Number of Citations: 0

Submitted: 19 October 2024
Accepted: 28 April 2025
Published online: 1 July, TAPS 2025, 10(3), 84-88
https://doi.org/10.29060/TAPS.2025-10-3/SC3547

Eranthi Weeratunga, Shashika Karunanayaka, Pramudika Kariyawasam & Bimba Wickramarachchi

Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka

Abstract

Introduction: Palliative care nursing (PCN) supports individuals with life-threatening illnesses, aiming to improve the quality of life (QoL) for patients and families. The objective was to assess the necessity of establishing an Advanced Certificate Course in PCN at University of Ruhuna, Sri Lanka.

Methods: A descriptive cross-sectional study was conducted among 220 registered nurses (RNs) using purposive sampling, working at National Hospital Galle. A pre-tested, interviewer-administered questionnaire was used, including questions on prior education or training experiences on palliative care (PC), and its principles, services, and management. Descriptive statistics and the chi-square test were used to analyse.

Results: The majority of the RNs were aged 31-40 years (45.2%), females (86.0%), and married (55.7%). A higher proportion of RNs were nursing diploma holders (67.4%), with 55.7% having less than ten years of nursing experience. Only 11.3% of the RNs had formal additional training on PC, such as workshops and a few training hours. Most RNs correctly identified PC aims: improving survival (59.7%), improving QoL of patients and their families (91.4%), providing relief and pain (93.7%), understanding PC (80.1%), etc. The majority (84.6%) had a good attitude toward palliative caregiving, though only 20.4% had average knowledge of PC. Formal PCN training was significantly associated with PC knowledge (p=0.004).

Conclusion: Limited educational exposure, average knowledge levels, and good attitudes toward PC suggest the need for a PCN course for nurses. Providing a special education programme reduces the current gaps in PC by equipping RNs with the respective knowledge, skills, and attitudes to deliver complex management for patients requiring PC.

Keywords:           Palliative Care Nursing, Sri Lanka, Educational Needs, Registered Nurse

I. INTRODUCTION

Palliative care (PC) is an approach that aims to improve the quality of life (QoL) of patients and their families facing the physical, psychosocial, and spiritual problems associated with life-threatening illnesses (World Health Organization [WHO], 2022). About forty million people need a PC every year in the world, but the majority are from lower-middle-income countries (LMICs) (WHO, 2022). PC is offered by a range of professionals comprising physicians, nurses, support workers, etc., who are equally important, in addition to family members (WHO, 2022).

The major obstacle to improving PC among healthcare professionals (HCPs) and policymakers in LMICs is a lack of education/training (WHO, 2022) and a need for knowledge on PC for nursing professionals, which emphasised in previous findings in Sri Lanka (Meegoda et al., 2018) in addition to less PC content in the undergraduate curriculum (Pesut & Greig, 2018).  Further, less awareness of PC, cultural/social barriers, and misconceptions was found among HCPs; PC education improved nurses’ knowledge, confidence, attitudes, and communication abilities (WHO, 2022).  In Sri Lanka, there is a growing number of non-communicable diseases (NCDs), such as cancers, end-stage renal disease, HIV/AIDS, motor neuron disease, etc., that require comprehensive PC at every stage of the disease process in addition to the rapidly aging population.

PC services in Sri Lanka remain limited due to a shortage of trained HCPs. In response to the rising burden of NCDs, the Ministry of Health has emphasised the need to strengthen PC across all levels of the healthcare system. However, gaps in knowledge, skills, and attitudes among HCPs hinder effective implementation. While universities have introduced theoretical PC education, nursing undergraduates receive minimal practical exposure. Although a one-year post-basic diploma in palliative care nursing (PCN) has been launched for registered nurses (RNs), it is insufficient to meet the growing national demand. The initiation of a new course is of paramount importance, as specialisation in PCN has become an urgent necessity both nationally and internationally. The rising number of patients requiring PC, driven by demographic transitions, underscores this need. In developed countries such as Japan and Australia, the demand for PCN is expected to increase due to aging populations. Nationwide studies in Japan estimated that PC needs will continue to rise. Evidence suggests a growing demand for PC services in Australia, in particular, as the number of Australians aged over 85 continues to increase, the need for PC services has also surged. As a result, the demand for Sri Lankan RNs specialising in PC is expected to rise in these developed countries.

To address the existing gaps in PC knowledge and skills among RNs, we sought to quantify RN’s readiness for specialisation in PCN. The key objective was to assess the necessity of establishing an Advanced Certificate Course in PCN at the Department of Nursing, Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR), Sri Lanka, to enhance professional competency and meet the growing demand for PC services.

II. METHODS

This descriptive cross-sectional study was conducted at the National Hospital Galle (NGH), Sri Lanka. The study participants were 220 RNs purposively selected based on having at least one year of experience, surveyed from June to December 2023. Data were collected using a content-validated and pre-tested questionnaire, which had been previously utilised in a Sri Lankan study (Fernando & Prathapan, 2019). The questionnaire comprised sections designed to assess socio-demographic characteristics and knowledge of four distinct domains: basic principles, service organisation, clinical management, and ethical considerations. Additionally, participants’ attitudes were evaluated after obtaining written informed consent. Statistical Package for Social Science (SPSS) 26 software was used; the descriptive statistics, frequencies, and percentages were checked. Further, a chi-square test was used. All results were regarded as statistically significant at p < 0.05.

III. RESULTS

The majority of the RNs were aged 31-40 years (45.2%). The mean±SD age was 36.61 ± 7.47 years. The majority were female (86.0%) and married (55.7%). Of the RNs, 35.7% had a monthly income between Sri Lankan Rupees 50,000 and 74,999. A higher proportion of RNs were nursing diploma holders (67.4%), with 55.7% having less than ten years of nursing experience. Emergency trauma care was the special training received by the RNs (4.5%). Only 11.3% of the RNs had formal additional training on PCN, such as workshops and a few training hours. Most RNs correctly identified PC aims (Table. 1). However, the majority gave incorrect answers regarding general knowledge/concepts of PC principles, such as increasing the life expectancy of terminally ill patients (59.7%) and consultants as ideal coordinators for PC (87.8%). Most RNs agreed that PC offers hope to patients (47.1%) and considered it a basic human right (79.6%). The majority (84.6%) had a good attitude toward PC, though only 20.4% had average knowledge of PC. Knowledge of PC was significantly associated with formal PCN training (p=0.004).

Table 1. General principles of PC among RNs, service organisation, drug management aspects, and ethical concerns

IV. DISCUSSION

This study assessed PC knowledge, management, ethical concerns, and attitudes among RNs in the NHG, Sri Lanka. RNs reported average knowledge and satisfactory attitudes, with age and prior PC training significantly influencing knowledge levels. Compared to the current study, Fernando and Prathapan (2019) reported higher satisfactory scores.

Sri Lankan medical graduates showed limited PC knowledge (37.23%), lower than RNs (20.4%), likely due to curriculum gaps (Fernando & Prathapan, 2019; Prem et al., 2012). While young medical graduates had adequate knowledge of general principles (63%), ethics was the weakest area (19.55%), mirroring findings among RNs.

PC is a relatively new discipline in Sri Lanka, contributing to limited ethical awareness. Cultural norms favor “hiding bitter truths” over transparency rather than “telling the truth,” which is a fundamental principle in Western healthcare practices, influencing attitudes and ethical concerns (Fernando & Prathapan, 2019).

The medical graduates studied by Fernando and Prathapan (2019) were younger than the RNs in this study. Despite some PC exposure, RNs had fewer opportunities for specialised training, impacting knowledge levels. Nevertheless, their positive attitudes likely stem from empathy-based patient care within the Asian context.

A previous study highlighted insufficient PC preparedness among nurses, attributing it to curriculum deficiencies and inadequate training in pain management (Prem et al., 2012). Female RNs performed better than males, but knowledge gaps remain a global issue. Student nurses and new RNs often feel inadequately prepared to discuss end-of-life issues, death, and other ethical concerns.

Meegoda et al. (2018) emphasised the need for adequate PC knowledge among nurses, as limited PC services worsen cancer care challenges. Heavy workloads and time constraints hinder learning, and 96% of RNs had not attended PC training. In-service programmes were considered beneficial, but specialised training is mainly available in Colombo, restricting accessibility. Distance learning could bridge this gap.

Nurses are vital in PC across various healthcare settings. Skilled PCNs provide essential support to patients and families. WHO (2022) stresses PC’s role in alleviating suffering and advocates its integration into national healthcare. However, LMICs face educational and awareness barriers.

Although Sri Lankan nurses have access to higher education, PC specialisation remains limited, especially in remote areas. With rising NCDs and aging populations, introducing PCN courses is crucial. Establishing a PCN programme aligned with national priorities would enhance patient care and improve career opportunities, particularly for nurses seeking employment abroad. A PCN course at FAHS, UoR, outside Colombo, could improve access to PC education.

A. Limitations

This study highlights the need for PC training, but it has limitations. Sampling bias may affect validity, and self-reported data could introduce response bias.

V. CONCLUSION

Limited educational exposure, average knowledge, and positive attitudes toward PC indicate a need for PCN courses to address existing gaps. RNs at NHG support an Advanced Certificate Course in PCN, emphasising the necessity for specialised training. Expanding PC education will enhance patient care and create new professional opportunities. Future research should assess the impact of PC training on HCP competencies and patient outcomes. Collaboration between the University of Ruhuna and the Ministry of Health is essential for establishing a sustainable PCN course.

Notes on Contributors

EW was involved in conceptual development, data collection/entry/analysis, manuscript drafting, editing, and final correction. SK was incorporated into conceptual development, data collection/entry/analysis, and editing. Data entry/analysis, editing, and final correction were done by PK, and BW was involved in manuscript draft editing.

Ethical Approval

Ethical approval (Ref. No. 83.11.2021) and institutional approval were obtained from the Ethics Review Committee of the FAHS, UoR, and the relevant institutions/authorities.  

Data Availability

Data analysed during the current study will be available from the corresponding author upon reasonable request.

Acknowledgment

The authors are grateful to the Dean, FAHS, UoR, Galle, Sri Lanka, and the Head, Department of Nursing, FAHS, UoR, Galle, Sri Lanka. The Director, Chief Grade Nursing Officer, and all in-charge nursing sisters of the National Hospital Galle are acknowledged for their permission. Ms. Nimesha and Mr. Dilan (11th batch/nursing graduates) are appreciated for their enormous contribution while collecting data despite their busy schedules. All consented RNs were further acknowledged for giving their true opinions and great support to uplift nursing education in the PCN field. 

Funding

The authors received no funding for this study.

Declaration of Interest

The authors declare that they have no competing interests.

References

Fernando, G. V. M. C., & Prathapan, S. (2019). What do young doctors know of palliative care; How do they expect the concept to work? BMC Research Notes, 12(1), 1–6. https://doi.org/10.1186/s13104-019-4462-2

Meegoda, D. L., Fernando, D. M. S., Atulomah, N., Sivayogan, S., & Marasinghe, R. B. (2018). Improvement of nurses’ skills following a hybrid model educational intervention on cancer palliative care. International Journal of Health Sciences & Research, 8(5), 196–203. http://www.ijhsr.org/IJHSR_Vol.8_Issue.5_May2018/IJHSR_Abstract.031.html

Pesut, B., & Greig, M. (2018). Resources for educating, training, and mentoring nurses and unregulated nursing care providers in palliative care: A review and expert consultation. Journal of Palliative Medicine, 21(S1), S50–S56. https://doi.org/10.1089/jpm.2017.0395

Prem, V., Karvannan, H., Kumar, S. P., Karthikbabu, S., Syed, N., Sisodia, V., & Jaykumar, S. (2012). Study of nurses’ knowledge about palliative care: A quantitative cross-sectional survey. Indian Journal of Palliative Care, 18(2), 122–127. https://doi.org/10.4103/0973-1075.100832

World Health Organization. (2022). Palliative care. https://www.who.int/news-room/fact-sheets/detail/palliative-care

*Eranthi Weeratunga
Department of Nursing,
Faculty of Allied Health Sciences,
University of Ruhuna
Galle, 80 000, Sri Lanka
+94 71 440 2662, +94 77 225 8519
Email: eranthiw@ahs.ruh.ac.lk,
eranthiweeratunga@yahoo.com