or other health care settings might be different from those of nurses in the hospital. An expanded study that includes physicians and other staff as participants would provide a deeper insight into how health care professionals work together to provide quality safe EOL care.