In t er n a t ion a l Jou r n a l of Nu r sin g Dida ct ics, 6 : 1 2 Decem ber (2 0 1 6 ).

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INTERNATIONAL JOURNAL OF NURSING DIDACTICS

homepage: http://innovativejournal.in/ijnd/index.php/ijnd

Impact of Palliative Care Educational Program on Nursing Students' Knowledge and

Attitudes toward Care of Dying Patients
Om Ebrahim Ali Elmelegy1 ; Rasha Elsayed Ahmed2 ; Entisar Abo Elghite Elhossiny Elkazeh3 .
1
Assist. Prof. of Medical Surgical Nursing,2 Lecturer of Medical Surgical Nursing,3 Assist. Prof. of Community Health
Nursing, Faculty of Nursing, Tanta University, Egypt.
E-Mail: [email protected]

DOI:http://dx.doi.org/10.15520/ijnd.2016.vol6.iss12.182.
Abstract: Background:-The need for palliative care is fast increasing as the population ages increase, particularly amongst those who with non-
cancer diagnoses and with the numbers of people aged 85 or over. The aim of this study: -This study aimed to evaluate the effect of palliative
care educational program on nursing students' knowledge and attitudes toward care of dying patients . Material and methods:-Q uasi
experimental design was utilized. A representative sample of 40% from nursing students who enrolled in second, third and fourth year study at
the faculty of nursing. Tools of data collection:Data of the study was collected through utilizing the following two tools: Tool (I): Structured
Interview Questionnaire: It was consisted of two parts: Part (1): Socio-demographic characteristics of the students. Part (2): Knowledge
Questionnaire Sheet about palliative care. Tool (II): Frommelt’s attitude toward care of the dying (FATCOD) scale. Results: -It was observed
that there was no significant difference between total Frommelt’s attitude score (negative, fair and positive) among second, third and fourth
undergraduate students during the pre and post observations, while the significant difference was present only during follow up observational
period p=0.00.Also, there was significant difference between total knowledge and total Frommelt's attitude among 4th year students in relation to
post and follow up observations (p=0.002).The difference was present clearly in knowledge comparing with the attitude. Conclusion and
recommendations: -, the current study revealed that the majority of second and third year students had no previous experience in caring of
dying. Also, there was significant difference between total knowledge and total Frommelt’s attitude among 4th year students in relation to post
and follow up observations. Palliative care must be an integral part of the nursing curriculum and encourage students strongly to have a correct
principle of care of dying patients to develop positive attitudes toward palliative terminal care.

Keywords: Palliative care, knowledge, attitudes, dying patients.

INTRODUCTION diseases (4).Although palliative care is considered a new

med ical specialty as introduced in 2007, the number of
Palliat ive care (PC) is considered as one of the most programs and specialists have increased considerably in the
important aspect for patients' care at the end stage of life. It last decade (5).
provides the patients' with comfort and decreases the period
of suffering fro m illness. So world today concerns its In Egypt, palliat ive care and cancer pain control are
interests toward practice of palliat ive care for patients with considered at an early stage of development. There are many
end stage of life to alleviate the sympto ms of disease and obstacles face palliative care such as restricted opioid
ensure about peace death (1). accessibility and availability for medical use (6). In general
palliative care is still misapprehended among health
The World Health Organization (2014) defined the palliat ive professionals, cancer patients and the public because its aim
care as "an approach wh ich improves the patients' quality of doesn't communicate clearly in the clin ical area, wh ich is
life and their families that facing life -threatening problems providing better quality of life, wh ile co mbating cancer (7). It
through prevention and relief of suffering by early detection, is important to integrate pain and palliative care into the
pain management and assessment of physical, psychosocial health units, where healthcare providers have adequate
and spiritual problems" (2) . knowledge of pain assessment and management of palliat ive
care(8).
So, the palliative care contains integrated multid isciplinary
collaboration between the patients, their families, health Palliat ive care is tradit ionally associated with a range of
professionals and the public toward a continuum of care principles of care including the view of dying as a natural
confirming on physical, mental, social, spiritual and process, while at the same time affirming life and of acting
emotional dimensions of care for life-limiting or life- neither to hasten nor postpone death. Now a palliat ive care
threatening conditions (1). In the USA, the National Hospice is applied in the course of illness in a comb ination with
and Palliative Care Organization (NHCPO) defined other treatments at early stage, that are aimed to prolong the
palliative care as "It is a treat ment that enhances comfort life, such as chemotherapy or radiat ion therapy, as in
and provide better quality for an indiv idual's life during the terminal care (9). It is not restricted to cancer or even to the
last phase of life" (3).The goal of palliative care is not to cure, late stages of illness; but also can be applied to any life-
but to provide comfort and reach the h ighest possible quality threatening diseases. So, the palliative care is not a
of life for individuals suffering from severe substitute to other care, but is an integral and essential
component of total

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 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,

patient care and it is not limited to a certain setting but takes Aim:
place in different environ ments of palliative care and at any The aim of the study was to evaluate the effect of palliative
situation (4,5). There is confusion between palliat ive care and care educational program on nursing students' knowledge
end of life care, where the first refers specifically to care and attitudes toward care of dying patients.
provided in the last phase of life wh ich often defined as
approximately the last year (10).But end of life care MATERIAL AND METHODS
sometimes refers to the last weeks or even days of life and
can include care into bereavement (11). Design: quasi experimental design was utilized in this study
Research hypothesis:
Education and training of palliative care influences not only
the level of care p rovided but also the level of team The researcher expects that the nursing students who receive
participation of the healthcare professionals, where the educational program about palliative care will exh ibit
knowledge of nurses influences the quality of care provided improvement of their knowledge and attitudes toward care
to these patients (12).The trainers and trainees face a of dying patients.
challenging process toward training of palliative care, where Setting:
as a real-life scenario can never be simu lated in an
educational environment (13,14). Nursing schools have not The study was conducted at the Faculty of Nursing in Tanta
adequately inserted palliat ive care into the curriculu m to University.
increase awareness of (PC) contents and skills. Sadhu et al., Subjects:
(2010) asserted that students are lacking in knowledge on A representative sample of 40% fro m nursing students who
(PC). Students cannot be expected to be experts in any way enrolled in second, third and fourth year study. The study
due to lack of experience in the clin ical area; however the sample were selected rando mly and consis ted of 173
schools and hospitals are holding students and new students from second year, 110 students from third year and
graduates accountable for this material and expect an 110 students from fourth year.
adequate competency level despite lack of train ing and
teaching on the subject. Implementation of palliat ive care Inclusion criteria:
experiences with in the nursing curriculu m is essential for -Students who enrolled in second, third and fourth year
better preparing to students toward care of dying -Students who are willing to participate in the study.
individuals (15).
Tools of data collection:
Palliat ive care clinical nurse specialists play an important Data of the study was collected through utilizing the
role in providing the palliat ive care to patients, where they following two tools:
spend more time with patients and their families, helping Tool (I): Structured Interview Questionnaire:- It was
them co me to terms with an array of co mp lex emotional and consisted of two parts as follow:
practical problems, facilitating co mmunication, giv ing Part (1): Socio-demographic characteristics of the
informat ion and advice about treatments and also offering students:-which include age, sex, previous education on
expertise in controlling pain and other distressing death and dying, previous experience in caring of dying,
symptoms (16). These nurses are equipped with specialist previous death experience and current experience in the care
skills to assess the complex palliative care needs of patients of terminally ill.
referred to the service (17, 18) .
Part (2):Knowledge Questionnaire Sheet about Palliative
In the majority of teaching universities and palliat ive Care: it was developed by the researchers based on literature
med icine considered a palliative care as a part of its teaching review (Kassa et al., B MC Palliati ve Care 2014)(21). It
program (19). However, most programs in med icine teaching included (17) questions to measure the undergraduate
universities worldwide include adult palliative care. Despite students' knowledge regarding care of a dying patients.
dynamic develop ment of the palliative care, there are Scoring system of these questionnaires:
difficult ies in nursing staff recru it ment and significant
Score +1 for a correct answer, zero fo r an incorrect answer
deficits in the knowledge about palliative care and care of
dying. These difficu lties arise as a result of a lack of was considered. The total score of questionnaires were less
than 50% was graded as poor, 50% to less than 75% score
palliative care t rain ing among nursing students because the
was graded as average, and mo re than 75% score was
undergraduate nursing curricula are negligent palliat ive care
(PC) issues (20) . graded as good score.
Tool (II): Frommelt’s Attitude toward Care of the Dying
Significance of the study:
(FATCOD) Scale:
Because the nursing schools give limited emphasis for
It developed by the Fro mrnelt 1991 (18). This scale measured
palliative care in the educational curriculu m plan, in clin ical
the undergraduate students' attitudes toward a care of dying
areas and the incidence of death patients increase each year
patients. It was consisted of 30 items using as 7 items
with no developing to palliat ive care, it is necessary to
related to students' attitude toward care of dying, 10 items
conduct our study to evaluate the effect of palliat ive care
related to students' attitude toward death, 6 items related to
educational program on nursing students about their
students 'attitude toward families and 7 items related to
knowledge and attitude toward care of dying.
students' attitude toward relationship.

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 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,
Scoring system of the (FATCOD) scale:  Tool I of the study was developed by the researchers
Five points Likert scale to indicate respondents' attitudes after review of relevant literatures (21), while Tool II was
toward caring for dying patients. The instrument consists of adopted by the researchers.
an equal number of positive and negative worded statements  A pilot study was carried out on 30 students to test the
with response options of strongly disagree, disagree, feasibility and applicability of the developed tools;
uncertain, agree, and strongly agree. Positive items are accordingly, needed modification was done. The p ilot
scored one (strongly disagree) to five (strongly agree). study was excluded from the study sample.
Scores are reversed for negative items. Possible scores can  Socio-demographic sheet was administered for each
range fro m 30–150. A higher score ind icates a mo re positive student to fill the personal data as age, sex….etc.
attitude toward caring for dying patient and vice versa. The  A pre-knowledge test questionnaires was handed to all
levels of students' attitude classified as follow; students (n=393)to test their knowledge about palliative
1. Positive attitude ≥ 65% of the total score of Fro mmelt’s care.
attitude toward Care of the Dying (FATCOD) Scale.  Also, the students' attitudes toward care of dying patients
2. Fair attitude was 50% to less than 65% of the total score was assessed using Frommelt’s attitude scale, wh ich
of Fro mmelt’s attitude toward care of the dying utilized by the researchers to measure the students'
(FATCOD) scale. attitudes regarding care of dying patients.
3. Negative attitude was< 50% of the total score of  The students were divided into three groups by years;
Fro mmelt’s attitude toward care of the dying (FATCOD) each year's group divided into subgroups, the number of
Scale. the students in each subgroup was not more than twenty.
Method for data collection: The training program sessions were held three
times/week for 3 weeks to each year's group. Each
Content validity: session lasted about 45-60 minutes. The contents of
Both tools were handed to 5 experts fro m med ical surgical program sessions were as follow: defin ition of palliative
nursing departments at different Universities to assess its care and its supported services, goal for provid ing
clarity and based on their reco mmendations the necessary palliative care, difference between palliat ive care and
modifications were done. hospice care, importance of palliative care for patient
and relatives, types of settings producing this care and
Tools reliability: who receive and provides palliative care.
The reliability of the tool was 0.744 by using  The researchers utilized the fo llo wing instructional
Cronbach’s Alpha test. It was done by the researcher. med ia and materials as follow: power point presentation,
Procedure: video tape film, hand out for theoretical content (in
class).
 Prior to data collection an official permission was - To assess the impact of palliative care training program
obtained from the dean of nursing college at Tanta on nursing students' knowledge, the same knowledge test
University. This was intended to explain the purpose of questionnaires was handed to students immediately after
the study and to facilitate data collection. The implementation of the program and one month later
researchers explained study purpose and procedures to (follow up). As well as the researchers utilized the same
all participants. Fro mmelt’s attitude test to measure students' attitudes
 Privacy and confidentiality was maintained. regarding care of dying patients immediately after
implementation of the program and one month later.
RESULTS Data collection period consumed bout 2 months.
T able (1): Distribution of the studied students according to their sociodemo graphic data:

2 nd year 3 rd year 4 th ye ar
Sociodemographic characteristics (n=173) (n=110) (n=110)
N % N % N %
18-20 years 84 48.6 2 1.8 0 0
Age
20-22years 88 50.9 107 97.3 90 81.8
(years)
More than 22 years 1 0.6 1 0.9 20 18.2
Male 36 20.8 25 22.7 41 37.3
Sex
Female 137 79.2 85 77.3 69 62.7
No 122 70.5 80 72.7 69 62.7
Previous education on death and dying
Yes 51 29.5 30 27.3 41 37.3
No 149 86.1 93 84.5 77 70
Previous experience in caring of dying
Yes 24 13.9 17 15.5 33 30
No 118 68.2 78 70.9 69 62.7
Previous death experience
Yes 55 31.8 32 29.1 41 37.3
No 129 74.6 81 73.6 76 69.1
Current experience in the terminally ill
Yes 44 25.4 29 26.4 34 30.9

Table (1) illustrates the distribution of the studied students that regarding age more than half of the study (50.9% of the
according to their sociodemographic data. It was observed second year students,(97.3%) of the third years students, and

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 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,

(81.8%) of the fourth year students were aged fro m 20- students(86.1%,84.5% respectively) had no prev ious
22years. Regard ing sex nearly two thirds (62.7%) of the experience in caring of dying. In relation to previous death
fourth year students, more than three quarters of the second experience nearly two thirds (62.7%) of fourth years
and third year students (79.2%, 77.3% respectively) were students, more than two thirds of the second year students
females. In relation to previous education on death and and third year students (68.2%%,70.9% respectively) had no
dying nearly two thirds (62.7%) of the fourth years students, previous death experience. In relation to current experience
nearly three quarters of the second and third year students in the terminally ill mo re than two thirds (69.1%) of the
(70.5%,72.7% respectively) had no previous education on fourth years students, nearly three quarters of the second
death and dying. Regarding previous experience in caring of year students and third years students(74.6,73.6%
dying mo re than two thirds (70%) o f fourth years students, respectively) had no current experience in the terminally ill.
majority of the second and third years
T able (2): Mean scores of students’ Frommelt’s attitude toward care of the dying scale for 2 nd year undergraduate students (n=173).

Mean ± SD
Items Range F P
Pre Post Follow up
1. Students' attitude toward care of dying. 28.38±3.402 28.08±4.194 27.83±3.214 0.993 0.371
35-18 35-11 35-23
2. Students' attitude toward death 27.79±3.752 27.60±4.455 30.06±3.795 20.101
47-20 42-14 37-22 0.000*
3. Students' attitude toward families 16.88±2.312 16.80±2.337 16.12±3.679 3.805
23-12 22-6 22-6 0.023*
4. Students' attitude toward relationship 4.88±1.979 4.76±2.076 5.40±2.154 4.687
10-2 10-2 10-2 0.010*
5. Students' attitude toward patients' rights 15.12±2.207 15.16±2.474 14.77±2.847 1.193 0.304
21-5 24-9 19-9
Significant at level P< 0.05

Table (2) shows the mean scores of students’ Fro mmelt's of the2nd year undergraduate students mean score regard ing
attitude toward care of the dy ing scale fo r 2nd year students 'attitude toward death, families and relat ionship
undergraduate students (n=173). It was observed that there P=0.000,0.023,0.010 respectively.
was a significant difference between pre, post, and follow up
T able (3): Mean scores of students’ Frommelt's Attitude toward Care of the Dying Scale for 3 rd year undergraduate students (n=110).

Mean ± SD
Items Range F P
Pre Post Follow up
1. Students 'attitude toward care ofdying. 27.67±3.589 28.78±3.439 27.04±3.234 7.323
35-15 35-18 35-18 0.001*
2. Students' attitude toward death 27.66±4.263 28.00±3.798 29.05±3.199 4.058
44-19 37-16 35-23 0.018*
3. Students' attitude toward families 16.30±2.402 15.92±2.401 15.38±2.209 4.277
22-10 26-11 20-12 0.015*
4. Students' attitude toward relationship 4.91±2.466 4.44±2.253 4.73±2.158 1.186 0.307
10-2 10-2 10-2
5. Students' attitude toward patients' rights 15.43±2.252 15.53±2.478 16.23±2.437 3.655
21-7 22-9 21-12 0.027*

Significant at level P< 0.05

Table (3) shows the mean scores of students’ Fro mmelt’s the 3nd year undergraduate students mean score regarding
attitude toward care of the dying scale for 3rd year students 'attitude toward care of dying , death, families and
undergraduate students. It was observed that there was a patients' rights P=.0.001,0.018, 0.015, 0.027 respectively.
significant difference between pre, post, and follow up of
T able (4): Mean scores of students’ Frommelt's Attitude T oward Care of the Dying Scale for 4 th year undergraduate students (n=110).

Mean ± SD
Items Range F P
Pre Post Follow up
1. Students 'attitude toward care ofdying. 27.15±3.151 27.18±2.956 26.30±3.372 2.763 0.065
35-19 35-18 35-20
2. Students 'attitude toward death 28.80±3.935 28.39±3.942 28.48±3.654 0.343 0.710
39-18 39-18 39-17
3. Students 'attitude toward families 16.45±2.688 16.16±2.621 15.65±2.186 2.867 0.058
23-9 22-8 23-12
4. Students 'attitude toward relationship 4.36±1.952 4.42±2.052 4.15±1.900 0.591 0.554
10-2 10-2 10-2
5. Students 'attitude toward patients' rights 15.79±2.176 15.49±2.097 15.69±2.196 0.552 0.576
21-10 21-9 23-11

Significant at level P< 0.05

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 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,

Table (4) shows the mean scores of students’ Fro mmelt’s the 4nd year undergraduate students mean score regarding
attitude toward care of the dying scale for 4th year students 'attitude toward care of dying, death, families,
undergraduate students. It was observed that there was no relationship and patients' rights.
significant difference between pre, post, and follow up of
T able (5): Comparison between the studied students according to pre, post and follow up total From melt's attitude throughout period of study.

2 nd year 3 rd year 4 th year Total

Total Frommelt P
(n=173) (n=110) (n=110) (n=393) χ2
Attitude
N % N % N % N %
Negative 56 32.4 44 40 37 33.6 137 34.9
Pre Fair 111 64.2 60 54.5 71 64.5 242 61.6 4.466 0.347
Positive 6 3.5 6 5.5 2 1.8 14 3.6
Negative 61 35.3 32 29.1 39 35.5 132 33.6
Post Fair 106 61.3 73 66.4 68 61.8 247 61.6 1.742 0.783
Positive 6 3.5 5 4.5 3 2.7 14 3.6
Negative 39 22.5 43 39.1 54 49.1 136 34.6
Follow
Fair 134 77.5 63 57.3 54 49.1 251 63.9 30.004 0.00*
Up
Positive 0 0 4 3.6 2 1.8 6 1.5

Significant at level P< 0.05

Table (5) explains co mparison between the studied students attitude score (negative, fair and positive) among second,
according to pre, post and follow up total Fro mmelt's third and fourth undergraduate students during the pre and
attitude throughout period of study. It was observed that post observations, while the significant difference was
there was no significant difference between total Frommelt’s present only during follow up observational period p=0.00.
T able (6): Comparison between the studied students according to pre, post and follow up total knowledge score throughout peri od of study.

2 nd year 3 rd year 4 th year Total

Total knowledge (n=393)
(n=173) (n=110) (n=110) χ2 P
Scores
N % N % N % N %
Poor 100 57.8 72 65.5 60 54.5 232 59.1 16.778 0.002*
Pre average 33 19.1 18 16.4 36 32.8 87 22.1
Good 40 23.1 20 18.2 14 12.7 74 18.8
Poor 37 21.4 29 26.4 40 36.4 106 26.9
Post average 85 49.1 41 37.3 42 38.2 168 42.7 24.575 0.00*
Good 51 29.5 40 36.4 28 25.5 119 30.2
Poor 42 24.27 41 37.3 53 48.2 136 36.6 16.708 0.002*
Follow average 87 50.28 39 35.5 40 36.4 166 42.2
Up
Good 44 25.43 30 27.2 17 15.4 91 23.1
Significant at level P< 0.05

Table (6) illustrates comparison between the studied (poor, average and good) among second, third and fourth
students according to pre, post and follows up total undergraduate students during the pre, post and follow up
knowledge score throughout the period of study. There was observational periods.
a significant difference between total knowledge score
T able (7): Correlation between total's attitude and socio -demographic data throughout period of study:

Sociodemographic data 2 nd year 3 rd year 4 th year

(n=173) (n=110) (n=110)
pre post Follow Pre Post Follow Pre post Follow
Up Up Up
Age R 0.091 -0.054 -0.112 -0.095 0.006 -0.037 0.091 0.032 -0.157
P 0.234 0.482 0.141 0.323 0.947 0.698 0.342 0.740 0.102
Pre vious education on R 0.087 0.031 -0.032 0.124 -0.072 -0.040 -0.067 -0.041 -0.074
de ath and dying P 0.255 0.686 0.671 0.198 0.455 0.681 0.485 0.671 0.445
Pre vious experience in R 0.108 -0.013 0.168 * 0.201 * -0.079 0.081 0.007 -0.027 -0.073
caring of dying P 0.159 0.861 0.027* 0.036* 0.414 0.402 0.946 0.780 0.449
Pre vious death R 0.110 0.024 0.075 0.107 0.009 0.065 0.092 -0.042 0.084
e xpe rience P 0.149 0.753 0.325 0.267 0.927 0.499 0.338 0.667 0.385
Current e xperience in R 0.168 * -0.084 0.117 0.124 -0.106 -0.004 -0.114 -0.030 -0.005
the terminally ill P 0.027* 0.269 0.127 0.198 0.272 0.968 0.236 0.757 0.962

Significant at level P< 0.05

Table (7) shows that correlation between total Fro mmelt's study. It was observed that there was significant positive
attitude and socio-demographic data throughout period correlation between total Frommelt's attitude and previous
of

26
 O m Ebrahim Ali Elmelegy et al, International
nd Journal of Nursing Didactics, 6 (12) December,
ex p eri en c e in c ari ng of dyin g duri ng f ollo w u p o f the 2 ye ar positive correlation between current experience in the
students and pre intervention period of the 3rd year students terminally ill and total fro mmelt 's attitude in and pre
P = (0.027,0.036 respectively.) Also there was significant intervention period of the 2rd year students.
T able (8):Correlation between total knowledge score and sociodemographic data throughout period of study:

Sociodemographic data 2 nd year 3 rd year 4 th year

(n=173) (n=110) (n=110)
pre Post Follow Pre post Follow Pre Post Follow
up Up up
Age R 0.224** -0.083 0.018 0.176 0.030 0.102 0.252** 0.227* -0.097
P 0.003* 0.276 0.813 0.066 0.759 0.288 0.008* 0.017* 0.312
Pre vious education on R 0.178* -0.056 -0.035 0.184 0.009 0.065 0.112 0.215* 0.039
de ath and dying P 0.019* 0.461 0.643 0.054 0.923 0.499 0.244 0.024* 0.689
Pre vious experience in R 0.226** -0.075 0.012 0.060 0.112 0.167 0.221* 0.233* -0.134
caring of dying P 0.003* 0.329 0.878 0.536 0.242 0.081 0.020* 0.014* 0.162
Pre vious death R 0.154* -0.065 -0.027 0.222* -0.016 0.038 0.073 0.015 0.034
e xpe rience P 0.044* 0.394 0.720 0.020* 0.870 0.692 0.450 0.880 0.728
Current e xperience in R 0.204** 0.081 -0.012 0.175 0.046 0.134 0.047 0.037 -0.083
the terminally ill P 0.007* 0.290 0.874 0.067 0.636 0.162 0.624 0.699 0.387
Significant at level P< 0.05

Table (8 ) shows the correlation between total knowledge knowledge score and previous death experience in the pre
score and sociodemographic data throughout the period of intervention. In relation to 4th year students that there was
study. It was observed that there was significant positive significant positive correlation between total knowledge
correlation between total knowledge score and age, p revious score and age, and previous experience in caring of dying
education on death and dying, previous experience in caring death and dying in the pre and post intervention of the 4th
of dying, prev ious death experience and current experience year students. Previous education on death and dying in the
in the terminally ill in the pre intervention of the 2rd year same group there was significant positive correlation
students. Among the third years undergraduate students between total knowledge score and previous education on
there was significant positive correlation between total death and dying post intervention of the 4th year
students.
T able (9): Relationship between total knowledge score and total From melt's attitude among 2 nd year students.

Total Frommelt’s Total knowledge score Total χ2

Attitude Poor Average Good P
N % N % N % N %
Pre Negative 25 14.5 30 17.3 1 0.6 56 32.4 4.367
Fair 43 24.9 61 35.3 7 4.05 111 64.2 0.359
Positive 1 0.6 4 2.3 1 0.6 6 3.5
T otal 69 39.9 95 54.9 9 5.2 173 100
post Negative 12 6.9 30 17.3 19 11 61 35.3 3.512
Fair 25 14.5 50 28.9 31 17.9 106 61.3 0.476
Positive 0 0 5 2.9 1 0.6 6 3.5
T otal 37 21.4 85 49.1 51 29.5 173 100
Follow Negative 19 17.3 13 11.8 7 6.4 39 22.5 6.668
up Fair 81 73.6 20 18.2 33 30 134 77.5 0.036*
T otal 100 90.9 33 30 40 36.4 173 100
Significant at level P< 0.05

Table (9) shows the relationship between total knowledge attitude among 2nd year students during the follow up
score and total Fro mmelt’s attitude among 2nd year students. observation, while the difference was not significant during
It was observed that there was significant difference pre and post observations periods.
between total knowledge and total Frommelt’s
T able (10): Relationship between total knowledge score and total Frommelt’s attitude among 3 rd year students.

Total Frommelt’s Total knowledge score Total χ2

Attitude Poor Average Good P
N % N % N % N %
Pre Negative 22 20 17 15.5 5 4.5 44 40 0.604
Fair 29 26.4 24 21.8 7 6.4 60 54.5 0.963
Positive 2 1.8 3 2.7 1 0.9 6 5.5
Total 53 48.2 44 40 13 11.8 110 100
Post Negative 7 6.4 15 13.6 10 9.1 32 29.1 4.143
Fair 22 20 24 21.8 27 24.5 73 66.4 0.387
Positive 0 0 2 1.8 3 2.7 5 4.5
T otal 29 26.4 41 37.3 40 36.4 110 100
Follow Negative 22 20 9 8.2 12 10.9 43 39.1 29.007
Up Fair 50 45.5 9 8.2 4 3.6 63 57.3 0.000*
Positive 0 0 0 0 4 3.6 4 3.6
T otal 72 65.5 18 16.4 20 18.2 110 100

Significant at level P< 0.05

27
 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,

Table (10) illustrates the relationship between total Fro mmelt’s attitude among 3rd year students during the
knowledge score and total Fro mmelt’s attitude among 3rd follow up observation, while the difference was not
year students. It was observed that there was significant significant during pre and post observations.
difference between total knowledge and total
T able (11): Relationship between total knowledge score and total Frommelt’s attitude among 4 th year students.

Total Frommelt’s Total knowledge score Total χ2

Attitude Poor Average Good P
N % N % N % N %
Pre Negative 24 21.8 8 7.3 5 4.5 37 33.6 17.477
Fair 36 32.7 28 25.5 7 6.4 71 64.5 0.002*
Positive 0 0 0 0 2 1.8 2 1.8
Total 60 54.5 36 32.7 14 12.7 110 100
Post Negative 20 18.2 12 10.9 7 6.4 39 35.5 4.357
Fair 30 27.3 19 17.3 19 17.3 68 61.8 0.360
Positive 1 0.9 0 0 2 1.8 3 2.7
Total 51 46.4 31 28.2 28 25.5 110 100
Follow Negative 29 26.4 16 14.5 9 8.2 54 49.1 5.022
Up Fair 24 21.8 22 20 8 7.3 54 49.1 0.285
Positive 0 0 2 1.8 0 0 2 1.8
Total 53 48.2 40 17.3 17 15.5 110 100
Significant at level P< 0.05

Table (11): illustrates the relationship between total students (79.2%,77.3% respectively) were females, this
knowledge score and total Fro m melt’s attitude among 4th results may be present due to the faculty of nursing was
year students. It was observed that there was significant accepted female students only in the past. Recently it
difference between total knowledge and total Fro mmelt’s permits of male students enrolled in it.
attitude among 4th year students during the pre management
observation, while the difference was not significant during In relation to previous education on death and dying nearly
post follow up observations. two thirds (62.7%) of the fourth year students, nearly three
quarters of the second year students and third year students
Statistical analysis:
(70.5%, 72.7% respectively) had no previous education on
The analysis was performed using statistical software SPSS death and dying. Regarding previous experience in caring of
version 18.For quantitative data, the range, mean and dying more than two thirds (70%) of the fourth year
standard deviation were calculated. For qualitative data, a students, majority of the second year students and third
comparison between one group before and after intervention years students( 86.1%, 84.5% respectively) had no previous
was done by using Chi-square test (χ 2 ). For a co mparison experience in caring of dying. In relation to previous death
between more than two means, the F-value of ANOVA was experience nearly t wo thirds (62.7%) of the fourth years
calculated. Significance was adopted at P<0.05 for students, more than two thirds of the second year students
interpretation of results of tests of significance. Correlat ion and third years students (68.2%%,70.9% respectively) had
was done by using Spearman correlation test. no previous death experience. In relat ion to current
experience in the terminally ill more than two thirds (69.1%)
DISCUSSION of the fourth years students, nearly three quarters of the
Nurses play a central role in palliative and end-of-life care. second year students and third years students (74.6,73.6%
respectively) had no current experience in the terminally ill.
Nursing roles include developing plans of care, providing
These results necessitate the need for educational
leadership for staff, and guidance and support for patients
interventions these results agree also with Jafari et., al.,
and families. Ho wever, researchers have found that not all
(2015)(22), who emphasize on the importance of education
nurses feel co mfortable, or are knowledgeable about the care
about end-of-life care. The study suggests that educational
needed for a dying patient (21). One of the important factors
programs about death and caring for dying patients should
influencing a successful delivery of palliat ive healthcare is
be added to undergraduate nursing curricula.
the health care professionals’ knowledge, attitudes, beliefs,
and experiences, which determine not only their procedure
The difference was significant between pre, post, and follow
but also their behavior during evaluation and treatment of
up of the 2nd year undergraduate students mean score
patients (22). So this study is aimed to evaluate effect of
regarding students' attitude toward death, students 'attitude
educational program on nursing students to imp rove their
toward families and students' attitude toward relationship.
knowledge and attitude toward palliative care.
Also, the mean scores of students’ Fro mmelt’s Attitude
toward care of the Dying Scale for 3rd year undergraduate
Regarding age more than half of the study (50.9% of the
students. It was observed that there is a significant
second year students, (97.3%) of the third years students, difference between pre, post, and follow up of the 3nd year
and (81.8%) o f the fourth years students were aged 20-22 undergraduate students mean score regarding students
years. This is because the most common age for join to 'attitude toward care of dying, students 'attitude toward
university in Egypt is fro m 19-20 years. In relation to sex death, students 'attitude toward families, and students
nearly two th irds (62.7%) of the fourth year students, mo re 'attitude toward patients' rights. This result agree with
than three quarters of the second year students and third year Jafari et al.,(2015)(22), who found that students showed
moderately
28
 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,

negative to neutral attitudes toward caring for dying Also there was significant positive correlat ion between
patients. Education has improved students’ attitude current experience in the terminally ill and total Fro mmelt’s
significantly (mean score of FATCOD before study were 3.5 attitude in pre intervention of the 2rd year students. This
± 0.43 and after intervention were 4.7 ± 0.33) (P< 0.001).In result was in the consistency of the study done by Grubb
another study carried out by Cevik and Kav (2013)(23). and Arthur, (2016)(27), who stated that the attitude scores
About The attitudes of Turkish nurses toward death and were h igher for students reporting having experience of
caring for dying patients are less positive than the reported preparing the body of a patient who had died and fo r thos e
attitudes of nurses in other studies. Although the majority of who had experienced caring fo r a dying patient or cared for
nurses stated that they had received education on end of life, a dying relative or friend. In the present study, there was
most of them were not comfortable talking about death. significant positive correlation between total knowledge
score and age, previous education on death and dying,
The mean scores of students’ Fro mmelt’s Attitude toward previous experience in caring of dying, previous death
care of the dying scale for 4th year undergraduate students. It experience and current experience in the terminally ill in the
was observed that there was no significant difference pre intervention of the 2rd year students. This might be due
between pre, post and follow up of the4th year undergraduate to their curriculu m contained some items related to
students mean score regarding students 'attitude toward care palliative care and their contacts with patient during the
of dying, students 'attitude toward death, students 'attitude clinical practice. This finding contradicts with Grant et al.
toward families, students 'attitude toward relat ionship and ,(2011)(28), who reported the negative association of age,
students 'attitude toward patients' rights. This result may be gender, work experience, experience of caring terminally ill
due to the long period of experience in practical settings patients, and duration of training with nurses’ knowledge
compared to the second and third year's undergraduate might be due to palliat ive care is a novice discip line in
students. This result disagree with Henoch et al., (2014)(24), Ethiopia.
who found that earlier years of experience doesn't influence
the attitude toward care of dying patients. Among the third years undergraduate students there was
significant positive correlation between total knowledge
There was significant difference between poor, average and score and previous death experience in the pre intervention.
good knowledge among the second, third and fourth In relat ion to 4th year student that there was significant
undergraduate students during there, post and follow up positive correlation between total knowledge score and age,
observations. While there was no significant difference and previous experience in caring of dying, death and dying
between negative, positive and fair attitude among the in the pre and post intervention of the 4th year student group.
second, third and fourth undergraduate students during the Previous education on death and dying in the same group
pre and post observations while the significant difference there was significant positive correlat ion between total
was present only during follo w up observations. So the knowledge score and prev ious education on death and dying
difference is present clearly in knowledge comparing with post intervention of the 4th year student group. This in the
the attitude this may be due to easy change in student line with Ayed et al.,(2015)(29),who found that there was a
knowledge co mparing with attitude this result agree with positive relationship between experience, qualification and
Muttoet al., (2010)(25), who stated that changing in attitude training on palliative care and knowledge of nurses (p=
need long time and repeated stimulus without reinforcement. 0.004, 0.020, and 0.015) respectively. It means when the
nurses' experience and qualificat ion increase or if the nurses
The current study showed that there was no significant had training course on palliative care their favorable
correlation between total Fro mmelt’s attitude with age and knowledge also improves.
previous education on death and dying. This finding was in
agreement with the findings of Ali and Ayoub, (2010)(26), The attitude becomes more positive as a result of increasing
who found that there is no statistically significant of the knowledge of the palliative care after attending the
relationship between nurse's age (P=0.240), and total scores intervention program. In measuring the effect iveness of the
of FATCOD scale attitude measuring tools. The experience program, many continuing educational programs use a
appears to be an important key. These were some factors comparison of the participants' pre-test and post-test scores
that were significantly associated with 2nd year nursing as an indicator for program effect iveness. The present study
students’ attitude in this study might be due to the fact that has shown that the intervention program of the students
in Egypt, the trainings are g iven most of the t ime for staff in could imp rove their total attitude scores by increasing the
governmental hospitals and the nursing students working in knowledge. The current study showed that there was
the med ical ward had rather than outpatient department significant difference between total knowledge and total
because the chronic illnesses patients are mostly admitted to Fro mmelt’s attitude among 2nd year and 3rd year students
the med ical ward and, thus, nurses who worked in the during the follow up observation while the difference was
med ical ward had daily contact with those patients, and may not significant during pre and post observations. This is
have developed positive attitude towards PC. accordance with by Budkaew and Chumworathayi
(2013)(30), demonstrated that there was positive correlat ion
The current study reveals that, there was significant positive between level of knowledge and attitudes toward palliat ive
correlation between total Fro mmelt’s attitude and previous terminal cancer care. Attitude scores were statistically
experience in caring of dying during fo llo w up o f the 2nd correlated to knowledge scores (p=0.036). It means when
year students and pre intervention of the 3rd year students. the nurses knowledge improve their favorable attitude also
improves.

29
 O m Ebrahim Ali Elmelegy et al, International Journal of Nursing Didactics, 6 (12) December,

On pre intervention, the result of our study revealed that [8]. Joseph A, Vicki A, Jackson C, Diane E, M eier M , Jennifer S.
there was significant d ifference between total knowledge Early integration of palliative care services with standard
and total Fro mmelt’s attitude among 4th year students in oncology care for patients with advanced cancer. Cancer
relation to post and follow up observations (p = 0.002). This journal for clinicians,2013;63(5):349-363.
result may be return to that the 4th year students passed the
[9]. Becker R. Palliative care 1: principles of palliative care
most courses which included in their curricu lu ms as this is
nursing and end-of-life care. Nursing Times, 2009; 105: 13.
the last year in their study. This finding was resemble to
study in Taiwan by Shih et al., (2010) (31), who showed that [10]. Kuebler K. Implications for palliative care nursing
junior doctors were strongly encouraged to have correct education. Clinical Scholars Review, 2012; 5(2):86-90.
principles of palliative care and develop positive attitudes [11]. Costello J. Nursing the Dying Patient: Caring in Different
toward palliative terminal care by educating in medical Contexts. Palgrave M acmillan, Basingstoke,2004.
program.
[12]. Ahmedzai S, Costa A, Blengini C, Bosch A, Sanz-Ortiz J,
CONCLUSION Ventafridd V, & Verhagen S. New international framework
for palliative care. European Journal of Cancer, 2004;
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nursing students' knowledge and attitudes toward care of the [13]. Aleksandra K, Łukasz P, Bogna K, M ałgorzata
dying patients, the current study revealed that the majority S, and Wojciech M . The Impact of Pediatric Palliative Care
of second and third year students had no previous Education on M edical Students’ Knowledge and Attitudes.
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Training Program on Knowledge, Attitudes, Beliefs and
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Quasi-experimental Study. Indian J Palliat Care. 2011;17
Based on findings of this study, the researchers (1): 47–53.
recommended that;
[15]. Sadhu S, Salins S, Kamath A. Palliative Care Awareness
1. Palliat ive care must be an integral part of the nursing
among Indian Undergraduate Health Care Students: A needs-
curriculu m and encourage students strongly to have a
assessment study to determine incorporation of palliative
correct principle of care of dying patients to develop
care education in undergraduate medical, nursing and allied
positive attitudes toward palliative terminal care.
2. Educational program to nursing students for improving health education, Indian Journal of Palliative Care,2010;
their knowledge and attitudes toward palliative care. 16(3): 154-159.
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