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Abstract

Background:

Palliative care is an essential component of holistic healthcare, addressing the physical, emotional, social, and spiritual needs of patients with serious illnesses. In Ghana, the development and integration of palliative care services remain in their infancy, with nurses playing a crucial role in service delivery.

Objective:

This study aims to assess the level of palliative care knowledge among nurses at a major Ghanaian hospital and identify factors associated with their knowledge using the Palliative Care Quiz for Nursing (PCQN).

Design:

Cross-sectional design

Methods:

This study was conducted among 252 nurses at the 37 Military Hospital in Accra, Ghana. Participants completed the PCQN, a 20-item validated questionnaire, and provided sociodemographic information. Data were analyzed to determine the relationship between various factors and the nurses’ PCQN scores.

Results:

The mean score was 9.3 (SD: 2.3). Of the 252 participants, 129 (51.2%) passed with a total score of >10, whereas the remaining 48.8% failed. Male nurses demonstrated significantly higher adjusted odds of scoring higher on the PCQN compared to their female counterparts (adjusted odds ratios (AOR) = 1.81, 95% CI: 1.05–3.10). Additionally, nurses who self-rated themselves as competent to discuss death and bereavement (AOR = 1.77, 95% CI: 1.03–3.03) and competent to provide pain and symptom management at the end of life (AOR = 2.05, 95% CI: 1.01–4.19) had significantly higher adjusted odds of achieving higher scores on the PCQN. Muslim nurses were more likely to score higher on the PCQN compared to their Christian counterparts (AOR = 2.55, 95% CI: 1.00–6.47).

Conclusion:

The study highlights a moderate level of palliative care knowledge among nurses at the 37 Military Hospital. Significant factors influencing knowledge levels include gender, self-rated competence, and religious affiliation. To advance equitable, high-quality palliative care in Ghana, policymakers and educators must prioritize three imperatives: (1) gender-sensitive training reforms to dismantle barriers limiting female nurses’ educational participation; (2) competency-based curricula that pair knowledge acquisition with confidence-building through simulation, mentorship, and reflective practice; and (3) culturally responsive pedagogies co-designed with faith leaders and communities to harmonize palliative care with Ghana’s socioreligious ethos.

Keywords

palliative care nursing quiz knowledge health education

Background

Palliative care (PC) offers essential relief from the symptoms and emotional stress associated with serious illnesses, focusing on improving the quality of life for both patients and their families.¹ This approach is comprehensive, addressing not only physical, but also emotional, social, and spiritual needs.^2,3 Globally, PC is recognized as a critical component of holistic healthcare, particularly in the context of increasing chronic illnesses and aging populations.^4,5 The World Health Organization advocates for the integration of PC into national healthcare systems, stressing the importance of policies that ensure equitable access to PC across all levels of care.^6,7

In Ghana, however, PC services are still in the early stages of development, facing substantial challenges to widespread adoption.^8,9 The healthcare system in Ghana remains predominantly focused on curative care, often overlooking the importance of PC services.^10,11 This is particularly concerning given the rising prevalence of chronic diseases, such as cancer, and cardiovascular illnesses, all of which require integrated PC.⁴ These challenges are compounded by limited resources, inadequate healthcare infrastructure, and a shortage of trained professionals, all of which further hinder the expansion of PC services.^8–10

Nurses, who are often the frontline healthcare providers in Ghana, play a critical role in the delivery of PC.⁸ The effectiveness of PC services is closely tied to nurses’ knowledge and their attitudes toward providing such care.^12,13 Evidence consistently shows that nurses with a solid understanding of PC are better positioned to offer high-quality care, manage symptoms effectively, and provide emotional and psychological support to both patients and their families.^14–17 Despite the importance of this, research on the level of PC knowledge among nurses in Ghana remains scarce, raising concerns about the quality of care currently being provided.

Knowledge gaps in PC among nurses represent a global issue, often driven by inadequate training and a limited understanding of PC principles.^18,19 In Ghana, these knowledge gaps are likely exacerbated by the inconsistent inclusion of PC education in nursing curricula across institutions, along with the limited availability of continuing education opportunities for practicing nurses. Addressing these knowledge deficits is important for improving the quality of PC services in the country especially as the demand for such services continues to rise. This study assesses the level of PC knowledge among Ghanaian nurses using two validated tools: Palliative Care Quiz for Nursing (PCQN) and the Perceptions of Preparedness and Ability to Care for the Dying (PPACD).^20,21 It seeks to contribute to the development of educational programs and policies aimed at improving PC services in Ghana.

Current state of palliative care education in Ghana

To accurately situate the PC knowledge levels of nurses, it is important to understand the context in which this occurs. There is evidence suggesting that PC is currently included in the educational curriculum of fifth-year medical students in Ghana.⁹ Additionally, family physicians and other healthcare providers, including nurses, are exposed to PC and on the job training during their mandatory national service (also known as rotation). Salifu and Davies³ also report how charity organizations, such as COMPASS Ghana, are using a non-Westernized PC approaches to train healthcare professionals including nurses on compassionate PC service delivery. There are other collaborative models, such as the Nyansapo partnership between Ghanaian and Canadian institutions, which offers short courses that aim to strengthen primary care through PC education.²² Despite this progress, Ghana’s medical education does not currently have a comprehensive PC curriculum that integrates PC education at all level of education.

Methods

Study design and setting

The cross-sectional study was conducted at the 37 Military Hospital, a leading military healthcare institution located in Accra, the capital of Ghana.¹⁰ The hospital is situated near Jubilee House, the seat of government. Originally established by British military officer General George Giffard during World War II to provide medical aid to soldiers, the facility was then known as 37 General Hospital. Over time, it expanded its services to the general public, though the majority of its staff continues to be military personnel. With a bed capacity of about 600, the hospital frequently accepts referrals from other healthcare facilities and is recognized for its vital role during national emergencies and disasters.^10,23 Additionally, the hospital hosts a Nursing and Midwifery Training School and provides specialized training programs in Anesthesia, Emergency Medical Technician, and postgraduate medical education.²³

Population

The study targeted all nurses working at the 37 Military Hospital. Respondents were selected if they met one the following criteria: (a) be a nurse on post at the hospital during the questionnaire distribution who consented to participate in the study, and (b) be rotation nurses (nurses doing the 1-year mandatory national service). Subsequently, nurses on leave and international peacekeeping missions and student nurses were exempted. Student nurses were exempted on the assumption that they may not yet have experience in caring for individuals with life-threatening illnesses.

Study variables

Outcome variable

Knowledge score on the PCQN was the outcome variable. A total knowledge score was computed by summing responses to 20 items from the PCQN (range: 0–20), with scores ⩾10 classified as “Pass” and <10 as “Fail.” The PCQN has a Cronbach’s alpha score of 0.71, which suggests a high internal consistency.

Explanatory variables

The explanatory variables examined in this study encompassed a range of sociodemographic and self-assessed professional competencies. Sex was categorized as female or male. Educational qualification was grouped into three levels: certificate, diploma, and bachelor’s degree or higher. Years of professional nursing experience was stratified into four categories: 1–5 years, 6–10 years, 11–15 years, and more than 15 years. Religious affiliation was categorized as Christian, Muslim, or other religions. Three self-rated measures of end-of-life (EoL) communication and care competence were also included: comfort in discussing death and bereavement (yes/no), perceived competence in discussing death and bereavement (yes/no), and self-rated competence in providing pain and symptom management at the EoL (yes/no). These variables were selected based on theoretical relevance and prior literature indicating their potential influence on PC knowledge among nurses.^14–17,20

Sampling and sample size

Using Yamane’s formula,²⁴ an initial sample size of 260 nurses was calculated from the 800 nurses recorded in the hospital’s workforce records at the 37 Military Hospital during the data collection period. The calculation was based on a confidence level of 95% and a margin of error of 0.05. However, a total of 252 nurses ultimately participated in the study. The difference in the number of participants was due to factors such as non-response, unavailability of during the data collection period, and exclusions based on the study’s inclusion criteria. Convenience sampling was used to select participants for the quantitative aspect of the study from the population of nurses at the 37 Military Hospital. The researcher chose participants based on availability. However, participation was voluntary and required consent.

Pilot testing

Although the instruments had proven reliable in previous studies,^12,20 the researcher conducted pilot testing since this was the first time they were being used in the Ghanaian context. The pilot test was conducted with 10 military nurses from the 1 Infantry Battalion Medical Reception Station (1 MRS), a small clinic attached to a military infantry unit. An issue arose when all 10 participants answered “Don’t know” to question 16 in the PCQN. Feedback indicated that the question referred to Demerol, a brand name for the opioid meperidine, which is not commonly used in the Ghanaian context. As a result, Demerol was replaced with pethidine, the generic name more widely recognized in Ghana. The remaining questions were clear. None of the participants scored more than 7 out of 20 on the PCQN.

To further verify, the questionnaire was distributed to six second-year residents at the Ghana College of Nurses and Midwives specializing in PC nursing. These residents, who were considered knowledgeable in PC, scored above 13 out of 20, validating the instrument’s use in this context.

Data collection procedures and instrument

An online survey strategy was employed to collect data from the nurses, offering both convenience for participants and facilitating easy dissemination of the questionnaire. The questionnaire was created using Google Forms and distributed to the nurses through their emails and preferred communication channels. It consisted of three sections: Section A gathered sociodemographic information, Section B utilized the PCQN, and Section C included questions from the PPACD instrument. The PCQN, a validated 20-item questionnaire developed by Ross et al.,²¹ is designed to identify misconceptions, assess knowledge, and stimulate discussions on PC. Respondents were asked to choose from “True,” “False,” or “Don’t know” to complete the items. The PPACD, a reliable six-item tool created by Todaro-Franceschi,²⁰ assesses the readiness of nurses and health workers to care for dying patients.

Statistical analyses

Data were analyzed using Stata version 18 (StataCorp, College Station, TX, USA). Descriptive statistics, including means, standard deviations, and score distributions, were computed for the total score. Frequencies and proportions were used to summarize the binary outcome variable (pass status) and key sociodemographic characteristics such as sex, education level, years of nursing experience, religion, and training in communication, pain management, and medication administration. Bivariate associations between each predictor and pass status were examined using cross-tabulations and Pearson’s chi-square tests. Bivariate logistic regressions with robust standard errors were conducted to estimate unadjusted associations between each independent variable and pass status. Multivariable logistic regression models were used to identify independent predictors of passing the PCQN. The final model reported adjusted odds ratios (AORs) with 95% confidence intervals. We followed the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) Checklist in reporting the study (see Supplemental File 1).

Results

Participants’ characteristics

Table 1 presents the background characteristics of the participants in the study. Regarding sex, the sample consisted of 61.5% females and 38.5% males. Most nurses had a bachelor’s degree or higher (52.4%), and had worked for 1–5 years (54.4%). In terms of religion, 83.3% identified as Christian, 11.9% as Muslim, and 4.8% belonged to other religions. The majority of the nurses felt comfortable to discuss death and bereavement (61.5%), rated themselves as competent to discuss death and bereavement (65.1%), and competent to provide pain and symptom management at the EoL (83.7%).

Table 1.

Background characteristics of participants.

Characteristics	Sample (n)	Proportion (%)
Sex
Female	155	61.5
Male	97	38.5
Qualification
Bachelors or higher	132	52.4
Diploma	103	40.9
Certificate	17	6.8
Years of experience
1–5	137	54.4
6–10	59	23.4
11–15	35	13.9
More than 15	21	8.3
Religion
Christian	210	83.3
Muslim	30	11.9
Other	12	4.8
Comfortable with discussing death and bereavement
No	97	38.5
Yes	155	61.5
Competent to discuss death and bereavement (self-rated)
No	88	34.9
Yes	164	65.1
Competent to provide pain and symptom management at the EoL (self-rated)
No	41	16.3
Yes	211	83.7

EoL: end-of-life.

Pass score from PCQN

The mean score was 9.3 (SD: 2.3). Of the 252 participants, 129 (51.2%) passed with a total score of >10, whereas the remaining 48.8% failed (see Figure 1).

Figure 1.

Pass score of participants.

Proportion of nurses who met the pass score (>10)

Table 2 shows the distribution of those who passed the knowledge test. Higher scores were reported among male nurses (59.8%), those with more than 15 years of experience (76.2%), and Muslim nurses (70.0%). Nurses who rated themselves as competent to provide pain and symptom management at the EoL (53.5%), those who were comfortable (55.5%), and competent to discuss death and bereavement (53.5%) passed the PCQN test.

Table 2.

Proportion of nurses who met the pass score (>10).

Variables	Proportion who passed, n (%)	p Values
Sex		0.031
Female	71 (45.8)
Male	58 (59.8)
Qualification		0.398
Bachelors or higher	69 (52.3)
Diploma	54 (52.4)
Certificate	6 (35.3)
Years of experience		0.066
1–5	71 (51.8)
6–10	25 (42.4)
11–15	17 (48.6)
More than 15	16 (76.2)
Religion		0.079
Christian	103 (49.1)
Muslim	21 (70.0)
Other	5 (41.7)
Comfortable with discussing death and bereavement		0.085
No	43 (44.3)
Yes	86 (55.5)
Competent to discuss death and bereavement (self-rated)		0.782
No	44 (50.0)
Yes	85 (51.8)
Competent to provide pain and symptom management at the EoL (self-rated)		0.089
No	16 (39.0)
Yes	113 (53.5)

EoL: end-of-life.

Factors associated with nurses’ score on the PCQN

Male nurses demonstrated significantly higher adjusted odds of scoring higher on the PCQN compared to their female counterparts (AOR = 1.81, 95% CI: 1.05–3.10). Additionally, nurses who self-rated themselves as competent to discuss death and bereavement (AOR = 1.77, 95% CI: 1.03–3.03) and competent to provide pain and symptom management at the EoL (AOR = 2.05, 95% CI: 1.01–4.19) had significantly higher adjusted odds of achieving higher scores on the PCQN. Furthermore, Muslim nurses were more likely to score higher on the PCQN compared to their Christian counterparts (AOR = 2.55, 95% CI: 1.00–6.47; Table 3).

Table 3.

Factors associated with nurses’ score on the PCQN.

Variables	Unadjusted model (COR, 95% CI)	Adjusted model (AOR, 95% CI)
Sex
Female	Ref.	Ref.
Male	1.76 (1.05–2.94) *	1.81 (1.05–3.10) *
Qualification
Bachelors or higher	Ref.	–
Diploma	1.01 (0.60–1.69)	–
Certificate	0.49 (0.17–1.43)	–
Years of experience
1–5	0.34 (0.12–0.97) *	–
6–10	0.23 (0.07–0.71) *	–
11–15	0.29 (0.09–0.98) *	–
More than 15	Ref.	–
Religion
Christian	Ref.	Ref.
Muslim	2.42 (1.06–5.54) *	2.55 (1.00–6.47) *
Other	0.74 (0.23–2.42)	0.78 (0.22–2.76)
Comfortable with discussing death and bereavement
No	Ref.	–
Yes	1.07 (0.64–1.81)	–
Competent to discuss death and bereavement (self-rated)
No	Ref.	Ref.
Yes	1.56 (0.94–2.61)	1.77 (1.03–3.03) *
Competent to provide pain and symptom management at the EoL (self-rated)
No	Ref.	Ref.
Yes	1.80 (0.91–3.57)	2.05 (1.01–4.19) *

AOR: adjusted odds ratio: COR: Crude Odds Ratio; EoL: end-of-life: PCQN: Palliative Care Quiz for Nursing. Ref: reference category; (–) variables excluded after backward stepwise approach. Bold texts are the statistically significant results.

p < 0.05.

Discussion

This study provides critical insights into the factors associated with Ghanaian nurses’ knowledge of PC, as evidenced by their performance on the PCQN. Almost half of the participants (48.8%) did not achieve a passing score, reflecting significant gaps in PC knowledge, which is consistent with trends observed in other low- and middle-income countries in Africa such as Nigeria¹⁵ and Ethiopia.¹⁷ Trends in PC knowledge deficits are consistently observed in other developing nations, where research similarly highlights inadequate levels of PC knowledge among nurses.^25–28

One of the key findings was the influence of gender on knowledge levels. Male nurses had significantly higher odds of scoring well on the PCQN compared to their female counterparts. This is inconsistent with a related study conducted among healthcare professionals in Portugal where females had a higher knowledge on PC than their male counterparts.²⁹ It is plausible that differences in access to training opportunities or educational pathways may exist between male and female nurses in this context. For instance, male nurses may have greater access to specialized PC training programs, mentorship, or continuing professional development opportunities, which could enhance their knowledge base.

In addition to gender, nurses’ self-rated competencies were strongly associated with their performance on the PCQN. Specifically, nurses who reported confidence in their ability to engage in sensitive discussions around death and bereavement, as well as those who perceived themselves as proficient in managing EoL pain and symptoms, demonstrated significantly higher knowledge scores. This correlation aligns with existing literature emphasizing self-efficacy as a critical mediator of clinical competence, particularly in PC contexts where psychosocial and technical skills intersect.³⁰ While knowledge acquisition remains foundational, the findings highlight the necessity of integrating pedagogical strategies that explicitly target the development of confidence alongside technical expertise. Simulation-based training focused on difficult conversations (e.g., breaking bad news, addressing cultural beliefs about death) or immersive clinical experiences in symptom management could bridge the gap between abstract knowledge and self-assured practice.³¹

The study also found that religious affiliation was significantly associated with PC knowledge levels, with Muslim nurses being more likely to achieve higher scores compared to their Christian counterparts. This finding invites a nuanced exploration of how socioreligious frameworks in Ghana – a nation where faith deeply permeates cultural norms, healthcare decision-making, and conceptions of mortality – may shape professional engagement with PC principles.³² The disparity in knowledge levels could reflect divergent theological, ethical, or cultural orientations toward death, suffering, and caregiving embedded within Islamic and Christian traditions. For instance, Islamic teachings emphasizing communal responsibility for the sick and dying (e.g., the concept of Sadaqah (charity) as a spiritual duty) may foster greater exposure to EoL care practices within Muslim communities, thereby enhancing nurses’ familiarity with palliative approaches.³³ Conversely, Ghanaian Christian traditions, which often prioritize divine healing and resurrection hope, might inadvertently frame death as a “failure” of faith or medical intervention, potentially distancing practitioners from PC’s holistic ethos.

Implications for policy and practice

The moderate level of PC knowledge among nurses at the 37 Military Hospital underscores the need for targeted educational interventions. Integrating PC training into both undergraduate nursing curricula and continuing professional development programs could help bridge these gaps. Such interventions would ensure that nurses, as frontline healthcare providers, are equipped with the knowledge and skills necessary to provide high-quality PC, which is critical as the prevalence of chronic and terminal illnesses continues to rise in Ghana.

One key implication for practice is the need to focus on building nurses’ self-perceived competence in PC. The strong association between self-rated competence and actual knowledge scores suggests that improving nurses’ confidence in their ability to manage PC situations could enhance the quality of care delivered. Educational programs should, therefore, focus not only on imparting knowledge but also on practical, skills-based training that boosts nurses’ confidence in handling EoL care scenarios. From a pedagogical perspective, these results advocate for interprofessional and interfaith collaborations in PC education. Partnering with religious leaders to co-design curricula or host community dialogues on EoL care could bridge doctrinal divides and foster shared understanding.

Additionally, these findings support the need for healthcare institutions like the 37 Military Hospital to prioritize ongoing training in PC. Regular in-service training programs that address both theoretical knowledge and practical competencies could help ensure that nurses remain well-prepared to deliver high-quality PC throughout their careers. As PC becomes an increasingly important component of Ghana’s healthcare system, these policy and practice changes will be essential to improving patient outcomes and ensuring equitable access to care.

Strengths and limitations

One major strength of this study is the use of validated instruments, the PCQN and PPACD, which have been widely used in PC research. This allows for the comparison of results with studies conducted in other regions and healthcare systems. Additionally, the study was conducted at the 37 Military Hospital, one of the largest and most respected healthcare institutions in Ghana, ensuring that the findings are applicable to a major segment of the nursing workforce in the country. Furthermore, the pilot testing of the instruments in the local context ensured that the data collected were culturally relevant and appropriate for the Ghanaian healthcare setting.

However, the study also has limitations that must be acknowledged. First, the use of convenience sampling may introduce selection bias, as nurses who were more available or willing to participate might have differed in their knowledge or perceptions from those who did not participate. This limits the generalizability of the findings to all nurses in Ghana. Second, the study was conducted in a single institution, and while the 37 Military Hospital is a major healthcare facility, the results may not fully represent nurses working in different types of healthcare settings, such as rural or private hospitals. Additionally, the cross-sectional design of the study only captures a snapshot in time, meaning that it cannot assess changes in PC knowledge or readiness over time. Finally, self-reported data, especially regarding perceived competence, may be subject to bias, as participants could overestimate or underestimate their true abilities.

Conclusion

The study highlights a moderate level of PC knowledge among nurses at the 37 Military Hospital. Significant factors influencing knowledge levels include gender, self-rated competence, and religious affiliation. To advance equitable, high-quality PC in Ghana, policymakers and educators must prioritize three imperatives: (1) gender-sensitive training reforms to dismantle barriers limiting female nurses’ educational participation; (2) competency-based curricula that pair knowledge acquisition with confidence-building through simulation, mentorship, and reflective practice; and (3) culturally responsive pedagogies co-designed with faith leaders and communities to harmonize PC with Ghana’s socioreligious ethos.

Supplemental Material

sj-pdf-1-pcr-10.1177_26323524251346223 – Supplemental material for Factors associated with Ghanaian nurses’ knowledge of palliative care: Evidence from a cross-sectional survey based on the Palliative Care Quiz for Nursing

Supplemental material, sj-pdf-1-pcr-10.1177_26323524251346223 for Factors associated with Ghanaian nurses’ knowledge of palliative care: Evidence from a cross-sectional survey based on the Palliative Care Quiz for Nursing by Samuel Asamoah Boateng and Joshua Okyere in Palliative Care and Social Practice

Footnotes

Acknowledgements

The authors acknowledge the all participants of the study.

ORCID iDs

Samuel Asamoah Boateng

Joshua Okyere

Ethical considerations

Ethical approval for this study was obtained from the 37 Military Hospital Institutional Review Board (IRB) (37MH-IRB/FLP/IPN/608/2022).

Consent to participate

Written and verbal informed consent was obtained from all participants after they had read and demonstrated an understanding of their rights and responsibilities. Participation was strictly voluntary, and participants were assured of confidentiality and their right to withdraw from the study at any time.

Author contributions

Samuel Asamoah Boateng: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Writing – original draft; Writing – review & editing.

Joshua Okyere: Data curation; Formal analysis; Investigation; Methodology; Software; Validation; Writing – original draft; Writing – review & editing.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Due to ethical reasons, the data are not accessible to the public. However, this can be obtained upon request from the first author.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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