Knowledge in palliative care of nursing professionals at a Spanish hospital

Resume Objective: to determine the level of knowledge in palliative care of nursing staff at a Spanish tertiary care hospital. Method: descriptive, cross-sectional study. Data were collected about the results of the Spanish version of the Palliative Care Quiz for Nurses (PCQN), sociodemographic aspects, education level and experience in the field of palliative care. Univariate and bivariate descriptive analysis was applied. Statistical significance was set at p < 0.05 in all cases. Results: 159 professionals participated (mean age 39.51 years ± 10.25, with 13.96 years ± 10.79 of professional experience) 54.7% possessed experience in palliative care and 64.2% educational background (mainly basic education). The mean percentage of hits on the quiz was 54%, with statistically significant differences in function of the participants’ education and experience in palliative care. Conclusions: although the participants show sufficient knowledge on palliative care, they would benefit from a specific training program, in function of the mistaken concepts identified through the quiz, which showed to be a useful tool to diagnose professionals’ educational needs in palliative care.


Introduction
Traditionally, cancer patients have received palliative care, although the changes in the social epidemiological patterns have entailed new indications of this care.
Today, neurodegenerative conditions and organ failure in advanced stages are the most frequent non-oncologic indications (1)(2)(3) . In 2002, WHO defined palliative care as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual", further indicating the comprehensive approach, early care and quality of life as the main objectives and guidelines for its development (2)(3) .
Palliative care is considered a part of the health care systems and a fundamental element of citizens' rights.
It should be guided by the patient's needs, considering his values, preferences, dignity and autonomy (4)(5) .
In Spain, these aspects have been articulated with recommendations for the basic education of all professionals and the development of specific programs that permit intervention at all care levels (4)(5)(6) .
The European Association of Palliative Care (EAPC) proposes the development of three education levels: basic education for all nursing professionals, intermediary qualification for professionals who frequently attend to patients who need palliative care and specialized education for professionals working in specific palliative care areas (7)(8) . The nursing professionals consider they are key in care practice to the population in any phase of the lifecycle, but require suitable education to deliver high-quality care.
In Spain, undergraduate education in palliative care is included in curricula with heterogeneous contents. Similarly, at the postgraduate level, a wide range of programs exists (with difference in hours, competences and entities) (9) .
Previous studies have analyzed nurses' level of knowledge in palliative care and also the outcomes of educational programs in palliative care for nursing professionals, mostly without using validated tools (10) .
The validated tools to measure outcomes of palliative care education include the Palliative Care Quiz for Nursing (PQCN) (11) , a self-administered questionnaire that consists of 20 multiple-choice items (true/false/ does not know/did not answer) to assess three aspects of palliative care: philosophy and principles of palliative care ((4 items: 1,9, 12 and 17), control of pain and other symptoms (13 items) and psychosocial aspects of palliative care (3 items: 5, 11 and 19). According to different studies (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22) , the PCQN has showed to be a useful tool to assess knowledge and also to identify mistaken concepts in the palliative care context. Its internal consistency according to the Cronbach test corresponds to 0.78, with correlation coefficients superior to 0.5 on before/after reliability tests undertaken as part of studies in different contexts. Its components mainly refer to aspects applicable in the clinical sphere (12,16) .
Therefore and based on the hypothesis that professionals with a background and/or experience in palliative care could score better on the quiz (larger number of hits and higher global score) than professionals without experience or education in this sphere, we intend to assess the level of knowledge of nursing staff members in the field of palliative care in a Spanish tertiary-care hospital.

Method
Cross-sectional and descriptive study, undertaken at Hospital General Universitario de Valencia (Spain).
The study population corresponded to the nursing staff working in January 2015 at the inpatient wards (360), emergency unit (80) and critical care wards (60) and who accepted to answer the questionnaire. Being a pilot study, the sample size was not delimited, although we intended to collect at least 100 questionnaires to guarantee the reliability of the results, calculating that, with this number of questionnaires and considering 60% to be the mean number of hits for the participants with an educational background in palliative care and 40% for the participants without experience, 45 subjects in each group would allow us to obtain a statistical test power superior to 70%.  Finally, the internal consistency of the quiz was analyzed using Cronbach's alpha coefficient, showing a coefficient of 0.67, considered acceptable by authors who defend that "the minimum acceptable reliability coefficient depends on what the tool will be used for", making reference to the initial phases of a research and/ or exploratory study (24) .
After that process, a questionnaire was designed that included, besides the PCQN translated to Spanish, a range of items to assess the participants'

Characteristics of the population
In Table 1  Variables that influence the level of knowledge in palliative care In   (19) , with a PH of 44.75%, and the results of nursing students in one of the validation studies of the original version of the PCQN (11) with a PH of 46%, and highly similar to the results found in a study undertaken in Florida and involving pediatric nurses (21) , with a PH of 51.8%; and the PH obtained in the assessment of the French version of the PCQN, in which the participants also worked at different wards and very few had palliative care experience (which makes the population very similar to our study), corresponding to 54.8% (17) .
The other studies that we have reviewed presented PH bordering on or superior to 60% and involved nurses working at long-stay institutions, asylums, palliative care centers (14,16,18) or oncology services (20) or who had participated in palliative care training programs (12,15,22) , which would explain the better www.eerp.usp.br/rlae On the other hand, in three of the studies reviewed (15,16,20) , the percentage of subjects with experience and education in palliative care was measured among the participants, but the effect of these variables on the quiz results was not analyzed. In another study developed in Corea in 2011 (12) , the level of knowledge in palliative care was measured before the start of an education program, concluding that participants with some kind of education obtained better results at the beginning of the study.
Ronaldson et al. (19) and Raudonis et al. (16) measured the level of knowledge in palliative care of nursing professionals working at nursing homes, analyzing the results obtained on the three scales of the quiz.
They found that the highest PH were obtained on the psychosocial aspects scale (62% and 75.67%, respectively) and the worst on the philosophy scale (50% and 57.25%, respectively), superior to the results of our study in all cases.
Another study developed at three Iranian hospitals, involving nurses working at oncology and ICU services (13) , analyzing the results of the three subscales, found the lowest outcomes as follows: PH 37.95%, with the best PH corresponding to symptoms' control (46.07%) and the worst to the subscale of psychosocial aspects (19.3%), justifying the low percentages found for the participants' lack of experience and education in the field of palliative care and due to the influence of cultural and religious aspects.
When reviewing the educational programs at our universities and studies developed in other contexts, we observe that the content is mainly focused on aspects like symptoms' management and that the content related to the psychosocial aspects appears less frequently (10,25) . In our study, we were able to prove that the worst results correspond to the psychosocial aspects of palliative care. Therefore, we raise the need to further include these psychosocial aspects since undergraduate nursing education; thus, at least in Spain, these areas should be further  (12,15).

Conclusions
The