International Journal of Community Medicine and Public Health

Shigwedha NN et al. Int J Community Med Public Health. 2022 Jun;9(6):2466-2473

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

Original Research Article DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20221522

Assessment of the knowledge, attitude and practice towards

palliative care amongst the 4th year nursing degree students at
Windhoek Campus, University of Namibia
Nive N. Shigwedha1, Taimi Amakali-Nauiseb2*, Kalista Runone3

1
School of Nursing & Public Health, 2Department of Community & Mental Health Nursing Science, 3Department of
General Nursing Science, University of Namibia (UNAM), Windhoek, Namibia

Received: 19 April 2022

Accepted: 07 May 2022

*Correspondence:
Taimi Amakali-Nauiseb,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Nursing students who will be future nurses should have adequate palliative care knowledge, positive
attitude and good practices. In Namibia, the nursing students’ knowledge, attitude and practice regarding palliative
care remain unknown. This study was aimed at assessing the knowledge, attitude and practices towards palliative care
amongst the 4th year nursing degree students at Windhoek Campus, University of Namibia.
Methods: A cross-sectional survey using a quantitative approach with self-administered questionnaire as a tool for
data collection was utilised among 83 nursing degree students. A simple random sampling technique was used in
selecting the participants and a response rate of 98.7% (n=82) was achieved.
Results: Showed the following: knowledge towards palliative care is suboptimal as only 54.9% (45) participant had
good knowledge towards palliative care, while 45.1% (37) participants had poor knowledge on palliative care.
Practice towards palliative care was good as 91.5% (75) participants had good practice towards palliative care, whilst
8.5% (7) participants bad practice. The overall level of attitude shows positive attitude amongst participants as 76.8%
(63) had positive attitude towards palliative care, while 23.2% (19) had negative attitude.
Conclusions: Integrating palliative care education is required as a pillar to improve student’s knowledge where the
nursing educators are not only designing proper teaching content but also, they are using various teaching strategies to
promote active and experimental learning regarding palliative care.

Keywords: Attitude, Knowledge, Palliative care, Practice, Student nurses

INTRODUCTION paramedics, pharmacists, physiotherapists and volunteers

in support of the patient and their family. Palliative care is
World Health Organization (WHO) defines palliative care also required for the wide range of diseases as majority of
as an approach that improves the quality of life of patients adults in need of palliative care have chronic diseases
and their families facing the problems associated with life such as cardiovascular disease (38.5%), cancer (34%),
threatening illness, through prevention and relief of chronic respiratory diseases (10.3%), AIDS (5.7%) and
suffering by means of early identification and impeccable diabetes (4.6%). Besides this, each year estimated 40
assessment and treatment of pain and other problems such million people need palliative care; 78% of them live in
as physical, psychological and spiritual. Palliative care low-and middle-income countries, worldwide, only about
involves a range of services delivered by a range of 14% of people who need palliative care currently receive
professionals that all have quality important roles to play; 1,2
including physicians, nursing, support workers, it.

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Based on the review of palliative care in Africa, the palliative care. Therefore, this study was aimed at
African Palliative Care Association (APCA), a non-profit assessing the knowledge, attitude and practice towards
organization with its head office currently based in palliative care amongst the 4th year nursing degree
Kampala, Uganda, was provisionally established in students at Windhoek Campus, University of Namibia.4,7
November 2002. APCA’s vision is to ensure access to
palliative care for all in need across Africa, whilst its
METHODS
mission is to ensure palliative care is widely understood,
underpinned by evidence and integrated into all health
Study design
systems to reduce pain and suffering across Africa. Africa
is characterised by an increase rate of communicable
A non-experimental cross sectional survey was conducted
diseases such as HIV and AIDS and a high burden of
using a quantitative approach on 104, 4th year nursing
non-communicable diseases such cancers, cardio vascular
degree students at UNAM. A probabilistic sampling
diseases, diabetes and respiratory diseases. This creates
technique using a simple random sampling method was
an increased need for a well-developed understanding of
used in selecting the students.
and integration of palliative care.3
Study place
APCA brought an office for Palliative Care to Namibia in
2004. In 2011, a full semester of Palliative Care was
established at the University of Namibia. However, the The study took place at Wanaheda, Hakahana, Maxwilili,
country with the total population of 2 456 830 in 2015, Okuryangava, Otjomuise, Khomasdal, Katuture Health
was reported to have only 2 numbers of hospitals with Center and Donkerhoek clinic in Windhoek, Khomas
inpatient palliative care unit out of 45 hospitals across the region were 4th year nursing degree students were placed
country. The density of palliative care services per for their clinicals.
population (per million inhabitant) according to
population data from the World Bank is 0.81 hospice or Study period
palliative care services/ million inhabitant. In addition to
this, Namibia only has 1 number of houses based The study was conducted over the period of 8 days, from
palliative care services offered. The estimated number of 23 June 2021 till 30 June 2021.
patients cared for palliative care in 2016 was 600.
Undeniably, Windhoek Central Hospital had some Study population
aspects of PC while Catholic AIDS Action has satellites
with active PC with staff trained in community/ home The study target population was all nursing students. This
based palliative care. However, the country has no is because they have been allocated to various
palliative care programme specific to paediatric. This departments of health (Health Centre, General Wards,
creates a huge burden of suffering for the Namibian ICU, NICU) during their clinical allocation since 1st year
people with extremely limited access to pain medications and palliative care or end of life care is most likely to
and other palliative care intervention.4 happen in this departments.

As a matter of that, nurses play a central role in palliative Table 1: Inclusion and Exclusion criteria of study
and end-of-life care which include developing plans of population.
care, providing leadership for staff and support for patient
and families. Insufficient knowledge may make nursing Inclusion criteria Exclusion criteria
students feel unprepared and stressful regarding palliative Nursing students None-Nursing students
care providing, which perhaps leads to the developments Registered for Bachelor Not Registered for
of negative attitude towards caring for the dying. Thus, a of Nursing Clinical Bachelor of Nursing
deep understanding and assessment of nursing student’s Honours Clinical Honours.
knowledge, attitude and practice is needed.5,6 In the 4th academic year Not in 4th academic year
Residing at Windhoek Not residing at
Lack of assessment and proper investment in research is campus, University of Windhoek campus,
one the biggest challenges facing palliative care in Namibia. University of Namibia.
African countries including Namibia. Therefore, Allocated to various Not allocated to various
confirming adequate knowledge, positive attitude and departments of health departments of health
good practice towards palliative care are vital educational (Health Centre, General (Health Centre, General
features when training undergraduate nursing students to Wards, ICU, NICU) Wards, ICU, NICU)
act on difficulties of care for people affected by during their clinical during their clinical
progressive, life limiting illness. To this end, the allocation allocation
researcher is not aware of any study conducted in
Namibia particularly at University of Namibia, School of In this study the target population was all nursing
Nursing that assessed and determined the knowledge, students, registered for Bachelor of Nursing Clinical
attitude and practice of the nursing students regarding Honours, in 4th year at Windhoek campus, University of
Namibia. This is because, it was the suitable population to

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the research topic as the 4th year nursing students have Procedure for data collection
been taught about palliative care during their 3rd year as
indicated in (School of Nursing Prospectus, 2019) the
The researcher targeted the participants during lunch time
module content for General Nursing Science 3.
13h00-14h00, where each participant was randomly
Additionally, they have been allocated to various
selected and had an equal chance of being selected.
departments of health (Health Centre, General Wards,
Before handing out the questionnaires, the researcher
ICU, NICU) during their clinical allocation since 1st year
explained the study’s aims and objectives and participants
as a requirement for completing the course where
were given clear and homogenous instruction regarding
palliative care or end of life care is most likely to happen.
the problems seen in the questionnaire during pilot study.
This was as well as the same population which the
Data collection from the participants also strictly
researcher used to access and obtain data (accessible
followed the ethical principles of the study. After
population).8
obtaining permission from the students, the researcher
distributed the questionnaires. The researcher then
Sample size collected the completed questionnaires and thanked the
participants. The whole procedure of completing the
A sample size of eighty three, fourth year nursing degree questionnaire took 3-7 minutes.
students was determined using a formula. Calculation was
done as follows: Data analysis
𝑛 = 𝑁 ÷ (1 + 𝑁𝑒2) The study employed descriptive statistics to summarise
the study’s variables into tables and charts presenting
where; n = sample size frequencies and percentages. Data were analysed using
computer Statistical package for social sciences (SPSS)
𝑛 = 104 ÷ (1 + 104(0.05)2) version 27.

N = population size RESULTS

e = margin of error Demographic information

n=104÷(1+0.26) Age

n=104÷1.26 Majority of the participants 84.15% were between the age

of 20-25 years. While participants between the age 26-31
n=82.53 years were 10.98% (11) and participants between the age
32-37 years were 4.88% (4).
n=83
Gender
Data collection
A total 92.68% (76) were females and males 7.32 % were
Research instrument males.

A self-administered English questionnaire, with open Highest level of education

ended questions was used for data collection. It included
4 sections. Section A: A socio-demographic variable The sum 92.68% (76) of students obtained their
included (age, gender, highest level of education and if NSSC/NSSCH, with 7.32% students having who obtained
they have ever cared for a terminally/ dying patient). Certificate in nursing and it shows that they were enrolled
Section B; consisted of statements with possible in nursing before.
responses of ‘true’, ‘false’, and ‘I don’t know’ describing
knowledge regarding palliative care which measured the Ever care for terminally ill/ dying patient
understanding of the philosophy and principles of
palliative care, pain, symptoms management and A total 82.93% of students have cared for a terminally ill/
psychological care. Section C; used a Likert scale with dying patient. While 17.07% (14) of students have never
five level of scale ranging from strongly agree to strongly cared for a terminally ill/ dying patient.
disagree (strongly agree=5, agree=4, uncertain=3,
disagree=2, and strongly disagree=1) to assess the Results on knowledge, attitude and practice towards
attitudes regarding nursing students’ practices towards palliative care
palliative care with ‘yes’ or ‘no’ statements.
A good number of participants know the aim of palliative
care as 98%. Nearly all participants 91% understands that
drug addiction is the major problem when morphine is

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administered on a long term in managing pain. On the the family members need to be along the bedside of their
other hand, majority of the participants have zero patient, it is not so crucial for them to be there until death
knowledge on whether the extend of the disease occur, which is correct. Half of the participants 50%
determines the methods of pain treatment. In contrast knows that the pain measuring tool used mostly in
35% participants do not knowing the importance of children is face scale and 45% of participants did not
adjuvant (non-opioids). know the key concepts of administering analgesics.
Table 2: Knowledge on palliative care amongst the 4th Nearly half of the participants 48% participants have
year nursing degree students n=82. strongly agreed that they would want to care for a dying
patient. Unfortunately, only 33% strongly agreed that
Don’t
Statement True False giving care to a terminally ill patient is a worthwhile
know
(%) (%) experience. However, majority of participants 62%
(%)
participants strongly agree that they are not afraid to go in
Primary aim of palliative the room of a terminally ill/ dying patient alone. In
care is to relieve contrast, 30% participants strongly disagreed “the length
suffering from pain of time required to give nursing care to a terminally ill
98 0 2
which could be physical, patient would frustrate me”. Surprisingly, 28%
emotional, social or participants strongly agree that they are confident enough
spiritual
to face the family members of a terminally ill/ dying
Drug addiction is a patient. On the other hand, majority of the participants
major problem when 77% strongly agree that terminally ill/ dying patient
morphine is used on a 91 6 2 should be given honest answers about their conditions.
long-term basis for the Half of the participants 51% strongly agreed that nursing
management of pain
care of the patient’s family should continue during the
The extent of the disease period of grief and bereavement. In contrast 73%
determines the method of 80 5 15 participants strongly disagreed that it would be best if a
pain treatment terminally ill or dying patient is left alone until he/ she
Adjuvant (non-opioids) actually dies with 73% strongly disagree “I would not
therapies are important 54 11 35 care if a terminally ill/ dying patient gave up hope of
in managing pain getting better” while 43% strongly disagreeing “I would
The provision of hope the person I am caring for dies when I am not
palliative care requires 20 63 17 around”.
emotional detachment
Manifestation of chronic Majority of the participants 95% responded ‘no’ that as a
pain is different from 73 16 11 nurse is near death, the nurse should withdraw from
that of acute pain his/her involvement with the patient, and 89% of the
Suffering and physical students responded “yes” the family should be involved
54 29 17
pain are synonymous in the care of a dying patient as much as possible.
It is crucial for the family Incredibly, all participants 100% responded ‘yes’ the
members to stay at the terminally ill/ dying patient should be treated equal and
41 46 12
bedside until death with dignity the same as other patients while a good
occurs number of participants 90% answered “no” the terminally
Pain measuring tool ill or dying patient should not be allowed to make
mostly used in children is 50 10 31 decisions about his/her own physical care. On the other
face scale hand, 85% participants indicated “no” if medical
Key concepts of equipment and materials are few in the ward, they should
administering analgesics not be used on terminally ill/dying patient, rather the be
37 18 45
are by mouth, by clock reserve for a healthier patient. And majority of
and by ladder participants 98% responded that “yes” families need
emotional support to accept the behaviour changes of a
More than half of the participants 63% answered dying person. Surprisingly, 95% answered “no” that
correctly that provision of palliative care does not require terminally ill patient should not know about their
emotional detachment. Like-wise, a large number of condition as this will stress them more. A good number
participants 73% know that manifestation of chronic pain 70% of participants indicated “no” when addressing
is different from that of acute pain and 54% participants spiritual issues, the nurse should impose his or her own
know that; suffering and physical pain are synonymous. views while 95% participants have practically agreed that
In general, 46% participants responded that as much as yes, decision making of the patient should involve the
patient.

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Table 3: Attitudes towards palliative care amongst the 4th year nursing degree students: n=82.

Strongly Agree Uncertain Disagree Strongly

Statements Agree Disagree
5 (%) 4 (%) 3 (%) 2 (%) 1 (%)
I would want to care for a dying patient. 48 39 10 2 2
Giving care to a terminally ill patient is a
33 45 12 7 0
worthwhile experience.
I am not afraid to go alone in the room of a
62 23 10 4 2
terminally ill or dying patient.
The length of time required to give nursing care
1 11 18 39 30
to a terminally ill patient would frustrate me.
I am confident enough to face the family
28 35 27 9 1
members of a terminally ill/ dying patient.
Terminally ill person should be given honest
77 21 1 1 0
answers about their conditions.
Nursing care of the patient’s family should
continue during the period of grief and 51 33 15 1 0
bereavement.
It would be best if a terminally ill or dying
1 1 4 15 79
patient is left alone until he/ she actually dies.
I would not care if a terminally ill/ dying person
1 0 7 18 73
I was caring for gave up hope of getting better.
I would hope the person I am caring for dies
6 11 20 21 43
when I am not around.
Table 4: Practices towards palliative care amongst the 4th year nursing degree students n=82.

Statement YES (%) NO (%)

As a patient is near death, the nurse should withdraw from his/her involvement with the
5 95
patient
The family should be involved in the care of a dying patient as much as possible 89 11
The terminally ill or dying patient should be treated equal and with dignity the same as
100 0
other patients
The terminally ill patient should not be allowed to make decisions about his/her own
10 90
physical care
If medical equipment and materials are few in the ward, they should not be used on a
13 85
terminally ill or dying patient, rather they should be reserved for a healthier patient
Families need emotional support to accept the behaviour changes of a dying person 98 2
Terminally ill patients should not know about their conditions as this will stress them
5 95
more
When addressing spiritual issues, the nurse should impose his or her own views 30 70
Decision making of the terminally ill/dying patient should involve the patient 95 5

The overall results on the level of knowledge, attitude and

practice towards palliative care amongst the 4th years
nursing degree students

Data obtained from the participant’s knowledge, attitude

and practice were added all together and divided by the
total number of statements measuring knowledge. The
final score was categorised as good knowledge and poor
knowledge; positive attitude and negative attitude; good
practice and bad practice. The results are summarised
below.

Figure 1: Overall level knowledge towards palliative

care amongst the 4th year nursing degree students.

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DISCUSSION

Knowledge towards palliative amongst the 4th year

nursing degree students

Assessing nursing student’s knowledge is important

because knowledge plays a crucial role in attitude or
behavioural consistence. Firstly, in this study 98% of the
participants were correctly able to identify the primary
aim of palliative care. This is promising finding as
students appear to understand and have an idea of what
palliative care. This finding is not supported by the study
done in Georgia by who’s findings were (86.1%). In
contrast, a study done in Arab American only 58.6% of
students could get this statement correct. Besides this, in
this study, the highest number of incorrect answers on
knowledge towards palliative were on the following
statements: the extent of the disease determines the
method of pain treatment 5%; suffering and physical pain
Figure 2: Overall attitude towards palliative care are synonymous 24% and the results on key concepts of
amongst the 4th year nursing degree students. administering analgesics are by mouth, by clock and by
ladder 37%. This can be due to inadequate palliative care
The study gained 54.9% of participants who had good education in nursing programme.7,5,9
knowledge towards palliative care. While 45.1%
participants had poor knowledge on palliative care. This In addition, this study’s level of knowledge score shows
means, more than half of the participants had good that 54.9% of students had good knowledge on palliative
knowledge on palliative care. care which was classified as suboptimal level of
knowledge while 45.1% nursing students had poor
The participants 76.8% who have positive attitudes knowledge towards palliative care. To contrary this
towards palliative care. Whilst the least number of study’s findings the following studies had poor
participants 23.2% had negative attitudes towards knowledge on palliative care among nursing students: a
palliative care. study done in Rwanda only 9.3% nursing students had
good knowledge, a study done in Arab American only
40.58% nursing students had good knowledge and
another study done in Indonesia shows that only 24.3%
students nurses had good level of knowledge towards
palliative care.7,9,10

Attitude towards palliative care amongst the 4th year

nursing degree students

Assessment of attitude towards palliative care in this

study looked at factors such as: giving care to a dying
patient; whether care should be extended care to the
family of a dying person; and whether a dying patient
should be given honest answers about their condition
were observed. Adding to this, students were also asked
how confident they are in facing family members of a
dying patient and if the time required to care for a
terminally ill patient would frustrate them. Surprisingly,
not less than 60% was obtained from the results these
results contradict with the study done in Ethiopia by
Kassa, Woldenyohannes and Muragan. Reasons could be
Figure 3: Overall level of practices towards that the nursing students have nursed quite a number of
palliative care amongst the 4th year nursing degree terminally ill and dying patients thus their attitudes being
students. influenced by the experience. The attitude scale of this
study was scored and categorised into positive and
The study had majorities of participants 91.5% with good negative attitude. Thus, providing description of attitude
practice towards palliative care, whilst a least number of score which shows 76.8% of students had positive
participants 8.5% with bad practice towards palliative attitude towards palliative care. On the other hand, 23.2%
care. nursing students had negative attitude towards palliative

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care. These results are dissimilar to a study done in Saudi

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14. Howharn C, Phokhwang-Just W, Saraketrin A,

Cite this article as: Shigwedha NN, Amakali-
Thongphet P, Kantabanlang Y, Klaypugsri L, et al.
Nauiseb T, Runone K. Assessment of the knowledge,
Palliative Care Knowledge, Attitude, and Practice of
attitude and practice towards palliative care amongst
Nursing Students at Colleges of Nursing,
the 4th year nursing degree students at Windhoek
Praboromarajchanok Institute. Thai Journal of
Campus, University of Namibia. Int J Community
Public Health and Health Sciences. 2020;10:8-12.
Med Public Health 2022;9:2466-73.

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