Knowledge about Palliative Care and Attitudes toward Care of the Dying among Primary Care Nurses in Spain

Objective: To analyze the knowledge in palliative care and the attitudes toward caring for the dying of nurses who carry out their professional activity in primary care in Spain. Design: A cross-sectional descriptive observational study was carried out among Spanish primary care centers. Participants: A total of 244 nurses who had completed their primary care work and agreed to participate in this study were included. Main measurements: The level of knowledge in palliative care was analyzed using the PCQN-SV scale, and attitudes toward care of the dying were measured with the FATCOD-S scale, both of which are instruments that are validated in Spain. Results: Regarding the level of knowledge in palliative care, at a global level, the results revealed that 60% of the answers in the PCQN-SV were correct, with different results for each of the three subscales that compose it. When analyzing the attitudes of primary care nurses toward the care of the dying, an average of 132.21 out of 150 was obtained, representing a positive attitude. On the other hand, when analyzing these results in terms of knowledge and attitudes according to the population’s characteristics, we see that participants with both experience and training in palliative care present a better level of knowledge and a higher score regarding their attitudes toward care of the dying. However, the differences are only significant regarding the level of knowledge in palliative care. When analyzing the data from the two scales together, it is noteworthy that the participants with the most positive attitudes (highest scores on the FATCOD-S) also have the highest percentages of correct answers on the PCQN-SV.


Introduction
The progressive aging of populations, the increase in life expectancy, and the prolongation of survival with new therapies and support techniques have turned palliative care (PC) and support care into a critical and ethical challenge for quality healthcare [1]. In Spain, each year, approximately 500 people per 100,000 inhabitants die due to progressive illnesses that lead to a situation where they must receive quality palliative care (PC) [2,3]. According to the WHO, "Palliative care is an approach that improves the quality of life of patients and their families through the prevention and relief of suffering through early identification and impeccable evaluation and treatment of pain and other problems, physical, psychological and spiritual" [4]. hospitalization units that are external to the primary care teams [27]. On the other hand, care is frequently provided by general nurses from the primary care team who, in different studies, have shown the need for improving knowledge and skills in some aspects, such as symptom control or the relationship with the patient [26,28].
Nevertheless, texts and nursing training programs have little content regarding the subject [29]. However, various studies indicate that training programs for end-of-life care effectively improve the knowledge and attitudes of practicing nurses toward PC and providing care for people in the last days of their lives. Thus, in Spain, although the different centers teach content regarding palliative care, there is a disparity in the content and credit depending on the university of origin [14]. On the other hand, together with one's formal education [30,31], it should be taken into account that the nurse must maintain, as indicated in the Code of Ethics of the ICN (International Council of Nurses), the responsibility of the practice and maintain competence through continuous learning [32].
Despite research that indicates that specific training in PC does not reduce the anxiety of professionals when facing the death of patients [11], evidence of the influence as a function of the time elapsed since the formation has been found [33,34]. In addition, the World Health Organization reveals that the lack of training and awareness of health professionals concerning PC can be an obstacle to improving such care programs [4]. For this reason, the awareness of the level of training of professionals, not only in palliative care but also in terms of attitudes toward care for the dying, is an essential aspect that enables the development and implementation of specific plans that are adapted to the reality for nurses [25,[35][36][37].
This study aims to analyze the knowledge of palliative care and attitudes toward care for the dying among primary care nurses in Spain, identifying differences based on specific socio-professional characteristics. The starting hypothesis of this work is that Spanish nurses who carry out their care work in the primary care setting will present a higher level of knowledge in palliative care and a more positive attitude toward the care of the dying as their level of training or experience increases.

Design, Population, and Sample
A cross-sectional descriptive study is proposed and carried out among nursing professionals who carry out their care activities in the primary care field in Spain.
To this end, an online questionnaire was developed. With this questionnaire, it was possible to collect information concerning the population's socio-demographic variables and the answers to two instruments used to measure nursing knowledge in palliative care and attitudes toward care of the dying, both validated in their Spanish versions. The questionnaire was distributed with the help of the Community Nursing Association among its associates (about 600 nurses who work in the primary healthcare environment) and on social media networks. So, which helped the researchers to generate a non-probabilistic participant selection process with a "snowball"-type sampling.
The data collection document included an informative letter in which the data's confidentiality and the questionnaire's anonymity were communicated. Its content could only be accessed if one agreed to participate in the study.

Study Variables
The primary outcome variables were the level of knowledge in palliative care and attitudes toward the care of the dying among nursing professionals.
For the analysis of attitudes toward care of the dying, the FATCOD-S scale was used, which consists of 30 items with Likert-type responses (from 1, strongly disagree, to 5, strongly agree), with a score ranging between 30-150, with higher scores indicating more positive attitudes. Items 1,2,4,10,12,16,18,20,21,22,23,24,25,27, and 30 are all positively worded, while the remainder are framed negatively. The score of the negative items is converted into its inverse to calculate the overall score of the questionnaire.
The Spanish version of this instrument, developed by Edo-Gual et al. [15], presents a Cronbach's alpha index of 0.76.
The independent variables collected, characterizing the study population, were as follows: gender, age, years of professional experience (overall, in primary care and palliative care), having experience in palliative care, having received training in palliative care (as well as the type and hours of training received and if this had been received in the last five years), and having the specialty of family and community nursing.

Statistic Analysis
Univariate descriptive analysis of the different variables was performed using frequency distribution (categorical variables) or measures of central tendency (mean and median) and dispersion (standard deviation and interquartile range) (numerical variables).
Subsequently, a bivariate descriptive analysis was carried out, relating the results of the two scales to each other and the independent variables, using non-parametric tests to verify the non-adjustment to the normal distribution of the results obtained. Thus, Spearman's rho correlation coefficient was used to analyze relationships between two numerical variables. In the mean difference tests, the Mann-Whitney U test was used when the independent variable had two categories and the Kruskal-Wallis test was used if it had more than two categories.
Finally, linear regression models were estimated to analyze the level of palliative care and attitudes toward caring for the dying among the variables and other explanatory variables. The backward elimination method was used to adjust the model.
The statistical program SPSS v.25 for Windows was used for the analyses, and the statistical significance value of p < 0.05 was considered in all the tests.

Results
A total of 244 questionnaires with their corresponding informed consent were collected from the different primary care centers throughout Spain.

Population Characteristics
The main characteristics of the nursing professionals who participated in the study are shown in Table 1.

Characteristics of the Working Centers
In 15.6% of the participating centers, the professionals who work in them report that an analysis of palliative care needs has been carried out among the population. Although 73% of the participants are unaware of the instrument used for the analysis, it can be seen that the instrument used most frequently is the NECPAL CCOMS-ICO instrument.
A total of 49.2% of the centers have a case manager, and most of them (94.3%) have external resources for palliative care, with the home hospitalization unit (48.4%), support teams (46.7%), and hospital resources (34%) being the most commonly used.

Level of Knowledge about Palliative Care
The global results of the PCQN-SV questionnaire show a percentage of correct answers of 62.89% (median 65%). The item with the highest number of correct answers is eight, and the one with the highest percentage of wrong answers is five, as shown by the results for each item (Table 2). The percentages of correct and wrong answers obtained on the three subscales of the questionnaire were also analyzed and are presented in Table 3.

Attitudes toward Care of the Dying
The overall results of the FATCOD-S questionnaire show an average total score of 132,212 out of a maximum score of 150. Table 4 shows the average scores for each item that comprises the questionnaire and the percentage of participants who either agreed or disagreed with each statement.     Table 5 shows the results obtained by the participants in each of the two scales in a comparative way, in the case of the PCQN-SV in the form of percentages of correct and wrong answers and in the case of the FATCOD-S in the form of global scores. Although it is observed that the participants with higher experience or training in palliative care obtained better results, these differences are not statistically significant in all cases. When analyzing the relationship between the years of professional experience of the participants and the results in both instruments, a statistically significant relationship was found between the years of professional experience and the results in the FATCOD-S (rho = 0.14, p < 0.05). However, this relationship was not found with the percentage of correct answers in the PCQN-SV (rho = 0.02, p = 0.78). In the case of the relationship between the years of experience in primary care of the participants and the results in the instruments, a statistically significant linear relationship was also detected between both variables in the case of the FATCOD-S (rho = 0.16, p < 0.05), but not for the percentage of correct answers in PCQN-SV (rho = −0.03, p = 0.66).
A statistically significant linear relationship was found between the results of the two instruments and the years of experience in palliative care (rho = 0.15, p < 0.05 in the case of FATCOD-S, and rho = 0.20, p < 0.01 in the case of correct answers in the PCQN-SV), as well as between the results of the instruments and the hours of training in palliative care (rho = 0.182, p < 0.05 in the case of FATCOD-S, and rho = 0.180, p < 0.05 in the case of correct answers in the PCQN-SV). Table 6 shows the result of the correlation analysis between the results of the FATCOD-S and the PCQN-SV, both overall and for each of the subscales. Thus, it can be assessed that the higher the level of knowledge in palliative care (understood as a higher percentage of correct answers and a lower percentage of wrong answers in the PCQN-SV), the more positive the attitude toward the care of the dying among the subjects.  As shown in Table 7, the participants' knowledge level in palliative care can be explained by their experience and training in palliative care and their attitudes toward the care of the dying. The higher the experience and training in palliative care, the higher the percentage of correct answers.

Relationship between Both Instruments
At the same time, Table 8 shows that the attitudes toward the care of the dying would be explained by their level of knowledge in palliative care and their professional experience. As the knowledge level score increases, the attitudes score increases.

Discussion
This study's objective was to analyze palliative care knowledge and attitudes toward the care of the dying among primary care nurses in Spain, identifying differences based on specific socio-professional characteristics.
In our study, for the analysis of the level of knowledge and attitudes of nursing professionals, we have used two tools that have been validated in our country. These instruments are the Palliative Care Quiz for Nursing (PQCN) [11] for the evaluation of knowledge and the FATCOD-S to measure attitudes toward care of the dying [8,15]. These two instruments have been combined previously in other studies [5,[38][39][40]. Regarding the analysis of the FATCOD-S results, we can see that the participants showed a positive attitude toward the care of the dying. In this case, we also found differences among those professionals with training or experience in PC and among those specialists in Family and Community Nurses. All the analyzed studies agree that the participants' knowledge is medium-low and their attitudes toward care of the dying positive. However, the participants performed professional activities in different healthcare settings [11,33,34]. In addition, we found a linear relationship between the results of both scales, which indicates that professionals with a higher level of knowledge in palliative care have a more positive attitude toward the care of the dying. Studies such as that of Mastroianni indicate that attitudes are related to the quality of the studies provided [41].
Another variable studied with a relationship with the level of knowledge and attitudes toward care of the dying is the professional experience, as found in the study by Kassa et al. [33], among nurses from different hospitals (76.2% with a good knowledge of practice in palliative care, 76% with positive attitudes toward care of the dying). This study found a statistically significant linear relationship between the years of experience in primary care (which, in some subjects, could be assimilated into their professional experience) and the results on the two scales. Specific previous experience in palliative care, as in the study by Abudari [42], implies an improvement in the questionnaire results. In this study, experienced nurses obtained more correct answers in the questionnaire (46.55% vs. 41.5%, p = 0.05) and more positive attitudes toward care of the dying (112.49 vs. 109.10 in the FATCOD-S scale, p = 0.04). In the present work, those professionals who reported having experience in palliative care obtained better results in all the subscales. However, these differences were only statistically significant for the pain control subscale and others in the psychosocial aspects subscale, with 35.35% correct answers. These results are similar to publications such as those of Iranmanesh and Hertanti [43,44], in which it was found that professionals with more experience in palliative care obtained better results, with statistically significant differences in the subscales of pain control and other symptoms.
Suppose we delve into the attitudes toward the care of the dying by analyzing the answers to some of the FATCOD-S items separately. Our study reaches higher percentages regarding, among others, the expression of the patient's sensations before his death, with 89.4% responding negatively to item 11 ("When a patient asks the nurse, am I dying? I think it is better to change the subject") compared to 69.6% obtained by Katumbo [45]. However, in our study, it was detected that 45.8% of the nurses, according to the response to item 13 ("I would prefer that the person I am caring for dies when I am not there"), would not feel so comfortable if they had to be present at that last moment, something that, on the other hand, is not so frequent in the primary care environment (as opposed to environments such as hospitals or social health centers). This fear of death and being present at this last moment has been analyzed in our country in various ways about the importance of death as a traumatic event and its repercussions on professionals. Training is essential for health professionals to improve their attitude, emotional management, and coping with death to improve the quality of care provided to the population [33,42,43,45,46].
In addition, the presence of research that affects the difficulty of training in palliative care should be assessed due to, among other things, the lack of availability of professionals who are specialized in palliative care and who can serve as educators, units/institutions specialized in palliative care for learning, and the experiential and specific design of highfidelity simulations among others [33,47]. In our country, there is wide heterogeneity in the undergraduate study plans regarding palliative care and postgraduate training [14]. Although different studies have attempted to assess professionals' knowledge levels, validated tools are not often used [33]. In our country, the need to establish specific ongoing training programs for health system professionals was already being considered to adequately attend to the needs of patients with an advanced or terminal illness and their families [33]. Previous studies have suggested that the contents should include symptom control, communication skills, and optimization of care coordination. However, comprehensive evaluation, ethical aspects [48,49], and communication skills were missing, such as family support, the psychosocial aspects of care [50], and tools that allow for objectively knowing the gaps and training needs [13].
When analyzing the results obtained, we see that the nurses participating in our study have an averagely low level of knowledge, which is higher in those who report having some training or experience in the PC field. These results show the importance of these professionals receiving at least some basic training in PC during their undergraduate training, which is very heterogeneous in our country [51,52]. As indicated in previous studies, there is a need for improved palliative care education in clinical practice settings and undergraduate programs to improve registered nurses' knowledge, attitudes, and beliefs about end-of-life care [53,54]. It should be considered that different studies assess the improvement in professionals' comfort in caring for people with palliative care depending on their experience and training [50,55]. In addition, experience and training in palliative care improves attitudes toward care for the dying [28,42,47,50,51,56]. It is worth noting from the study by García-Salvador that despite a high percentage of nurses with PC training (86.1% of which 45.4% had basic training), only 40.5% felt quite or very prepared to work with palliative patients, stating that 68.2% of the nurses needed a lot or enough training. The self-perceived training needs of the subjects varied according to their level of training. Thus, in terms of nurses with more training, the training needs in psycho-emotional, spiritual, or grief care and coping with losses predominated. In contrast, those with no training or with basic training expressed training needs in symptomatic control, PC principles, psycho-emotional or mourning, and coping with the loss [23].
Another aspect to consider is the specialization of Family and Community Nurses, whom we see in the study obtaining better results at this level of knowledge, which could reflect their training during their residency [52,57,58]. Regarding the training of specialist nurses, it should be taken into account that among the learning outcomes of care for older people is found in the curriculum of the training of specialist nurses the "Plan, implement and coordinate jointly with other professionals and specialists in palliative care programs". However, not all specialist nurses have rotated through specific palliative care units [58]. As occurs with medical professionals, the family and community nurse specialist presents a global vision of the person and the community, with transversal care in different areas and allowing, among other things, comprehensive and continuous care based on empathy, favoring the early detection of palliative needs, the adequacy of treatments and resources, effective communication, the best resolution of ethical conflicts, and, above all, more effective and efficient control of symptoms [59,60]. Previous studies already indicate that the diversity of patients who require palliative care aimed at improving the quality of life through symptom control, communication, emotional support, and flexible organization is increasing. Additionally, it should be considered that at the primary care level, people's and families needs are considered more important than the diagnosis itself [34,61,62]. In addition, it must be taken into account that the involvement of professionals in training implies, based on different studies, higher values in attitudes toward care of the dying [61].
Another aspect that has improved people's care is the figure of the case manager nurse, which is a figure that enables, according to the bibliography, the continuity of care, allowing case management with advanced care practice [24], allowing optimization of resources [60]. Our country's continuity of care in palliative care does not meet international standards due to economic and training barriers, with further training being essential [24,58]. The presence of an expert nurse allows for an improved experience, interest, and confidence in nurses with less training. This is essential in collaboration with other team members to improve palliative care. At the same time, the nurse manager can contribute to highquality palliative care by directly influencing care and indirectly influencing the rest of the professionals [63,64]. These professionals are in a good position that enables the dissemination of knowledge and the improvement in practice by providing opportunities to improve practice [64].
The main limitation of this study is the method of selecting the participants without having performed a sample size calculation or designed a sampling strategy, making it challenging to represent the sample. However, it does offer us an approximation of the situation of this group of professionals. Therefore, it should be a starting point, expanding the study population size and designing training strategies appropriate to the current situation.

Conclusions
Spanish nurses who carry out their activity in primary care have a low level of knowledge in palliative care, which is higher in those who have received training in this area and those with more professional experience. On the other hand, positive attitudes toward caring for the dying and working with people in their last days were identified, which were also influenced by this training and experience.
Developing specific training programs in palliative care aimed at primary care professionals will improve the care for people who require it and the professionals' confidence in their care practice. Institutional Review Board Statement: Ethical review and approval were waived for this study due to not conducting any intervention on subjects and being an anonymous data collection.