Nurse’s Attitude Towards Palliative Care and Associated Factors in Ethiopia: a Systematic Review and Meta-analysis

Background: Palliative care signicantly improves the distressing symptoms of patients, especially those with cancer, heart disease, renal disease, and liver disease, and its need is increasing worldwide due to the growing burden of chronic disease. Nurses with an unfavorable attitude towards palliative care cannot skilfully assess the patient's needs, effective communication, and adequately address the patient's problems. Thus, this study was amid to assess the nurse’s level of attitude towards palliative care in Ethiopia. Method: PubMed/MEDLINE, HINARI, EMBASE, Scopus, Google Scholar, and African Journals Online (AJOL) were the databases used to search for articles. Cochrane I2 statistics and Eggers test was done to check heterogeneity and publication bias, respectively. Subgroup analysis and sensitivity analysis were also done to detect the source of heterogeneity and an inuential study, respectively. Result: The pooled prevalence of nurse’s attitudes towards palliative care was 67.15% (95% CI: 54.75-79.54. Palliative care training was a signicantly associated factor with the level of nurse’s attitude towards palliative care. Accordingly, nurses who have taken palliative care training (AOR=2.53; 95% CI; 1.88-3.40) was found a signicantly associated factor with the level of nurse’s attitude towards palliative care. Conclusion: More than half of the nurses had a favorable attitude towards palliative care. Palliative care training was a signicantly associated factor with the nurse’s level of attitude towards palliative care. Thus, palliative care training and improving nurse’s careers through continuous professional development should be given regularly for nurses to improve their knowledge about palliative care.


Introduction
Comprehensive and humanistic care are the main tasks of nurses that focus on the patient's body, soul, and environment. One of the types of nursing comprehensive and humanistic care is palliative care (1). Palliative care is an approach to pain management of patients facing a severe illness that enhances the patient's quality of life. It includes any form of medical and nursing care which is planned to decrease the intensity of symptoms (2). Palliative care signi cantly improves the distressing symptoms of patients, especially those with cancer, heart disease, renal disease, and liver disease (3). The need for palliative care is increased in the globe due to the growing burden of chronic diseases and aging populations (4). The incidence, prevalence, and death due to chronic illness are increasing worldwide with long-term disabilities and comorbidities. The estimated annual deaths of patients with chronic diseases in England are projected to rise by 25.4 % (from 501,242 deaths in 2014 to 628,659 in 2040) (5). The need for effective palliative care service may become more signi cant in low-income countries including Ethiopia (6). In low-income countries, lack of resources, ignorance regarding palliative care, the reluctance of nurses to give palliative care, and restrictive nurses who are responsible to provide palliative care were the most common barriers to access palliative care (7).
The nurse acts as a link between different levels of care, between professionals and patients and families which contribute to the quality of care to the individual patient (8). They play an important role in providing quality palliative care. The attitude of nurses towards palliative care can affect the quality of palliative care (9). Nurses with an increased capacity of giving palliative care can decrease the suffering of patients and reduce costs for hospitalized adults with serious and complex disease (10). However, nurses with an unfavorable attitude towards palliative care cannot skilfully assess the patient's needs, effective communication, and adequately address the patient's problems (11). Previous studies showed that nurses attitudes towards palliative care were; 69.1% (12), 56.6% (13), 44.25% (14), and 53.41% (15). Experience of nurses, level of education, palliative care training, knowledge on palliative care, and inservice education are possible factors that may affect the attitude of nurses towards palliative care (16-18). In Ethiopia, the issue of palliative care, the nurse's attitude towards palliative care was not well discussed previously. Therefore, it is necessary to evaluate the attitude of nurses towards palliative care in Ethiopian nurses. Thus, this study is designed to evaluate a nurse's attitude towards palliative care in Ethiopia.

Study protocol
This systematic review and meta-analysis was conducted to evaluate the attitude of nurses towards palliative care and its associated factors in Ethiopia using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) checklist for reporting of ndings (Table S1) (19).

Databases and searching strategies
In this systematic review and meta-analysis, the following searching databases were used; Google Scholar, Web of Science, African Journals Online (AJOL), HINARI, PubMed/MEDLINE, and EMBASE. We also searched the unpublished articles from the repositories of Ethiopian universities. The articles were searched from January 1st up to October 01, 2020. All articles that report the attitude of nurses towards palliative care and its associated factors in Ethiopia were included in the nal analysis. The searching engine terms used were "attitude", "feeling", "perception", "palliative care", "end of life care", "EOL", "caring terminally ill", "factors", "associated factors", "determinant factors", "nurses", "hospital-based nurses" and "Ethiopia". "AND" and "OR" Boolean operators strings were used. The date range for included study was from 2014-2020 (Table 1). Table 1 Search of databases about the attitude of nurses towards palliative care and its associated factors in Ethiopia.

Databases Searching terms
Number of studies MEDLINE/ PubMed "Attitude" OR "feeling" OR "perception" AND "palliative care" OR "PC" OR "EOL" OR "end of life care" OR "caring terminally ill" AND "factors" OR "associated factors" OR "determinant factors" AND "nurses" OR "hospital-based nurses" AND "Ethiopia" 89 Google Scholar "Attitude" AND "palliative care" OR "end of life care" OR "caring terminally ill" AND "associated factors" OR "determinant factors" AND "nurses" OR "hospital-based nurses Screening and eligibility of the study The retrieved articles were exported to EndNote Reference software version 8 (Thomson Reuters, Stamford, CT, USA) citation manager to sort and avoid possible duplications. Three investigators (AG, AD, and AW) independently evaluated each study by title and abstracts using predetermined inclusion criteria.
The rst name of the authors, publication year, a region where the study was conducted, sample size, study period, the attitude of nurses, and factors affecting nurse's attitudes towards palliative care were extracted. Any discrepancies between the authors during the process of extraction, evaluation, and reviewing of the articles were resolved.

Inclusion and exclusion criteria
All cross-sectional studies reporting the attitude of nurses towards palliative care and its associated factors in Ethiopia were included. Whereas articles that did not report outcome variables, qualitative studies, interventional studies, trials, case reports, news, and studies without full text were excluded from the analysis.
Outcome measurement of the study The outcomes of this study are the attitude of nurses and the associated factors that affect the attitude of nurses towards palliative care. The attitude of nurses was measured by the mean score of Frommelt Attitudes Toward Care of the Dying (FATCOD) scale. Then, the outcomes were leveled as a favorable attitude for those nurses who were scored mean and above of FATCOD scale, whereas nurses who were scored below the mean of the FATCOD scale were considered under unfavorable attitude.

Quality Assessment
Three authors; AG, AD, and AW independently evaluated the quality of each study using the Newcastle Ottawa Scale (NOS) for cross-sectional studies (20). The methodological quality, comparability, outcomes, and statistical analysis of the studies were the assessment tools used to declare the quality of the studies. Studies scored a scale of ≥ 7 was considered as achieving high quality. The disagreement between the authors was resolved by other reviewers (MB and GG). Then all authors independently assessed the articles for consideration and inclusion in the nal analysis.

Data processing and analysis
The pooled prevalence of nurse's attitudes towards palliative care and its associated factors in Ethiopia were weighted using the inverse variance randomeffects model at 95%Cl (21). The Microsoft Excel spreadsheet was used to extract and clean the data. Then, the data were exported to STATA version 11 statistical software for analysis. The heterogeneity of the studies was assessed using Cochrane Q-test and I2 with its corresponding p-value (22). Subgroup analysis by a region where the study was conducted, the study period, and the sample size was done to examine the source of heterogeneity. The presence or absence of in uential studies was checked by conducting sensitivity analysis. Egger's test was also done to detect the presence of publication bias and was presented with a funnel plot (23). Regarding the associated factors, a log odds ratio was used to decide the association between associated factors and the nurse's attitude towards palliative care. In this study, a statistical test with a P-value of < 0.05 was considered statistically signi cant.

Result
All retrieved articles were 289. Of these articles, 96 were excluded due to duplication. One hundred fty-one articles were further excluded after reviewing the titles and abstracts of the studies. Furthermore, 33 articles were excluded that did not ful ll the inclusion criteria. Finally, nine articles were included in the nal analysis (Fig. 1).

Characteristics of the studies and study participants
Nine articles with a total study population of 2709 (1137 males and 1572 females) were included in this review. The studies were; three from the Amhara region (14, 15, 24), two from Addis Ababa city administration (25, 26), two from the Tigri region (27, 28), one from the Oromia region (29), and one from Harar region (30). All studies were cross-sectional in design and the sample size of the included studies was ranged from 197-392 (Table 2). Attitude of nurses towards palliative care The pooled prevalence of the attitude of nurses towards care in Ethiopia was 67.15% (95% CI: 54.75-79.54) (Fig. 2).

Heterogeneity and publication bias
Heterogeneity was detected within the studies included in the analysis (I 2 = 98.5%, p < 0.001). There is an asymmetrical distribution of studies in the funnel plot and the Egger's test was statistically signi cant (p = 0.001), suggesting the presence of publication bias (Fig. 3).

Subgroup analysis
To detect the source of heterogeneity, subgroup analysis by region, study period, and sample size was done.

Sensitivity analysis
None of the points estimated outside of the overall 95% con dence interval indicates that there is no in uential study (Table 4). Factors associated with the level of the nurse's attitude towards palliative care In this systematic review and meta-analysis, there is a signi cant association between palliative care training and nurse's level of attitude towards palliative care. Then, the odds of a nurse's attitude towards palliative care were 2.53 times more likely among nurses who had taken palliative care training than those nurses who did not take palliative care training (AOR = 2.53; 95% CI; 1.88-3.40) (Fig. 4).

Discussion
Nurses are central in providing palliative care with a holistic nursing approach of physical, psychological, emotional, social, and spiritual aspects. The current review assessed the attitude of nurses towards palliative care in Ethiopia. Accordingly, more than half, 67.15% (95% CI: 54.75-79.54), of nurses had a positive attitude towards palliative care. However, more than 30% of participants had unfavorable attitudes, which might be due to; the lack of motivation due to low salary, lack of experience, role confusion, and low level of knowledge. Similar ndings were reported in different countries; 56.6% in Sudan (13), 69.1% in Mongolia (12), 62.4% in Palestine (31), and 58.9 in Democratic Republic of Congo (32). The nding of this study was lower than studies conducted in Iran (81.8%) (33) and India (92.8%) (34). This difference might be because of the cultural differences related to giving care to the dying patients, the difference in case ow, in which previous studies were conducted in high-income countries, which helps the nurse to have more exposure to patients who need palliative care, and this builds their attitude towards palliative care. It might be also due to the absence of curriculum education content about palliative care in Ethiopia. However, the current study was higher than a study done in Egypt, 37.6% of nurses had a positive attitude towards palliative care (35). This de ciency might be due to the difference regarding in-service training, knowledge about palliative care, formal palliative care education, and job satisfaction of nurses. In the subgroup analysis, the pooled prevalence of nurse's attitudes towards palliative care was higher among nurses working in Southern Ethiopia than Northern Ethiopia. This might be due to the difference in the study setting, in which most of the study settings in Southern Ethiopia are referral and specialized where most patients who need palliative care are found. Similarly, the level of nurse's attitude towards palliative care was higher among studies conducted after 2017. This is due to the fact that nurses are building knowledge and attitude through time because they have taken training and continuous education. The higher prevalence of nurse's attitudes towards palliative care was also reported among those studies with a sample size of ≥ 300. This study results, there is a signi cant association between palliative care training and nurse's level of attitude towards palliative care. Accordingly, the odds of nurse's attitudes towards palliative care were 2.53 times more likely among nurses who had taken palliative care training than those nurses who did not take palliative care training. The reason might be because trained nurses will have good knowledge, which results in a positive attitude. This result is supported by different studies (2, 36, and 37)

Conclusion
More than half of the nurses had a positive attitude towards palliative care. In this regard, palliative care training was a signi cantly associated factor with the nurse's level of attitude towards palliative care. Thus, there should be the incorporation of palliative care in the nursing curriculum and palliative care training should be given regularly for nurses to improve their attitude towards palliative care.

Figure 1
Flow chart of selection for systematic review and meta-analysis on the attitude of nurses towards palliative care and its associated factors in Ethiopia.

Figure 2
Forest plot of the pooled prevalence of nurse's attitude towards palliative care and associated factors in Ethiopia.

Figure 3
Funnel plot with 95% con dence limits of the pooled prevalence of nurse's attitude towards palliative care and associated factors in Ethiopia.

Figure 4
The overall pooled odds ratio of the association between palliative care training and nurse's level of attitude towards palliative care in Ethiopia.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.