Developing the questionnaire item pool
An advisory committee of palliative care co-coordinators provided direction throughout the entire development process through a series of focus groups. Committee members were palliative medicine specialist experienced in palliative care with responsibilities for education and training. Their responsibilities entailed assessing the awareness and attitude of other medical specialties, identifying aspects of knowledge that were central to palliative care practice, determining the format to be used for the tool, specifying the appropriate level of difficulty for items, and generating the items [
16,
18].
On the basis of the review of the tools available in the current literature and how they created by their developers either about attitude [
13‐
15,
19,
20] or knowledge [
13,
16,
17,
21] towards palliative care, it was decided to divide the questionnaire into two main sections; the first section was to assess the attitude of physicians and the second section was to assess self-knowledge (self-efficacy) and aspects of the basic knowledge that were central for palliative care practice by any non-palliative physician such as the principles of palliative care, symptoms assessment and management, and the use of painkillers.
Generation and pre-testing of items
Members of the advisory committee generated a pool of approximately 102 items covering all dimensions [
16,
18]. For the attitude, 33 items were identified and measured through Likert scale [
22‐
24]. It helped to quantify subjective preferential opinion, attitude, thinking and feeling in a scientifically accepted, validated and reliable manner [
25‐
27]. We used Likert 5 points symmetrical scale. In many studies, five points scale is comprehensible, enabling respondents to accurately express their views [
24,
27]. Participants were asked to show their level of agreement (from strongly disagree to strongly agree) with the given statement (items) on a metric scale. Here all the statements in combination reveal the specific dimension of the attitude towards the palliative care, hence, necessarily inter-linked with each other [
26‐
28].
Attitude was defined as a system of beliefs and knowledge that everyone has got or has learned throughout his lifetime [
29]. Health care providers’ attitude toward caring patients with life threatening disease may have an important influence on the quality of care they provide [
20]. Dimension of self-knowledge included 7 items and measured by 5 points Likert scale ranging from excellent, very good, good, weak, to none. Self-efficacy was defined by Bandura, 1994 as ‘people beliefs about their abilities to make designated levels of performance that implement influence over events that affect their lives’ [
30] while self-knowledge was defined as ‘competence to perform certain procedure’ [
16].
Dimension of basic knowledge that where central to palliative care practice reflects the philosophy and principles of palliative care, the management and control of pain and other symptoms, and use of painkillers.
Sixty two items were identified with five response alternatives consisting of the correct response, three distracters and an ‘I don’t know’ alterative aiming to distinguish between lack of information and misinformation as well as to reduce guessing [
31]. Items were generated from the literature with expert advice from experienced palliative medicine specialists based on their knowledge and real life experiences with palliative care patients. It was believed that this process served to maximize the content validity of the questionnaire to ensure that items selected were representative of the whole area of attitude and knowledge being measured.
Knowledge was defined as ‘knowing something with familiarity that acquired through experience such as understanding of a science or technique’. [
32] While Ross et al. [
16] defined palliative care knowledge as ‘understanding of death and dying, symptom management, medications and any intervention needed for those patients care’. We meant by basic knowledge minimal knowledge needed in physicians to deal effectively in different clinical situation commonly seen in those patients.
We omitted any items related to death or dying as our aim to shift the focus of palliative care from only caring of patients at the end of life to the delivery of highly specialized supportive care to any patients with life threatening-illness through the disease trajectory.
To ensure high face validity and the representation of a reasonably valid sample of items from the substantive areas of interest, items were then reviewed by all members of the advisory committee and other specialists in palliative care to select the best in terms of clarity and relevance of the questions, accuracy of the palliative knowledge being tapped, doubling or closeness of the items, and interpretability [
16,
18]. This process reduced the number of items to 46 as a preliminary palliative care attitude and knowledge questionnaire with five response alternatives.
A number of demographic questions were added to the questionnaire to characterize the respondents. It includes 11 items about sex, age, nationality, educational level and qualification, specialty, place of work, position “job title”, years of experience, any formal palliative care training, and previous discussion with the patients or their families. Now, the preliminary instrument was then ready for piloting in a sample of physicians and included 57 items [
16,
18].