Evaluating ICU nurses’ education, practice, and competence in palliative and end-of-life care in Saudi Arabia: A cross-sectional study

Background

Improving the quality of care for patients with life-threatening illnesses and reducing stress for family members is essential to healthcare delivery. Palliative care is the approach employed to meet these objectives. According to the World Health Organization (2020), this care approach is focused on promptly identifying the spiritual, psychological, and physical challenges the patients face so that these can be managed effectively. On the other hand, end-of-life care targets patients who are in their terminal stage and have ceased to receive curative treatment. The highlight of such care is dealing with the wide-ranging needs of the patients and their families. The National Cancer Institute (n.d.) advises that several services play a crucial role in the terminal stages of patient care, including hospice care, supportive care, and palliative care. Despite an increasing need, there remains a significant gap in the availability of these services. According to the World Health Organization (2020), only around 14% of individuals needing palliative care have access to it, implying that approximately 56.8 million people each year lack access to essential palliative and end-of-life (PEOL) care services.

In Saudi Arabia, PEOL care was not part of the services made available by interdisciplinary specialties in the past (Alshammari et al., 2023). This has changed over the years, as PEOL care is becoming recognized as a priority in the Saudi Arabian healthcare sector, as illustrated by the Saudi Vision 2030 (Saudi Vision, 2022). For instance, the country now has more than 15 cancer centers with a specific emphasis on palliative care units, indicating the country’s growing recognition of PEOL care (Al-Jabarti et al., 2021). This recognition can be attributed to the escalation in the prevalence of severe life-threatening illness among patients.

In the context of intensive care units (ICUs), it is noted that PEOL is now an important factor, irrespective of whether the objective is curative treatment or a peaceful transition to the end of life (Athari et al., 2016). ICUs are not regarded as optimal environments for patients approaching the end of life (Angus & Truog, 2016). Nevertheless, PEOL care inescapably becomes part of the day-to-day practices within ICUs (Velarde-García et al., 2016). Research has revealed the significant advantages linked with incorporating PEOL care in ICUs. Firstly, it has been demonstrated that palliative care has the capacity to mitigate ICU admissions, which promotes a wide-ranging approach to the well-being of patients (Gade et al., 2008; Penrod et al., 2010). Additionally, implementing protocols associated with palliative care has shown a palpable reduction in the duration of ICU stays (Norton et al., 2007; Penrod et al., 2010). This makes it possible to move patients to more appropriate care settings when necessary. A relationship-between palliative care and a reduction in ICU mortality has been observed (Martins et al., 2017), highlighting the potential of palliative care to boost patient outcomes. Finally, when palliative care is integrated into ICUs, it has been shown to result in improvements in the quality and substance of family meetings, a situation that nurtures effective communication, shared decision making, and improvements in the general provision of care for patients and their families (Glajchen et al., 2022).

In the area of PEOL care, the implementation of care relies on the distinctive skills of nurses (Hagan et al., 2018; Schroeder & Lorenz, 2018). Nurses have numerous crucial roles, including educator, advocator, collaborator, care provider, and supporter, both for patients and their families (Eltaybani et al., 2021a; Eltaybani et al., 2021c). In their education role, nurses ensure that patients and their families are equipped with the required knowledge regarding PEOL care so that they can make informed decisions and take an active part in their care process. Nurses’ advocacy is illustrated when they champion the preferences and rights of patients, making sure that their voices are heard and taken into consideration (Hagan et al., 2018). Regarding collaboration, nurses participate in interdisciplinary teams to develop comprehensive care plans addressing patients’ and their families’ psychosocial, emotional, and physical needs (Sekse et al., 2018). When they assume the caring role, nurses ensure the delivery of evidence-based and compassionate interventions focusing on managing symptoms, ensuring comfort, and promoting general well-being (Hagan et al., 2018). Finally, nurses provide support to patients when they provide guidance and emotional solace to patients and their families as they navigate the complexities of PEOL care. Therefore, it can be concluded that nurses’ multifaceted expertise and roles make them vital contributors to implementing and facilitating PEOL care.

The provision of PEOL care by nurses is a widespread practice, regardless of the specific healthcare setting (Paice et al., 2018). Nonetheless, an analysis of the literature shows a dearth of research examining the factors associated with the performance of nurses and their perceived proficiency levels when providing PEOL care, particularly within an ICU setting (Eltaybani et al., 2021a). On the other hand, there is extensive research related to nurses' attitudes and knowledge regarding PEOL in Saudi Arabia and globally. An analysis of existing findings brings to the fore some worrying findings about the insufficient education and knowledge among nurses regarding PEOL care (Aboshaiqah, 2019; Alshaikh et al., 2015; Davis & Lippe, 2017; Eltaybani et al., 2021b; Etafa et al., 2020; Hussin et al., 2018; Muliira et al., 2023; Sesma-Mendaza et al., 2022; Wang et al., 2022). It has been noted that nursing schools fail to ensure that student nurses are sufficiently prepared to deliver care for patients nearing the end of life. This view is acknowledged by Qureshi et al. (2022), who noted that many nursing schools do not deliver elective or dedicated courses solely focusing on PEOL care. Instead, PEOL is incorporated into care-related subjects in different classes. This education deficiency has been noted as an important factor behind the subpar care received by patients (Gillan et al., 2014). Hence, there has been an urgent call to incorporate PEOL care education within nursing curricula and to sustain this training through clinical in-service programs (Ferrell et al., 2016; Li et al., 2019).

The attitudes of nurses and nursing students towards PEOL care have been investigated by several studies, the majority of which indicated favorable attitudes among nurses and nursing students (Alenezi et al., 2022; Alshammari et al., 2023; Wang et al., 2022; Zeru et al., 2020). These positive attitudes are encouraging, as they contribute to compassionate and patient-centered care. Nonetheless, it can be noted that some findings do not align with this trend. For instance, Hussin et al. (2018) and Etafa et al. (2020) presented findings indicating unfavorable views on PEOL care among their nurse participants. This contrast could be read as proof of the presence of disparities in particular settings, which brings to the fore the need to understand and address the underlying challenges.

Previous studies have evaluated a broad range of factors influencing PEOL care practice among nurses, including perceived advantages and obstacles, subjective norms, religious beliefs, intention, self-efficacy, skills, knowledge, qualifications, attitudes, experience, education, culture, and age (Alshammari et al., 2023; Jeong et al., 2020; Soikkeli Jalonen et al., 2020; Xu et al., 2023). From their studies, Alshammari et al. (2023) and Carvajal et al. (2019) concluded that nurses constantly emphasized the role of support from more experienced colleagues and collaboration with patients’ families in delivering impactful PEOL care. Nonetheless, together with these enablers, some hindrances to effective PEOL care have been noted. For instance, one of the worrying trends is the dearth of knowledge, coupled with negative attitudes among nursing staff. Such factors present considerable impediments to the achievement of the gold standard in caring for patients during the end-of-life stage (Alshammari et al., 2022; Carvajal et al., 2019; Griffiths, 2019; Hussin et al., 2018; Mani & Ibrahim, 2017; Meilando et al., 2022). Another impediment noted by numerous studies is the challenge associated with nurses managing their own emotions and meeting the emotional demands linked to the provision of PEOL care (Carvajal et al., 2019; Griffiths, 2019; Hafez et al., 2022; Jung & Matthews, 2021). From this observation, the need to adopt self-care and support strategies for healthcare workers in PEOL settings comes to the fore.

Effective communication is at the heart of quality PEOL care. It becomes essential when broaching sensitive topics like death and end-of-life considerations (Alenezi et al., 2022; Carvajal et al., 2019). Notwithstanding its importance, communication in such settings is usually mired by challenges, including cultural differences, language barriers, and varying beliefs about handling discussions associated with death. In countries such as Saudi Arabia, this challenge can be more acute for expatriate nurses, with significant language and culture challenges (Alenezi et al., 2022; Mani & Ibrahim, 2017; Oakley et al., 2019). Family members take an active role in decision-making within the ICU environment, usually accommodating unconscious patients (Meilando et al., 2022). Yet, navigating this realm is not without its complexities. Nurses frequently encounter challenges in facilitating and managing family participation in these crucial decisions (Alshammari et al., 2023; Alshehri et al., 2022; Griffiths, 2019; Jung & Matthews, 2021; Meilando et al., 2022).

There is a general dearth of studies with a primary focus on PEOL care, particularly from a nursing perspective. Consequently, there is a lack of comprehensive understanding regarding the training and education made available to ICU nurses in the area of PEOL care and the degree to which they are involved in the delivery of services associated with PEOL care. This study is at the forefront of addressing this gap by evaluating the perceived competence, practice, and education of ICU nurses in Saudi Arabia in the area of PEOL care. This study will inform the development of tailored strategies and interventions to enhance the quality and efficacy of PEOL care within the Saudi healthcare framework. In the present study’s context, the aim is to bring to the fore the prevailing status of PEOL care education, perceived competence, and practice among adult ICU nurses in Hail, Saudi Arabia, while also exploring the factors linked to PEOL care practice and perceived competence.

Methods

Results

In the selected hospitals, 12 nurse managers and 142 ICU staff nurses participated in the survey. All ICUs had a strict one-hour visitation policy, with each visitor limited to five minutes and required to wear full PPE. Each ICU also featured a room where families and patients could meet and follow standard institutional guidelines for end-of-life care. The patient-to-nurse ratio was between 1.2 and 1.3. A significant proportion of patients could not communicate, ranging from 60% to 80%, and patients’ stays varied from a day to a month.

The majority of nurse managers were females, with only two males; most held a bachelor’s degree and were aged between 25 and 35. Out of a population of 171 ICU nurses, 142 took part in the survey. This robust participation translates to a response rate of 83.04%. Of these, 89.4% (n = 127) were female, and 10.6% (n = 15) were male. The majority (81%) had prior experience in caring for dying patients, while only 30.3% (n = 43) received in-service training on PEOL care (Table 2).

Overall, the mean education score was 69.67 (SD = 15.81). Clinical practice and perceived competence mean scores were similar at 71.01 (SD = 15.99) and 71.61 (SD = 16.08), respectively (Table 3). Job satisfaction demonstrated a weak correlation with education, clinical practice, and perceived competence (p <0.05). Participants who had attended in-service training on PEOL care had significantly higher education, clinical practice, and perceived competence than those who did not (p <0.05) (Table 2). Cronbach’s alpha was calculated for each of the study’s eight domains. The mean score was 0.962, ranging from 0.962 to 0.973, indicating a high level of internal reliability.

Adjusted R-squared values indicate that PEOL care in-service training, increased job satisfaction, and having the authority to communicate to dying patients and their families explain 21.6% of the variation in clinical practice and 16.9% in perceived competence for PEOL care (Table 4).

Discussion

The main findings reveal that participants averaged scores of approximately 71 in perceived competence, clinical practice, and education, indicating proficiency in these areas. While those participating in PEOL care in-service training surpassed their untrained peers, only 30.3% had undergone this specialized training. Multiple regressions highlighted a positive relationship between clinical practice scores, perceived competence, and factors such as in-service training, enhanced job satisfaction, and the authority to converse with dying patients and their kin.

The study’s primary discovery is that participants achieved an average score of around 71 in areas like education, clinical practice, and perceived competence. This score suggests proficiency in these domains. Yet, when contrasted with the findings of Eltaybani et al. (2021c), which revealed a marked insufficiency in palliative care perceived competence, practice, and education among Egyptian ICU nurses, the disparities become evident. The inadequacy might be influenced by limited access to palliative care training or potential institutional hurdles.

Observing that those who attended PEOL care in-service training outperformed their peers without this specialized instruction aligns with the fundamental pedagogical understanding that specialized training often leads to more refined skills and better performance outcomes (Salas et al., 2012). Such training not only bolsters the quality of patient care but also significantly elevates the confidence levels of professionals, allowing them to function at their best capacity. However, a concerning conclusion was that only 30% had adequately attended training. This low number can negatively affect patient outcomes while increasing the emotional burden on healthcare professionals due to a perceived lack of competence (Institute of Medicine Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, 2011). The gap in education, particularly in the realm of PEOL care, has been a recurrent theme in many studies, indicating a systemic issue that transcends individual institutions (Davis & Lippe, 2017; Eltaybani et al., 2021b; Etafa et al., 2020; Hussin et al., 2018; Muliira et al., 2023; Wang et al., 2022). Addressing this educational gap should be prioritized, and the focus should be on amalgamating PEOL care modules in the foundation of nursing education and continuous professional development programs (Ferrell et al., 2016; Li et al., 2019).

Multiple regression analyses showed a positive correlation between perceived confidence, clinical practice scores, and numerous factors. Foremost, professional competence benefited immensely from in-service training. This brings to the fore the reality that PEOL care education is important both at university and during in-service training (Eltaybani et al., 2021c). Furthermore, enhanced job satisfaction was identified as a critical driver. Satisfaction among healthcare employees results in a natural escalation in competence and confidence levels, leading to improved patient care and better patient satisfaction (Lu et al., 2012). Another salient factor was the authority granted to nurses to communicate with patients nearing the end of their lives and their families. Studies on this subject are limited, yet existing research indicates that nurses were not part of the decision-making to implement the PEOL approach for ICU patients (Hamdan Alshehri et al., 2020). In settings where stress levels are naturally high, such as the ICU, where physicians are at the helm of decision-making and communication roles, Sexton et al. (2018) propose that there is always an urgent need for nurses to be empowered. Several studies support this view and note the challenges faced by nurses as they engage with families when important decisions are made (Alshammari et al., 2023; Alshehri et al., 2022; Griffiths, 2019; Jung & Matthews, 2021; Meilando et al., 2022). When nurses are trusted to make decisions, their perceived expertise and efficacy in PEOL care can be boosted.

Conclusion

The present study highlights the beneficial impacts of in-service training, job satisfaction, and the ability of nurses to effectively communicate with patients and their families on enhancing both clinical practice and perceived competence. The findings underline the necessity of ongoing training programs, the creation of satisfying job environments, and the empowerment of nurses in communication roles. These factors are critical not just for boosting the competence and confidence of nursing professionals but also for improving patient care outcomes. For healthcare systems aiming for excellence in patient care, recognizing and addressing these aspects is essential.