Knowledge and Attitude in Palliative Care Management
Elizabeth Putri Ria, Ester Apriana Refra, Yenni Ferawati Sitanggang and Elissa Oktoviani Hutasoit
Faculty of Nursing, University of Pelita Harapan, Tangerang, Indonesia
Keywords: Attitude, Knowledge, Nurses, Palliative Care.
Abstract: A palliative nurse is required to have the right knowledge and attitudes as one of the important factors that
influence the success of palliative care so that the patient is ready to accept the unwell physical condition
even in at its worst. The purpose of this study was to determine the relationship between knowledge and
attitudes of nurses regarding the management of palliative care in one private hospital in the West
Indonesia. The method was conducted using a quantitative descriptive correlational with cross sectional
design. A total sampling technique was applied by recruiting 45 nurses from two palliative cancer wards in
one private hospital. The level of knowledge and attitudes of the nurses were measured using two
questionnaires PCQN (The Palliative Care Quiz for Nursing) and FATCOD (Frommelt Attitudes Toward
Care of the Dying). Kendall’s tau-b correlations test was applied to identify the correlation. Most of the
nurses’ knowledge was moderate (68.9%) and their attitude was negative (55.6%). In addition, there is no
correlation between the levels of knowledge of nurses about palliative care with attitudes toward patient
management in the palliative care (p value 0.434). Further study is needed to explore other factors related to
nurses’ attitude towards palliative care management.
1 INTRODUCTION
According to the Ministry of Health of the Republic
of Indonesia (Kementrian Kesehatan Republik
Indonesia, 2013) in 2017, the palliative care program
is an effective way to reduce suffering and improve
the quality of life of patients and their families
whose diseases cannot be cured or so-called terminal
diseases such as diabetes mellitus, hypertension,
heart disease, cancer, chronic kidney failure, and
others. This method is done to minimize the impact
of disease progression and anticipate problems that
arise so that patients can optimally perform their
activities according to their conditions before they
die.
Cancer is one terminal illness that requires
palliative care and is one of the world's public health
problems that cannot be avoided because the
percentage increases every time. According to
World Health Organization (WHO, 2018), cancer is
the second leading death after cardiovascular disease
in the world with a percentage of 13% and it ranks
as number seven as the cause of death in Indonesia.
WHO also stated that by 2030 it is estimated that
there will be approximately 26 million people
suffering from cancer, of which 17 million are
expected to die.
Based on the data from the Republic of Indonesia
Basic Health Research in 2013, the prevalence of
cancer in Indonesia was 1.4% per mile (1.4 per 1000
population) from the prevalence of old cases and
new cases in a certain period of time. From the
above data, we can see that cancer patients trying to
improve their health and the stability of their
physiology function (Ministry Of Health Republic
Of Indonesia, 2014).
Ministry of Health No. 812 / Menkes / SK / VII /
2007 states that at an advanced stage patient with
chronic disease or terminal care does not only
experience various physical problems such as pain,
shortness of breath, weight loss, and disruption of
activities but also experiences psychosocial and
spiritual disorders that affect quality life of the
patient and his family (Kementrian Kesehatan
Republik Indonesia, 2007). It is obvious that the
needs of palliative care for patients with advanced
disease is crucial as it does not only deal with
physical symptom but also social, psychological and
spiritual both patients and their families. According
to Rome et al. (2011) most people still assume that
palliative care is only for patients in terminal
148
Putri Ria, E., Refra, E., Sitanggang, Y. and Hutasoit, E.
Knowledge and Attitude in Palliative Care Management.
DOI: 10.5220/0008206601480153
In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 148-153
ISBN: 978-989-758-406-0
Copyright
c
 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

conditions that will soon die; however the new
concept in palliative care emphasizes the importance
of early integration of palliative care so that
palliative patients' physical, psychosocial, and
spiritual problems can be well addressed.
Palliative care in Indonesia, especially for
patients with medical diagnoses of cancer, is still
slightly related to the resources of health workers
who have not properly understood the management
of palliative care. Fitria (2010) stated that hospitals
in Indonesia with the ability to provide palliative
care are still limited to five major cities, namely
Jakarta (Citra Mangunkusumo Hospital and
Dharmais Cancer Hospital), Yogyakarta (Dr.
Sardjito Hospital), Makassar (Wahidin
Sudirohusodo Hospital), Surabaya (Dr. Soetomo
Regional General Hospital), and Denpasar (Sanglah
Hospital). Currently, a Private Hospital in Western
Indonesia which was established in 2011 provides
hope for the provision of holistic palliative nursing
care amid the increasing needs and number of
terminal and chronic patients, especially cancer.
According to Mukemo et al (2017) in research
Sanderson & Tieman (2010) palliative care has
traditionally been regarded as providing intense care
from patients who are close to death (end of life). In
recent years, palliative care has been expanded to
include patients who can live for years with end-
stage organ failure and not just cancer.
One important factor that influences the success
of palliative health care by health professionals such
as nurses is the presence of knowledge, attitudes,
beliefs, and experiences that are not only determined
by their procedures but also the attitudes and
behavior of nurses while caring for these patients. In
providing holistic nursing care, a nurse needs to
have an extensive and positive knowledge and skills
so that she can provide good palliative care
(Pradana, Wira and Nym., 2012). Nurses are
members of the palliative care team who are able to
overcome the dimensions of physical, functional,
social, and spiritual care (Mukemo et al., 2017).
2 METHODS
A quantitative descriptive correlational study with
cross sectional design was conducted for this
research using univariate and bivariate analysis
technique. This study aims to describe the existing
phenomena and to identify and to determine the
relationship of knowledge level of the nurses
towards nurses’ attitude of palliative care
management. This study used total sampling of 45
nurses in palliative care of Western Indonesian
Private Hospital and three nurses are registered
palliative nurses who have had special training and
are certified as palliative nurses. The sampling
technique in this study used total sampling so that
the number of samples in this study also amounted
to 45 nurses that has settled in that room.
The instrument used was a questionnaire
containing two different types of questionnaires on
each variable, namely the Palliative Care Quiz for
Nursing (PCQN) and it was used to measure the
level of knowledge of the nurses and Frommelt
Attitudes Toward Care of the Dying (FATCOD) was
used to measure nurses’ attitude. The PCQN
questionnaire consists of 20 statements with 3
categories of answers which are 'true', 'incorrect',
and 'I don't know'. The score of each statement of
this questionnaire is one for 'correct' answer and zero
for 'not true' and 'I don't know' answer with the total
score of this PCQN questionnaire is zero to twenty,
for the lowest score indicating low knowledge. Total
scores of these statements will be divided into three
categories, which are low (0-7), moderate (8-14),
and high (15-20).
The FATCOD questionnaire was used to assess
attitudes of nurses towards the care of end of life
patients and their families that consists of 30
statements with a Likert scale. Rating categories
range starts from one (strongly disagree) to five
(strongly agree) and inverse score for negative
statements. This questionnaire is divided into two
categories, 15 positive statements and 15 negative
statements that were completed by a total value
ranging from 30-150. Higher scores reflect more
positive attitudes and the lowest reflect negative
attitudes.
Both questionnaires have been tested for validity
and reliability in previous studies and no statements
have been changed. A questionnaire was used in this
study after being tested for validity and reliability by
several previous researchers. FATCOD
questionnaire was tested for its validity and reliabilty
by A’la (2016), Cronbach Alpha and obtained a
result of 0.68. Validity test was done using Person
correlation which ranges between -0.278 to 0.544
and reliability is 0.713 which means valid.
According to Agustina et al., (2014) PCQN
instrument had also been modified in accordance
with the prevailing context in Indonesia. Nakazawa
et al., (2010) reported that the value of Cronbach
Alpha from this instrument was in the range of 0.67-
0.86 while the value of validity is 0.651 and the
reliability is 0.713 which means valid after the
instrument was tested on 947 respondents in various
Knowledge and Attitude in Palliative Care Management
149

hospitals in Japan . For Indonesia, the questionnaire
was used by Christantie (2012) for nursing students
in Yogyakarta that similar to Cronbach Alpha value
in the previous study Nakazawa. These results
indicate that this instrument is valid and reliable to
use in this study. Collecting data results is done
simultaneously at the same time to identify and
determine the existence and absence of a
relationship between the level of nurse knowledge
about palliative care and the attitude of management
of patients in palliative care. The data processing
process is carried out through four sequential stages
starting from editing, is the entire data obtained
needs to be re-examined, such as completing the
questionnaire and ascertaining whether all questions
have been filled. Then, coding is done to simplify
each answer, where the activity carried out is to give
a code that is changing the sentence or letter into the
number code on each questionnaire. During the data
entry stage edited data was imputed into the
computer system then was double checked by the
researcher to ensure accuracy. The data collection
procedure begins with the researcher requesting a
permission to conduct research by asking for a
research permit from University of Pelita Harapan
(UPH). To get ethical clearance the respondents
filled out the informed consent, without names and,
with initials only (anonymity). The researcher also
made sure that the study maintains data
confidentiality.
3 RESULTS
In this study, the researcher discussed the
descriptions of the frequency and percentage of
respondents' characteristics towards five
demographic variables, namely age, gender,
education, work experience and number of times the
respondents attended a special training related to
palliative care. Data results are shown in table 1
below.
Table 1: Distributions of Nurses Demographics.
Characteristics of Nurses
Frequency
(Number)
Percentage
(%)
Age
20-30 years old 33 73.3
31-40 years old 10 22.2
>40 years old 2 4.4
Total 45 100
Gender
Male 2 4.44
Female 43 95.6
Total 45 100
Nursing Qualification
Diploma 21 46.7
Bachelor of Nursing 24 53.3
Total 45 100
Working Experience
<1 years 5 11.1
1-5 years 32 71.1
6-10 years 6 13.3
11-15 years 2 4.4
Total 45 100
Palliative Care Training
Never 23 51.1
1 times 12 26.7
2 times 8 17.8
3 times 1 2.2
4 times 0 0
5 times 1 2.2
Total 45 100
The table above shows that the majority of
respondents 33(73.3%) were within the age 20-30
years old and more female 43(95.5%) rather than
male nurses. Educational qualifications recorded
include most respondents (53.3%) have Bachelor of
nursing degree with majority of nurses 32 (71.1%)
had around 1-5 years working experiences.
Respondents were asked and recorded if they had
received palliative care training. Finding revealed
that 23 respondents (51.1%) had never attended any
palliative care training, 12 respondents (26.7%) had
attended training once, 8 respondents (17.8%) had
attended training two times, and 1 (2.2%) respondent
had attended three and five times.
Table 2 shows that The majority of nurses
(68.9%) have a moderate level knowledge and
31.1% have a low level of knowledge.
Table 2: Distribution of Nurse Knowledge about Palliative
Care.
Knowledge Frequency Percentage (%)
Low 14 31.1
Moderate 31 68.9
High 0 0
Total 45 100.0
It can be seen (in table 3) that more than half
nurses (55.6%) have negative attitudes towards their
palliative care services while 44.4% had positive
attitudes.
ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association
150

Table 3: Distribution of nurses' attitudes about Palliative
Care.
Attitude Frequency Percentage (%)
Positive 20 44.4
Negative 25 55.6
Total 45 100.0
The result in table 4 revealed that there is no
relationship between the level of knowledge of the
nurses towards the attitude of palliative care
management. It is revealed that Sig. (2-tailed) of the
two variables has p value 0.434 where Sig> 0.05
then H
0
is accepted.
Table 4: Analysis of the Relationship between Nurses'
Knowledge Level and the Attitude of Management of
Palliative Patient Care.
Knowledge
Attitude
Percent (%)
- +
Low 9 5 31.1%
Moderate 16 15 68.9%
High 0 0 0%
Total 25 20 100%
Sig.2 Tailed Test Kendall’s Tau B
0.434
4 DISSCUSSION
Table 1 shows of 45 respondents in that hospitals,
female nurses are 43 respondents (95.6%) and male
nurses are two (4.4%) respondents. The results
turned out to be in accordance with Indonesian
Ministry of Health Data also the data in Indonesian
Nurses Association (PPNI) in April 2017 that was
found out from 359,339 registered nurses, 256,326
(71%) nurses are female, while male nurses are only
103,013 (29%). In addition, table 1 shows that the
age of respondents is mostly in the range of 20-30
years old are 33 respondents (73.3%), according to
Notoatmodjo Soekidjo (2012) age influences one’s
perception and mindset also how to think and act.
The highest proportions of respondents’ educational
background are Strata one (S1), 24 respondents
(53.3%) while the others are Diplomas 21
respondents (46.7%).
Table 2 shows that almost 70 % nurses were in
the moderate level of palliative care knowledge. The
results of the questionnaire data analysis showed that
31 out of 45 nurses were able to correctly answer
management of symptoms and pain questions.
However, it was only one nurse who was able to
answer questions related to palliative care principles
and psychological and spiritual symptoms. When
compared with the Notoatmodjo (2012) study
Wulandari (2015) of six levels of cognitive domains,
almost all nurses in this study contraindicated that
they know the basics of palliative care but they had
lack of applying palliative care management. This is
in accordance with the results of observations and
interviews that most of the samples were new nurses
who still followed directions and instructions from
their seniors in the wards. Researchers assume that
the need for giving the training that certify a nurse as
a palliative nurse and character guidance should be
given continuously to be able to increase knowledge
and attitude in providing psychosocial and spiritual
care.
Table 2, shows that 25 nurses (55.6%) have an
attitude with the tendency that leads to a negative
category. This can be supported by the interview that
revealed that five nurses mentioned that they had
empathy to their patients, however, they had a very
limited time to be responsible for giving palliative
care and they had to focus on their core work or
task. Based on Table 3, the results of the Kendall’s
Tau B Correlations test on 45 respondents with a
computerized system showed that Sig. (2-tailed) of
the two variables is 0.434 where Sig> 0.05. These
results indicate there is no correlation between the
level of knowledge of nurses about palliative care
and attitudes towards the management of patients in
palliative care at private hospitals in Western
Indonesia. A similar result by Alvaro (2009)
(Wulandari, 2015) which stated that there is no
relationship between knowledge and nurses'
attitudes. In their study, nurses had a positive
attitude, but the result of knowledge level is low.
This might be because nurses tried to follow the
regulations and culture that was set in the ward
which made them serve patients in a good attitudes
even though their knowledge of palliative care is
low.
According to Nursalam (2008), a good level of
knowledge and attitude can be obtained from
experience and is relatively easy to develop with
training. The negative attitudes shown by someone
can occur because there are several factors that
influence it. According to Kiran, Y., and Dewi, U.
(2017) the attitude was not gained since birth but
was learned and formed based on individual
experience throughout his life. As individuals, an
attitude arises based on what arises from within him
such as thoughts and feelings. As social beings, the
attitude that is raised by someone is inseparable
from the influence of external interactions from
other individuals, situations, events, and the
Knowledge and Attitude in Palliative Care Management
151

surrounding environment. Both also stated that
having good knowledge does not guarantee that
someone has a good attitude. Therefore, it is
important for each individual, especially the nurse to
recognize the factors that influence his attitude and
behavior to patients. Based on observations in the
ward, researchers also found that the pattern that
prevailed in the ward, the feeling of giving the best,
and the inability to manage themselves and time also
became factors that influenced them to be negative
.
5 CONCLUSSION
Based on the overall results of the research analysis
entitled "The Relationship of Nurses' Knowledge
Levels About Palliative Care with Attitudes Toward
Patient Management in Palliative Care in Western
Indonesian Private Hospitals”, from 45 respondents,
the result obtained from demographic data, the
highest proportion of working nurses is 20-30 years
old as many as 33 people (73.3%), with female as
many as 43 people (95.5%), having a Bachelor's
education background (S1) as many as 24 people
(53.3%), with experience working for one to five
years as many as 32 people (71.1%), and those who
have not yet attended the palliative basic training as
many as 23 people (51.1%). From univariate
analysis, it was found that the level of knowledge of
nurses in the moderate category consisted of 31
people (68.9%) based on the result from the PCQN
questionnaire. Whereas, for attitude, nurses who
have a tendency to behave negatively was amounted
to as many as 25 people (55.6%). After the Kendall's
Tau B Correlations test, it was found that Sig. (2-
tailed) of the two variables is 0.434 where Sig> 0.05,
the initial hypothesis is accepted. In conclusion, the
results of this study indicate that there is no
correlation between the level of knowledge of nurses
and the attitude of managing palliative patient care.
Based on the results of analysis, observation and
interviews, this can be caused by several factors
such as age, experience, and workload of nurses in
the hospital.
It is expected that future studies can focus on and
reexamine the possibility of other factors that may
influence the level of knowledge and tendency of
nurses' attitudes when doing management in
palliative patients. In addition, the researchers also
suggested hospitals to conduct periodic evaluations
of the level of knowledge and attitudes of nurses so
that they could improve the quality of care and
reputation of the hospital. In addition, it is expected
that there will be a character development seminar,
time and personal management and moral support
from various parties to improve the attitude of
nurses to be more positive. Nurses can also use the
opportunity not only to continue their education to a
higher level, or to enrich their knowledge and skills
by attending existing palliative seminars, but also
make some time to do meditation, counseling, and
other positive things.
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