Nursing Students’ Experiences With Patient Death and Palliative and End-of-life Care: A Systematic Review and Meta-synthesis

Much research has been done to explore different teaching modalities in palliative care, such as simulation-based learning, discussions, reflections, e-learning, which were effective in improving nurses and nursing students’ attitudes toward death and care of dying patients and enhancing their knowledge (Chua and Shorey, 2021, Donne et al., 2019, Ruiz-Pellón et al., 2020). Numerous reviews evaluating nurses and nursing students’ learning experiences and outcomes of palliative care educational interventions have been published (Chua and Shorey, 2021, Condry and Kirkpatrick, 2021, Ruiz-Pellón et al., 2020). However, reviews on nursing students’ experiences with patient death and palliative and end-of-life care, which would further illustrate the influence of palliative care education (or the lack of it) on their clinical experiences, are rare. A recent realist review included only studies on first-year nursing students’ first clinical death (Gorchs-Font et al., 2021) and the sole systematic review and meta-synthesis on nursing students’ experiences of caring for dying patients and their families included studies up to 2017 (Wang, 2019). An updated review is imperative to develop a more current and comprehensive understanding of nursing students' experiences.

In addition, the rapid development of palliative care globally over the past 50 years (albeit unevenly across countries) – from the initial hospice-based care to community care, the establishment of generalist and specialist care services and the current advocacy for integration of palliative care into existing healthcare systems requires parallel efforts in academia (Phillips and Currow, 2019). Even as a large body of research related to palliative care education interventions reported positive results in enhancing nursing students’ palliative care competencies (Chua and Shorey, 2021, Donne et al., 2019, Ruiz-Pellón et al., 2020), graduates continue to report feeling unprepared in providing palliative and end-of-life care (Latta and MacLeod, 2019, Puente-Fernández et al., 2020, Zheng et al., 2021), which is likely due to both the emotionally difficult aspects of the job and shortcomings in their education (Latta and MacLeod, 2019). This suggests that although nursing educational research on palliative and end-of-life care has increased in recent years, such topics may not be integrated into the curriculum and/or addressed thoroughly across nursing schools to adequately prepare nursing students for clinical practice, due to the variability in palliative care curriculum across and within countries (Davis et al., 2021, Latta and MacLeod, 2019, Nilsson et al., 2022, Pereira et al., 2021). Given these contradictory findings in nursing education and clinical practice, examining nursing students' experiences with patient death and palliative and end-of-life care is crucial for assessing their abilities to provide appropriate care and cope with these clinical encounters and for stakeholders to reflect on how to support and improve future nurses' competence in these areas.

Palliative care aims to improve the quality of life of patients and families who may be facing physical, psychological, social, or spiritual challenges due to life-threatening illness (World Health Organisation, 2020). Caring for dying patients is an unavoidable part of nursing (Chang, 2018) and nurses serve as a link between healthcare professionals, patients and families. They interact with patients the most compared with other healthcare professionals at end-of-life (Pereira et al., 2021). However, most healthcare professionals (inclusive of nurses) globally possess little or no knowledge of palliative care (Worldwide Palliative Care Alliance, 2020).

As outlined by the World Health Organisation, basic palliative care training should be provided to all healthcare professionals (Worldwide Palliative Care Alliance, 2020). Despite international organisations such as the European Association for Palliative Care recommendations’ on nursing palliative care competencies (Hökkä et al., 2020, Pereira et al., 2021), there is a significant lack of knowledge and skills among students and nurses in providing quality and appropriate end-of-life care to patients (Alhamdoun et al., 2021, Alshammari et al., 2022, Mason et al., 2020, Nilsson et al., 2022), which is a barrier to palliative care development and access (Worldwide Palliative Care Alliance, 2020). Nurses and nursing students viewed palliative and end-of-life care favourably (Jeong et al., 2020), but had low self-efficacy and confidence in tackling such issues. They had repeatedly advocated for increased education and training in palliative and end-of-life care (Puente-Fernández et al., 2020, Ruiz-Pellón et al., 2020). Current research shows that the integration of palliative care topics into the nursing curriculum remains slow and varies within and across countries (Davis et al., 2021, Latta and MacLeod, 2019, Nilsson et al., 2022, Pereira et al., 2021), showing that the continued lack of prioritisation across nursing schools have had negative impacts on nursing students’ experiences with dying patients and palliative and end-of-life care.

Evidence on nursing students’ lack of preparation to deal with palliative and end-of-life care dates to 1967, when Dr Jean Quint Benoliel, an early pioneer of palliative care nursing education, showed that caring for the dying was not a prominent focus in nursing curricula and nursing educators were also unprepared to teach such themes (D’Antonio, 2017, Pace and Lunsford, 2011). Since then, national and international associations such as the American Association of Colleges of Nursing and the European Association for Palliative Care have established desired nursing competencies in end-of-life care (Pace and Lunsford, 2011, Pereira et al., 2021). A notable achievement was the creation of the End-of-Life Nursing Education Consortium in 2000, which are online modules that have since educated thousands of nurses and nursing students worldwide (D’Antonio, 2017, Davis et al., 2021). While there has been some progress over the years (Martins Pereira and Hernández-Marrero, 2016, Pereira et al., 2021), nursing curricula vary widely internationally. Socioeconomic and political factors, such as the place of palliative care in the country's healthcare policy, cultural norms, perceptions of death and economic resources, influence nursing schools' resources and the country's ability to provide palliative and end-of-life care (Pace and Lunsford, 2011), which in turn affects nursing students’ experiences. A recent review found that available research on generalist palliative care content on undergraduate nursing curricula is scarce and were mostly limited to high-income countries (Nilsson et al., 2022). Therefore, researching nursing students' experiences with patient death and palliative and end-of-life care in clinical settings is considerably more practical and necessary for evaluating palliative care nursing education globally.

The previous systematic review and meta-synthesis examined students’ interactions with different stakeholders during the care of dying patients (dying patients, families, surroundings and themselves) with a strong focus on their experiences as they occurred. It included articles published up to 2017 only (Wang, 2019). To better comprehend nursing students' perspectives, personal and situational factors that shape their experiences should be examined as well. With the second edition of the Global Atlas of Palliative Care at the End of Life published in 2020 (Worldwide Palliative Care Alliance, 2020) and the unprecedented wave of deaths and suffering due to the COVID-19 pandemic (Sallnow et al., 2022, Zaman et al., 2021), an updated review is timely and relevant, which would further demonstrate the needed developments in palliative and end-of-life care nursing education and clinical practice.

The COVID-19 pandemic exacerbated and created new challenges in palliative and end-of-life care, including a continued emphasis on preventing deaths but not suffering, a lack of bereavement support services, increased inequalities in palliative and healthcare access as health system capacities were exceeded globally and dying alone due to visiting restrictions (Sallnow et al., 2022, Zaman et al., 2021). Learning from the pandemic, the increased awareness of death has driven societies, medicine and political spheres to prioritise palliative care as a critical component of future pandemic preparation efforts (Fadul et al., 2021, Radbruch et al., 2020, Zaman et al., 2021). Furthermore, Radbruch et al. (2020) asserted that “Basic palliative care training to all medical and nursing students has been the recommendation of the palliative care community for many years and had it been heeded, the health-care workforce would be more prepared for this pandemic.” This gives an even stronger impetus for improving nursing education in palliative and end-of-life care, making it available to all nursing schools and preparing nursing students to provide basic compassionate and supportive care. Just as healthcare workers continue to adapt and attempt to address palliative and end-of-life care needs on the job, nursing faculty need to regularly evaluate and improve curricula to address their students’ needs in a rapidly changing healthcare landscape, patient demographics and humanitarian emergencies such as pandemics.

The research question for this systematic review and meta-synthesis was: What were the experiences of nursing students (Population) encountering patient death and caring for patients receiving palliative and/or end-of-life care and their families (Concept) in clinical settings (Context)?

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