Assessment of Nurses’ Knowledge and Attitudes toward Palliative Care for Terminal Surgical Patients in Omdurman Teaching Hospital, Sudan 2025

Introduction

Palliative care is a holistic approach or practice that improves the quality of life of patients with life-threatening illnesses by relieving pain and meeting the physical, emotional, and spiritual needs to enable patients to live as comfortably (1, 2). It is estimated that 56.8 million individuals, both children and adults, require palliative care annually worldwide, and approximately 45 percent of all deaths have been recorded as having palliative care conditions (3, 4). A study in Sudan identified that the point prevalence of life-limiting and life-threatening illnesses (LL/LTI) was between 30.9 and 70.5 percent among in-patients (5). The limited availability of opioids like oral morphine, lack of continuous services and formal training in palliative care also undermine pain and symptom management of Sudanese patients with advanced stages of the disease (6, 7). Such lapses are especially vital in surgical and critical care areas where dying surgical patients are at risk of very high morbidity, complicated treatment choices and severe symptom suffering (8). In the case of nurses working with terminally ill surgical patients in Omdurman Teaching Hospital, good knowledge and acceptance of the concept of palliative care are crucial towards provision of holistic, culturally competent, and ethically appropriate care.

Palliative care in surgical and critical-care aspects assumes a rather essential role in a patient with terminal illness (9). The combination of acute surgery operation and the threat of complications and imminent death require the strategies based on the priorities of palliative care to be incorporated during the initial stages (10). An example is the use of interventions among surgical patients who have been identified to control symptoms, improve communication and decision making, and use of resources (11). Prognostic uncertainty, rapid deterioration, pain, dyspnoea, delirium and mixed psychosocial distress are common in the peri-operative and intensive care setting (12). The substantial literature on surgical palliative care emphasizes that surgical patients at the end of life encounter the vastness of symptom load and prognostic ambiguity combined with complicated choices (13). Nurses tend to be on the leading line in terms of measuring pain, orchestrating symptom management, of mediating between surgeon, patient and family, supporting goal-concordant care and providing psychosocial support (14). The knowledge and attitude of nurses towards palliative care in the surgical wards and the ICUs would be critical given the high-paced and acuity nature of surgical wards, alongside the surgery procedures (15).

Despite the role of palliative care in enhancing the quality of life of the dying surgical patients, nurses in Sudan hospitals do not have proper training and structured services to deliver effective care to patients. Although the number of terminal surgical cases in Omdurman Teaching Hospital continues to grow, the depth of knowledge and attitudes of the nurses towards palliative care is almost undocumented (16). Lack of easy access to necessary pain medications and pain-relief drugs in particular oral morphine, interferes with the management of the nurses in treating severe symptoms in terminal patients, which has always been a problem with the Sudan regulatory and supply system (17, 18). Sudanese patients admitted to hospitals have high symptom burden, with pain, family distress, and decreased mobility, which contributes to the problem of patients requiring skilled palliative interventions (19). The congestion and deficits in the surgical wards and the high staffing load among nurses subject them to high workload demands, thus limiting their opportunities and ability to deliver the holistic health palliative care in hectic surgical and critical-care units (20).

The current study contributes necessary data about nurses’ knowledge and attitude towards palliative care of terminal surgical patients in Omdurman Teaching Hospital where palliative services are underdeveloped and poorly incorporated into the surgical practice. The research aids in improving the quality of end-of-life care, management of symptoms, and patient dignity by revealing gaps in knowledge, training requirements, and barriers related to attitudes. Making informed decisions, addressing resource allocation, and integrating palliative-care principles into standard surgical practice, the findings can inform policymakers, hospital administrators, and nurses’ educators to design specific training programs and to implement palliative-care principles into routine surgical care. The purpose of the study was to determine the degree of knowledge and attitudes of nurses towards palliative care of terminally operated surgical patients in Omdurman Teaching Hospital, Sudan. The objectives of the research were to establish the knowledge of nurses on palliative care of terminal surgical patients, attitudes toward the end-of-life care, and identify areas of relationship between demographic factors, knowledge levels, and attitudes to find factors that impacted palliative-care competency among nursing professionals.

Despite the growing global emphasis on palliative care, there remains a significant lack of evidence regarding nurses’ knowledge and attitudes toward palliative care in surgical and critical care settings in Sudan. In particular, there are no published studies focusing specifically on nurses caring for terminal surgical patients in Omdurman Teaching Hospital. This study addresses this gap by providing empirical evidence on nurses’ knowledge and attitudes in a high-acuity surgical setting. The findings will contribute to improving palliative care education, informing hospital policy, and guiding the integration of palliative care principles into routine surgical and intensive care practice in Sudan.

Methods

Study Design

A descriptive cross-sectional study design was employed to assess nurses’ knowledge and attitudes toward palliative care for terminal surgical patients at Omdurman Teaching Hospital, Sudan. This design was selected because it allows for the assessment of variables at a single point in time without manipulating the study environment. It is particularly suitable for healthcare research, where timely evaluation of healthcare providers’ competencies can inform targeted interventions, training programs, and policy development. The study was conducted over a two-month period from May 1 to June 30, 2025.

Study Setting

The study was conducted at Omdurman Teaching Hospital, a major tertiary care hospital in Sudan. The hospital provides a wide range of surgical and critical care services, making it an appropriate setting due to the availability of nurses routinely involved in the care of patients requiring palliative services.

Study Population

The study population consisted of (n = 200) registered nurses who worked in the surgical wards and intensive care units of Omdurman Teaching Hospital throughout the study period. The study used a stratified random sampling method to achieve equal representation of nurses in surgical wards and those in the intensive care units. This sampled population provided critical information on what the nurses engaging in the study of provision of palliative care to terminally ill surgical patients know, and their attitudes associated with it.

Inclusion exclusion criteria

The inclusion criteria were that they had to be registered nurses and have a minimum of six-month clinical experience in surgical or ICU units and they have to be willing to participate in the study. Some of the exclusion criteria included nurses who were on leave during the data collection process, and those nurses who served in non-surgical wards because they did not deal directly with terminal surgery patients.

Sample Size

The sample size was calculated using Slovin’s formula:

Where:

• N= 200 (total nurses in target units)

• e=0.05 (margin of error)

= = ≈ 133

Sampling Technique

The study employed a stratified random sampling method to ensure adequate representation of nurses from both surgical wards and intensive care units. The total nursing population was first divided into two distinct strata based on work units (surgical wards and intensive care units). A complete list of eligible nurses within each stratum was obtained from the hospital nursing administration, which served as the sampling frame.

Within each stratum, simple random sampling was performed using a computer-generated random number method (Microsoft Excel random function). Each nurse was assigned a unique identification number, and participants were randomly selected until the required sample size for each stratum was achieved.

This sampling technique was selected because nurses in surgical wards and intensive care units differ in their exposure to palliative care practices and clinical responsibilities. Stratified random sampling ensured proportional representation from both units, reduced selection bias, and improved the comparability and generalizability of the study findings.

Data Collection Tool

The structured self-administered questionnaire was used to collect data where the interviewees were required to answer the questions and enable the researcher to have a good understanding of their responses. The questionnaire was developed by researchers based on an extensive literature review of previously validated instruments in palliative care, and its content validity was ensured by expert review.

A self-administered questionnaire that had three sections was used to collect data. In the initial part, demographic information was collected in the form of age, gender, education, experience, and department. The second was an evaluation of palliative care knowledge using a 20 multiple choices questions scored out of 20. The third part measured the attitudes using 10 Likert-scale statements. This instrument was piloted with 10 nurses and validated by three experts in palliative care to give a Cronbach alpha of 0.82 indicating reliability.

Data Collection Procedure

Data collection was conducted over a two-month period from May 1 to June 30, 2025. Written informed consent was obtained from all participants prior to data collection. The questionnaires were distributed in printed (paper-based) form to nurses during their duty shifts in the surgical wards and intensive care units. The paper-based questionnaire format was selected to accommodate participants’ clinical workload and to ensure a high response rate.

Participants completed the questionnaires independently and returned them directly to the researcher. Distribution during working shifts was intended to minimize disruption of clinical duties. Completed questionnaires were collected promptly to ensure data accuracy while maintaining participants’ privacy and confidentiality.

Completed questionnaires were manually coded and entered into Microsoft Excel, then exported to SPSS version 25 for statistical analysis. Double data entry verification was performed to minimize errors.

Data Analysis

The data analysis was conducted using SPSS 25 version to enter data and conduct statistical analysis. Demographic variables were summarized using descriptive statistics including frequencies, percentages, means, and standard deviations. Pearson correlation as a part of inferential analysis was used to study the relationships between continuous variables and Chi-square test was used as an inferential method to examine relationships between categorical variables. The p-value was set at P < .05, indicating statistical significance.

Ethical Considerations

Ethical approval was obtained from the Ethics Committee of Omdurman Teaching Hospital (Approval No.: OM-2025-128AP, dated April 27, 2025). Written informed consent was obtained from all participants after explaining the purpose, procedures, risks, and benefits of the study. Participation was voluntary, and participants were informed of their right to withdraw at any stage without any consequences. Participants were fully informed about the study objectives and assured that their participation or refusal would not affect their employment or professional evaluation.

Confidentiality and anonymity were strictly maintained by using coded identifiers instead of names. Data were securely stored and accessed only by the research team. The study adhered to the ethical principles outlined in the Declaration of Helsinki.

Results

1. Demographic Characteristics

The sample of the study consisted of 133 registered nurses at Omdurman Teaching Hospital. Most of the participants were female (66.9%), a verdict that is consistent with the typical gender distribution in the field of nursing. Most participants were in the age range of 20–30 years (42.1%), followed by 31-40 years (35.3%), which indicates that there is a relatively young workforce of nurses. In terms of experience, 36.1% (n=48) had less than 5 years’ experience, 39.1% (n= 52) had between 5 and 10 years and 24.8% (n=33) had more than 10 years (see Table 1).

2. Knowledge and Attitude Scores

The findings indicate that the mean knowledge score was 12.8 out of a possible 20, and the standard deviation was 3.2, and this could indicate that there was variation in knowledge amongst the respondents. Attitudinally, the average score stood at 4.1 over 5-point Likert scale and the standard deviation of .5. This also indicates a very positive attitude of the nurses to palliative care, which is characterized by the openness and readiness to support the patient with end-of-life care with a compassionate attitude (See Table 2).

3. Knowledge Levels

The results of Table 3 indicate significant differences in the levels of knowledge of nurses about palliative care. Most respondents (52.6%) indicated moderate level of knowledge which implies that they have moderate knowledge but can be better. This condition meant that only a small percentage of the nurses with scores in the good knowledge category were 24.1% which is a limited population with high competency on palliative care. The level of poor knowledge amounted to 23.3 percent, and this fact highlights great gaps that can lead to poor quality of care provided to terminal surgical patients.

4. Attitude Levels

Table 4 shows the distribution of the attitudes of nurses about palliative care 58.6% (n=78) had moderate attitudes, and 37.6% (n=50) had extremely positive attitudes, meaning that they were highly inclined to the supportive and compassionate care. A very small percentage 3.8% (n=5) of respondents showed low scores in the attitudes levels indicating that there were a few negative perceptions. The overall situation of the most nurses related to the attitude towards palliative care is quite positive and can be improved by specific trainings and educational programs.

5. Correlation between Demographics, Knowledge, and Attitudes

Pearson correlation analysis revealed significant positive associations between demographic variables and nurses’ knowledge and attitudes toward palliative care (Table 5).

Years of experience demonstrated a moderate positive correlation with knowledge (r = .42, P = .001) and a weak positive correlation with attitudes (r = .29, P = .02). Similarly, age was positively correlated with knowledge (r = .25, P = .006) and attitudes (r = .18, P = .04). A statistically significant positive correlation was also observed between knowledge and attitudes (r = .35, P = .004), indicating that higher knowledge scores were associated with more favorable attitudes toward palliative care.

No statistically significant association was found between gender and knowledge (r = −.08, P= .35) or attitudes (r = .12, P= .18).

Discussion

This study evaluated nurses’ knowledge and attitudes toward palliative care for terminal surgical patients at Omdurman Teaching Hospital in Sudan. The demographic characteristics observed in this study were consistent with findings reported in previous research on nursing populations in palliative care contexts. The predominance of female nurses reflected the traditional gender distribution within the nursing profession. Additionally, the relatively young workforce and variation in years of experience suggested potential for further professional development and skill enhancement. Previous studies emphasized the importance of clinical experience in improving palliative care competencies, as more experienced nurses demonstrated greater confidence and improved decision-making in managing terminally ill patients (21, 22).

Regarding knowledge and attitudes, the findings supported existing literature indicating that nurses often exhibited more positive attitudes toward palliative care than their level of knowledge suggested. Nurses demonstrated compassionate attitudes toward end-of-life care despite limited practical understanding (16) . This discrepancy highlighted the need to reinforce positive attitudes with structured education and training to enhance clinical competence. Improving nurses’ knowledge significantly enhanced clinical performance and communication skills (23). Educational interventions were also reported to positively influence both knowledge and attitudes in palliative care settings (24). Collectively, these findings suggested that while positive attitudes provided a strong foundation for care, they required continuous professional development and adequate knowledge to ensure effective practice.

The results of the present study indicated that most nurses had a moderate level of knowledge, with only a small proportion demonstrating high competency. This finding reflected a significant knowledge gap that may adversely affect the quality of end-of-life care for terminal surgical patients. Although nurses are involved in palliative care delivery, only a minority possess a comprehensive understanding of its principles and practices (25). This gap was attributed to the lack of formal palliative care education in nursing curricula and limited access to ongoing professional training, particularly in resource-limited settings such as Sudan. Inadequate exposure to palliative care concepts and limited access to training programs significantly contributed to poor knowledge among nurses (26). Consequently, this deficiency negatively affected patient comfort and overall care quality.

In contrast to knowledge levels, the findings revealed that nurses generally exhibited positive attitudes toward palliative care, with only a small proportion expressing negative perceptions. Nurses were willing to provide empathetic and supportive care to terminally ill patients even when their technical expertise was limited (27). Positive attitudes played a critical role in delivering compassionate, patient-centered care; however, they required structured training to ensure effective clinical practice. Fostering positive attitudes was identified as a key component in establishing a strong palliative care culture within healthcare institutions (28). Furthermore, a close relationship between knowledge and attitudes was observed, and improved knowledge enhanced nurses’ confidence and commitment to holistic care (29).

The study also identified significant positive correlations between years of experience, age, knowledge, and attitudes toward palliative care. These findings suggested that increased clinical exposure and professional maturity contributed to improved understanding and more favorable attitudes. Experienced nurses were better equipped to provide palliative care due to repeated exposure to end-of-life situations (30). Clinical experience enhanced decision-making, emotional resilience, and knowledge of palliative care practices (31). Older nurses were also found to possess greater emotional intelligence and ethical sensitivity, which are essential in palliative care settings (32).

Moreover, a significant positive relationship was observed between knowledge and attitudes, indicating that higher knowledge levels were associated with more favorable attitudes toward palliative care. Educational interventions significantly improved nurses’ knowledge and attitudes by increasing their confidence and clarity in palliative care practices (33). Knowledge-building strategies such as training programs, simulations, and curriculum integration were essential in developing a competent and compassionate nursing workforce (34). These findings highlighted the reciprocal relationship between knowledge and attitudes and underscored the importance of continuous education and mentorship in improving the quality of end-of-life care.

Limitations of the Study

This study has several limitations. First, the cross-sectional design limits the ability to establish causal relationships. Second, the study was conducted in a single hospital, which may limit the generalizability of the findings. Third, the use of self-reported questionnaires may introduce response bias. Additionally, the study did not assess actual clinical practice, which may differ from reported knowledge and attitudes.

Recommendation

Following the results, it is possible to provide several crucial suggestions that should be offered to improve the level of knowledge and attitudes towards palliative care in the surgical acute care units among nurses. To achieve the foundational knowledge during the initial stages of training, implementation of formal palliative care segment modules during undergraduate and postgraduate levels of nursing education is crucial. Continuous professional development programs like workshops, learning through cases, and simulation exercises organized by the hospitals should improve the process of practical application of palliative principles. The benefits of positive clinical exposure on the knowledge and attitude of less experienced nurses can be exploited by establishing mentorship and peer-support networks that provide guidance to the experienced ones through their assistance. Policymakers and administrative staff of healthcare institutions should secure universal access to the key palliative care amenities, such as morphine in oral, and conventional care guidelines. These combined measures can go a long way in enhancing the skills and self-confidence and compassion of nurses who are involved in end-of-life care of surgical terminal patients.

Conclusion

The study concluded that nurses had moderate knowledge and generally positive attitudes toward palliative care for terminal surgical patients. Years of experience and age were positively associated with both knowledge and attitudes. A significant relationship was found between knowledge and attitudes, indicating that improved knowledge enhances nurses’ attitudes toward palliative care. Strengthening education and training programs is essential to improve palliative care delivery in surgical settings in Sudan.

References

1. Medina S, Issac M. Palliative care: Improving quality of life in head and neck cancer patients. Head and Neck Cancer Rehabilitation: Elsevier; 2025. p. 237-62.

2. Mabonga L, Luvhengo TE, Chikanza IC, Lolas G, Dlamini Z. Palliative Care and Quality of Life. Understanding Pancreatic Cancer: CRC Press; 2026. p. 167-83.

3. Knaul F, Radbruch L, Connor S, de Lima L, Arreola-Ornelas H, Mendez Carniado O, et al. How many adults and children are in need of palliative care worldwide. Global atlas of palliative care. 2020;2:17-32.

4. Sjöberg M, Edberg A-K, Rasmussen B, Beck I. Documentation of older people’s end-of-life care in the context of specialised palliative care: a retrospective review of patient records. BMC palliative care. 2021;20(1):91.

5. Gafer N, Marhoom M, Siddig S, Ali H, Mursi M, Harðardóttir D, et al. Prevalence of life-limiting and life-threatening illness and associated palliative care needs among hospital inpatients in Sudan. Journal of pain and symptom management. 2022;63(1):124-30.

6. Mutinda J. Opioid Prescriber Related Barriers to Pain Management in Palliative Care. Nur Primary Care. 2022; 6 (1): 1-5. Jomo kenyatta university of agriculture & Technology School of nursing, Nairobi.

7. Elhassan MMA, Mohammed AAA, Omer AA, Azeem AAM, Mohammed HMA, Ibrahim IEM, et al. Adverse events of opioids for cancer-related pain in a resource-limited setting: a cross-sectional study from Sudan. ecancermedicalscience. 2022;16:1366.

8. Michels G, Schallenburger M, Neukirchen M. Recommendations on palliative care aspects in intensive care medicine. Critical Care. 2023;27(1):355.

9. Louie AD, Miner TJ. Palliative surgery and the surgeon’s role in the palliative care team: a review. Annals of Palliative Medicine. 2022;11(2):90717-917.

10. Alhazmi JD. Nursing strategies to improve the quality of life for terminally ill patients. Gland Surgery. 2024;9(2):111-7.

11. Zucker BE, Leandro L, Forbes K, Blazeby JM, Chamberlain C. Training surgeons to optimize communication and symptom management in patients with life-limiting conditions: systematic review. BJS open. 2023;7(2):zrad015.

12. Bramati P, Bruera E. Delirium in palliative care. Cancers. 2021;13(23):5893.

13. Marterre B, Kopecky K, Miller P. Primary palliative care for surgeons: a narrative review and synthesis of core competencies. Annals of Palliative Medicine. 2022;11(2):88506-906.

14. Gélinas C. Pain and pain management. Critical Care Nursing-E-Book: Critical Care Nursing-E-Book. 2021:116.

15. Mascellaro N. Discovering the Meaning of Quality Nursing Care Through the Lived Experience of Bedside Critical Care Nurses: Teachers College, Columbia University; 2024.

16. Alshammari F, Sim J, Lapkin S, Stephens M. Registered nurses’ knowledge, attitudes and beliefs about end-of-life care in non-specialist palliative care settings: A mixed studies review. Nurse education in practice. 2022;59:103294.

17. Aregay A, O'connor M, Stow J, Ayers N, Lee S. Perceptions of barriers to using opioid analgesics: a mixed methods study. Palliative Medicine Reports. 2023;4(1):249-56.

18. S. Moni S, Ayish F, Musawi S, Ravula SR, Abdelwahab SI, Salawi A, et al. Beyond pain relief: a comprehensive review of analgesic self-medication and its broad implications. Critical Public Health. 2025;35(1):2582887.

19. Kebudi R, Cakir FB, Silbermann M. Palliative care in high and low resource countries. Current Pediatric Reviews. 2021;17(3):220-4.

20. Acquah M. Palliative Care in Humanitarian Settings: Insights from Nurses on Experiences, Challenges, and Support Needs. 2024.

21. Suikkala A, Tohmola A, Rahko EK, Hökkä M. Future palliative competence needs–a qualitative study of physicians’ and registered nurses’ views. BMC Medical Education. 2021;21(1):585.

22. Pan H-H, Wu L-F, Chang L-F, Hung Y-C, Lin C, Ho C-L. Effects of dispositional resilience and self-efficacy on practice in advanced care planning of terminally ill patients among Taiwanese nurses: A study using path modeling. International journal of environmental research and public health. 2021;18(3):1236.

23. Alrashidi N, Pasay an E, Alrashedi MS, Alqarni AS, Gonzales F, Bassuni EM, et al. Effects of simulation in improving the self-confidence of student nurses in clinical practice: a systematic review. BMC Medical Education. 2023;23(1):815.

24. Abuhammad S, Almasri R. Impact of educational programs on nurses’ knowledge and attitude toward pediatric palliative care. Palliative & supportive care. 2022;20(3):397-406.

25. Xu Y, Zhang S, Wang J, Shu Z, Jing L, He J, et al. Nurses' practices and their influencing factors in palliative care. Frontiers in Public Health. 2023;11:1117923.

26. Durojaiye A, Ryan R, Doody O. Student nurse education and preparation for palliative care: A scoping review. Plos one. 2023;18(7):e0286678.

27. Wells C, Bressler T. “Unaware and Unprepared”: experiences of critical care nurses providing end-of-life care; A qualitative study. Journal of Hospice & Palliative Nursing. 2023;25(2):105-13.

28. Agunwah E, Nworie A, Eze C. Effect of supportive palliative care educational intervention on nurses’ knowledge and attitude towards palliative care in selected tertiary hospitals in South East Nigeria. Medicine and Public Health Research Journal, 2024, 14-31 https://doi.org/105281/zenodo. 2024;10843728:2

29. Alzwehry SKF, Al-husayni AMM, Almohammadi FHS, Aljohani KMG, Khan SAA, Alhazmi MSS, et al. Integrating Public Health Strategies and Health Education in Nursing Practice: A Holistic Approach to Patient-Centered Care. Journal of International Crisis and Risk Communication Research. 2024;7(S6):2119.

30. Fisher S, Gillanders D, Ferreira N. The experiences of palliative care professionals and their responses to work‐related stress: A qualitative study. British journal of health psychology. 2022;27(2):605-22.

31. De Boer M, Reimer-Kirkham S, Sawatzky R. How nurses’ and physicians’ emotions, psychosocial factors, and professional roles influence the end-of-life decision making process: An interpretive description study. Intensive and Critical Care Nursing. 2022;71:103249.

32. Geng S, Zhang L, Zhang Q, Wu Y. Ethical dilemmas for palliative care nurses: systematic review. BMJ supportive & palliative care. 2024.

33. Chen X, Zhang Y, Arber A, Huo X, Liu J, Sun C, et al. The training effects of a continuing education program on nurses’ knowledge and attitudes to palliative care: a cross sectional study. BMC palliative care. 2022;21(1):56.

34. Rykkje L, Søvik MB, Ross L, McSherry W, Cone P, Giske T. Educational interventions and strategies for spiritual care in nursing and healthcare students and staff: A scoping review. Journal of clinical nursing. 2022;31(11-12):1440-64.