Nurse Education Today 101 (2021) 104892

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Review

Effectiveness of end-of-life educational interventions at improving nurses

and nursing students’ attitude toward death and care of dying patients: A
systematic review and meta-analysis
Joelle Yan Xin Chua, Shefaly Shorey *
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11,10 Medical Drive,
Singapore 117597, Singapore

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To examine the effectiveness of end-of-life educational interventions in improving nurses and nursing
Attitude students’ attitude toward death and care of dying patients.
Death Design: A systematic review and meta-analysis of randomized controlled trials and controlled clinical trials.
Education
Data sources: English language studies were sourced from five electronic databases (PubMed, Embase, CINAHL,
End-of-life
PsycINFO and ProQuest Dissertations & Theses Global) to November 2020.
Meta-analysis
Nurse Review methods: A meta-analysis was conducted using the random-effect model. Standardized mean differences
Nursing student with 95% confidence intervals were used as the effect measure under the inverse-variance method. Heteroge­
Systematic review neity was assessed using the I2 statistics and Cochran’s Q chi-squared test. The Cochrane risk of bias tool con­
ducted quality appraisal at the study level while the Grades of Recommendation, Assessment, Development, and
Evaluation approach conducted quality appraisal at the outcome level.
Results: Nine studies were included. Meta-analyses showed that end-of-life educational interventions were
effective in improving attitude toward death and care of dying patients among nurses and nursing students at
post-intervention. The sustainability of improvement of both attitudes could not be determined due to the lack of
follow-up assessments by the included studies. Subgroup analyses revealed that both nurses and nursing students
showed similar attitude improvement, online educational courses were feasible and attitude toward death may
require longer interventions (more than 2 months) to show improvement.
Conclusions: Future trials could be improved by organizing both group-based segments and combined sessions for
nurses and nursing students. Online components could be incorporated for convenience. Topics related to
spirituality and grief management should be included. Future research is needed to examine the sustainability of
nurses and nursing students’ improvement in attitude toward death and care of dying patients, as well as how the
change in their attitude affects their clinical practices.

1. Introduction
1.1. Background
Death is a universal phenomenon that many healthcare workers face.
In the United States, over 50% of people die in inpatient hospital set­
tings, nursing homes or long-term care facilities (National Center for
Health, 2011). Moreover, previous reviews reported that 20–78% of
patients with chronic diseases die in acute care hospitals (Bekelman
et al., 2016; Broad et al., 2012; Cohen et al., 2008). Dying patients face a
myriad of physiological, psychological and social challenges (Bovero
et al., 2019; Puchalski et al., 2009). With more patients dying in non-
palliative care settings, healthcare professionals across all clinical set­
tings need to be comfortable in managing their care (William, 2014).
Nurses constitute the largest proportion of the healthcare team in charge
of caring for dying patients (Zargham-Boroujeni et al., 2011), and they
play a critical role in influencing the dignity, self-respect, self-worth and
general well-being of dying patients through their interactions with
them (Dwyer et al., 2008; Harrefors et al., 2009; Heliker and Nguyen,
2010). Therefore, it is important for nurses across different clinical
settings to be trained in managing the needs of dying patients (Conner
et al., 2014).

* Corresponding author.
E-mail address: nurssh@nus.edu.sg (S. Shorey).

https://doi.org/10.1016/j.nedt.2021.104892
Received 28 January 2021; Received in revised form 13 March 2021; Accepted 28 March 2021
Available online 15 April 2021
0260-6917/© 2021 Elsevier Ltd. All rights reserved.
J.Y.X. Chua and S. Shorey
The attributes of a good death identified by terminally ill patients
include symptom and pain control, no overtreatment, presence of loved
ones, being respected for their wishes regarding treatment and death,
inner peace, good communication with healthcare providers and an
avenue to share their emotions (Bovero et al., 2019; Steinhauser et al.,
2000). Another study reported that social and emotional support play a
critical role in ameliorating anxiety, pain, worries, as well as feelings of
loneliness during the dying process (Bolmsjö et al., 2018). As nurses
spend the most time interacting with dying patients, both patients and
their family often turn to them for much-needed support (Eues, 2007; Xu
et al., 2019).
However, studies have noted that nurses were not providing suffi­
cient support to dying patients due to their negative attitudes toward
death and care for dying patients and their family (Frommelt, 1991).
The negative attitudes were expressed in the form of feeling scared upon
facing death (fear of death) and refusing to think or speak about death-
related issues (death avoidance) (Brudek et al., 2020; Wong et al., 1994).
The studies have shown that the negative attitudes tend to coexist with
one’s reluctance to care for dying patients and their family (Cevik and
Kav, 2013; Frommelt, 1991; Wessel and Rutledge, 2005). Studies have
also reported that nurses showed reluctance in discussing issues
regarding death with dying patients and their family (Ay and Öz, 2018;
Glaser and Strauss, 2017), tend to avoid dying patients and also limited
their interactions with the patients (ÖSterlind et al., 2011). These
negative attitudes had apparently started developing during their
training days as studies have reported death anxiety, fear of death and
reluctance to care for dying patients among student nurses (A’la et al.,
2018; Abu-El-Noor and Abu-El-Noor, 2016; Chen et al., 2006; Xu et al.,
2019). Nurses’ negative attitudes toward death and care of dying pa­
tients negatively impacts patient care (Peters et al., 2013); nurses who
avoided discussing issues regarding death could make dying patients
doubt their self-worth and invalidate their worries (Haugan, 2014).
On the other hand, nurses who showed more positive attitudes to­
ward death (acceptance) and willingness to care for dying patients
demonstrated more respect toward their patients’ choices and were able
to provide patients and their family with sufficient support during their
last days, hence helping them achieve a good death (Boroujeni et al.,
2009; Bovero et al., 2019; Frommelt, 1991; Lange et al., 2008). There
are three types of acceptance toward death which people usually adopt
− neutral acceptance, approach acceptance and escape acceptance
(Brudek et al., 2020; Wong et al., 1994). Neutral acceptance means
neither fearing nor welcoming death, but instead viewing death as a
natural and inevitable end of life, while approach acceptance is
believing in a happier afterlife. Lastly, escape acceptance is viewing
death as a means to escape one’s current suffering (Brudek et al., 2020;
Wong et al., 1994). Research has established that the negative attitudes
toward death (fear of death and death avoidance) are negatively asso­
ciated with the three types of death acceptance (Wessel and Rutledge,
2005). As both nurses and nursing students have indicated that their
negative attitudes stem from a lack of knowledge regarding end-of-life
issues (Braun et al., 2010; Bush and Shahwan-Akl, 2013; Cui et al.,
2011; Tüzer et al., 2020; Xu et al., 2019), researchers have been focusing
on developing end-of-life educational programs to address the knowl­
edge gap (McClatchey and King, 2015; Xu et al., 2019).
An educational intervention can be defined as a program involving a
set curriculum and activities with a predetermined aim of increasing
participants’ knowledge (Organization for Economic Co-operation and
Development, 2004). The transformative learning theory states that
education encourages one to reflect on their current beliefs and views,
and transform them (Mezirow, 1991). Various studies have applied this
theory to improve nurses’ attitudes toward death and care of dying
patients via educational programs with promising results (Frommelt,
1991; Hainsworth, 1996; Inci and Oz, 2009; Matsui and Braun, 2010;
McClatchey and King, 2015). As nurses learn more about their patients’
needs and how they can help their patients during their last days, nurses
find themselves freed from their previous self-limitations, abandoning
2
Nurse Education Today 101 (2021) 104892
their previous fears about death, and renewed with the ability to better
support their patients (Howie and Bagnall, 2013). Therefore, end-of-life
educational interventions among nurses and nursing students should be
further examined.
There is a lack of available systematic reviews investigating the
effectiveness of end-of-life educational interventions at improving
nurses and nursing students’ attitude toward death and care of dying
patients. Previous reviews have focused on educational interventions for
healthcare providers (Lamppu and Lamppu and Pitkala, 2020), health­
care students (Centeno and Rodríguez-Núñez, 2015), and healthcare
providers as well as family caregivers (Nevis, 2014), but not for nurses
and nursing students. Degner and Gow (1988) was the only study that
focused on the effect of end-of-life educational interventions on nurses
and nursing students’ attitude toward care of dying patients. However,
as the review was conducted over 30 years ago, its findings need to be
reviewed to investigate their relevance now (Degner and Gow, 1988).
Therefore, this review aims to consolidate the available evidence on end-
of-life educational interventions with respect to nurses and nursing
students’ attitude toward death and care of dying patients at immediate
post-intervention (primary outcomes) and any follow-up timepoints
(secondary outcomes). This review questions how effective end-of-life
educational interventions are at improving nurses and nursing stu­
dents’ attitude toward death and care of dying patients at immediate
post-intervention and follow-up timepoints.
2. Method
The Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines guided this review (Moher et al., 2009).
A protocol can be found on the PROSPERO website (CRD42021224121).
2.1. Eligibility criteria
2.1.1. Population
Nursing students who studied in any educational institution and
nurses who worked in any clinical setting, with no restrictions on the
number of years of working experience, were included. Healthcare
students and professionals of other disciplines were excluded.
2.1.2. Intervention
Any educational intervention with a set curriculum focused on
training nurses and nursing students regarding end-of-life issues
(bereavement, terminal care, death and dying, and palliative courses)
were included.
2.1.3. Comparator
Studies with control groups which did not undergo any intervention,
placebo control (undergo educational interventions on non-end-of-life
issues) or waitlist control were included.
2.1.4. Outcomes
Included studies must measure either attitude toward death or atti­
tude toward care of dying patients self-reported by participants at pre-
and post-intervention. The immediate post-intervention values were of
primary focus and follow-up measurements were of secondary interest.
2.2. Study design
Only randomized controlled trials (RCTs), cluster RCTs and
controlled clinical trials (CCTs) were included.
2.3. Language and publication status
Peer-reviewed journal articles and unpublished dissertations that
were written in or translated to the English language were included.
J.Y.X. Chua and S. Shorey
2.4. Study selection
Five electronic databases (PubMed, Embase, CINAHL, PsycINFO and
ProQuest Dissertations & Theses Global) were searched from their
respective inception dates to November 2020. Relevant reviews and
included articles had their reference lists scrutinized and backward
searching was conducted to find additional relevant studies. Authors of
promising studies with unavailable full-texts were contacted to request
for access to the articles. All search results were exported to Endnote
Version X8, where they were sorted according to their databases and had
their duplicates removed. Titles and abstracts of all studies were
screened against the eligibility criteria. Next, full-texts of potential
studies were perused to establish their relevance. Study selection was
conducted by two independent reviewers who held discussions to
resolve any discrepancies. A sample search strategy for Embase database
is presented in Supplementary file 1, Table S1.
2.5. Data extraction
Characteristics related to the study’s sample, design, outcomes
measured, intervention content, duration and method of delivery were
extracted using a data extraction form. The mean and standard deviation
values of the review’s outcomes were extracted. When these specific
values were not provided, relevant formulas were used to transform the
data to obtain the values (Higgins and Green, 2011). Any discrepancies
that arose between the two independent reviewers were discussed until
consensus was reached.
2.6. Quality appraisal
The Cochrane Risk of Bias tool was used to assess five types of biases
for all studies: selection bias, performance bias, detection bias, attrition
bias and reporting bias (Higgins and Green, 2011). Each study’s overall
bias rating was determined by the worst score it received for any domain
(Kempler et al., 2016). Funnel plots were not produced to examine
publication bias due to the lack of forest plots containing at least ten
trials (Sterne et al., 2011).
Quality appraisal of the body of evidence at the outcome level was
determined by the Grades of Recommendation, Assessment, Develop­
ment, and Evaluation (GRADE) approach. Each outcome was initially
accorded high quality and this rating was dropped to moderate, low or
very low, when any of the following five factors were compromised: risk
of bias of individual study, inconsistency, directness of evidence, pre­
cision of effect estimates, and publication bias (Higgins and Green,
2011). The online GRADEpro software was used to rate each review’s
outcome separately (GRADEpro, 2015). Any discrepancies were
resolved by holding discussions between the reviewers.
2.7. Data synthesis
Characteristics of the included studies and the interventions were
summarized narratively. Meta-analyses were conducted to pool data for
the same outcomes under the random-effect model using the Review
Manager software 5.4. As all included studies reported outcomes using
continuous data and different scales, standardized mean differences
(SMD) and 95% confidence intervals (CI) were used as the effect mea­
sure under the inverse variance method (Higgins and Green, 2011).
Effect sizes were defined as very small (0.1), small (0.2), medium (0.5),
large (0.8), very large (1.2) and huge (2.0) (Sawilowsky, 2009). The two
studies that measured follow-up results for different outcomes were
narratively synthesized; Johnson (1986) assessed attitude toward death
at 3 months follow-up, and Henoch et al. (2013) assessed attitude to­
ward care of dying patients at 5–6 months follow-up. Mallory (2003)
only assessed attitude toward care of dying patients at 1 month follow-
up for the intervention group and was also narratively synthesized.
The I2 statistic and Cochran Q chi-squared test were used to assess
3
Nurse Education Today 101 (2021) 104892
heterogeneity of the results. I2 values were interpreted as low impor­
tance (≤40%), moderate (30–60%), substantial (50–90%) or consider­
able (75–100%). For the chi-squared test, statistically significant
heterogeneity was identified when its corresponding p value was less
than 0.10 (Higgins and Green, 2011). To reduce heterogeneity levels and
analyze the effect of certain variables on the outcomes investigated,
subgroup analyses were conducted (Higgins and Green, 2011; Sedgwick,
2013). The variables examined were nursing students versus nurses,
intervention duration and intervention delivery method.
3. Results
3.1. Search outcomes
The search from the five listed electronic databases and relevant
databases produced 17,150 articles. After deleting 6120 duplicate arti­
cles and excluding 10,815 articles based on their titles and abstracts, 215
articles were left to undergo full-text examination. Screening of full-texts
eliminated another 206 articles, leaving nine articles to be included in
this review. Seven articles were peer-reviewed primary studies (Conner
et al., 2014; Goris et al., 2017; Henoch et al., 2013; Hwang et al., 2005;
Jo et al., 2009; Mallory, 2003; Zargham-Boroujeni et al., 2011), while
two articles were unpublished dissertations (Alvaro, 2009; Johnson,
1986). The PRISMA flow diagram showing the search outcomes can be
found in Fig. 1.
3.2. Characteristics of the included studies
The nine studies were conducted in six different countries − Iran (n
= 1), Taiwan (n = 1), Korea (n = 1), Sweden (n = 1), Turkey (n = 1) and
United States (n = 4). There were five CCTs and the remaining four were
RCTs (Goris et al., 2017; Henoch et al., 2013; Hwang et al., 2005;
Zargham-Boroujeni et al., 2011). Four studies were conducted on nurses
from various clinical settings such as pediatric (Zargham-Boroujeni
et al., 2011) oncology (Goris et al., 2017; Henoch et al., 2013), intensive
care (Alvaro, 2009), and hospice care (Henoch et al., 2013), while the
remaining five were conducted on nursing students. Eight studies con­
ducted end-of-life educational interventions in a group-based format
using various teaching methods ranging from traditional lectures to
interactive activities such as group discussions, question and answer
segments, videos, role-play and case study discussions. The other study
conducted an individual-based online program by providing partici­
pants with reading assignments from their textbooks, links to online
resources and videos, and getting participants to engage in online
asynchronous group-based presentation and discussion of weekly course
content (Conner et al., 2014). The summary of included studies can be
found in Table 1 and detailed characteristics of included studies is
shown in Supplementary file 1, Table S2.
3.3. Quality appraisal
The risk of bias of all included studies were assessed by the Cochrane
risk of bias tool. The overall bias was rated as unclear for one study
(Hwang et al., 2005) and high for the remaining studies. Inter-rater
agreement between both reviewers was approximately 98% and the
Cohen’s kappa value was 0.96. The risk of bias graph is demonstrated in
Fig. 2. The GRADE approach was used to assess the quality of the body of
evidence at the outcome level. Both outcomes, attitude toward death
and attitude toward care of dying patients, were rated as very low
quality. The GRADE summary of evidence is presented in Supplemen­
tary file 1, Table S3.
3.4. Attitude toward death
The meta-analysis conducted for the five studies that assessed atti­
tude toward death at immediate post-intervention (Conner et al., 2014;
J.Y.X. Chua and S. Shorey
Fig. 1. PRISMA flow diagram.
Goris et al., 2017; Hwang et al., 2005; Jo et al., 2009; Johnson, 1986)
showed a statistically non-significant small effect favoring the inter­
vention group (SMD = 0.25, 95% CI: − 0.02 to 0.53, Z = 1.79, p = 0.07)
with low statistical heterogeneity (I2 = 34%, p = 0.19) (Fig. 3).
A subgroup analysis of nursing students versus nurses showed sta­
tistically non-significant subgroup differences (I2 = 0%, p = 0.47). The
nursing students’ subgroup reported a statistically non-significant small
effect while the nurses’ subgroup reported a statistically non-significant
negligible effect (Supplemental File 2, Fig. S1a).
A subgroup analysis of intervention duration showed statistically
non-significant subgroup differences (I2 = 0%, p = 0.47). The “up to 1
4
Nurse Education Today 101 (2021) 104892
month” subgroup reported a statistically non-significant negligible ef­
fect favoring the intervention group while the “more than 1 month to 2
months” subgroup reported a statistically non-significant negligible ef­
fect favoring the control group. The “more than 2 months” subgroup
reported a statistically non-significant small effect favoring the inter­
vention group (Supplemental File 2, Fig. S1b).
A subgroup analysis of intervention delivery method showed statis­
tically non-significant subgroup differences (I2 = 24.3%, p = 0.25). The
face-to-face subgroup reported a statistically non-significant small effect
while the online subgroup which only comprised of one study, reported
a statistically non-significant negligible effect (Supplemental File 2,
J.Y.X. Chua and S. Shorey Nurse Education Today 101 (2021) 104892

Table 1 Fig. S1c).

Summary of included studies.
Study Research Participants Intervention Review 3.5. Attitude toward care of dying patients
(country) design/arms number and duration outcomes:
Age mean (SD) (follow-up) 1. Attitude The meta-analysis conducted for the five studies that assessed atti­
or mean toward
tude toward care of dying patients at immediate post-intervention
(range) or death
range 2. Attitude (Alvaro, 2009; Conner et al., 2014; Henoch et al., 2013; Mallory,
toward care 2003; Zargham-Boroujeni et al., 2011) showed a statistically significant
of dying small effect favoring the intervention group (SMD = 0.46, 95% CI: 0.09
patients to 0.83, Z = 2.41, p = 0.02), with significant substantial statistical
Alvaro, 2 arm CCT 56 intensive Duration NS 1. No heterogeneity (I2 = 69%, p = 0.01) (Fig. 4).
2009 1.Intervention care nurses (no follow- 2. Yes A subgroup analysis of nursing students versus nurses showed sta­
(US) 2.Control Age: NS up)
tistically non-significant subgroup differences (I2 = 0%, p = 0.44). The
Conner 2 arm CCT 123 nursing 16 weeks 1. Yes
et al., 1. Online students (no follow- 2. Yes nursing students’ subgroup reported a statistically non-significant small
2014 death and Age: 18 to 36+ up) effect while the nurses’ subgroup reported a statistically non-significant
(US) dying course years old medium effect (Supplemental File 2, Fig. S2a).
(developed by A subgroup analysis of intervention duration showed statistically
faculty)
2. Placebo
significant substantial subgroup differences between the subgroups (I2
control group = 82.8%, p = 0.003). The “more than one month to two months” sub­
(Online course group reported a statistically non-significant negligible effect with low
on non-EOL heterogeneity (I2 = 0%, p = 0.98). Both the “up to one month” and
topics)
“more than two months” subgroups only had one study each and re­
Goris et al., 2 arm RCT 41 oncology 90 min twice 1. Yes
2017 1. Intervention nurses weekly for 3 2. No ported a statistically significant large and medium effect, respectively
(Turkey) 2. Control I: weeks (Supplemental File 2, Fig. S2b).
50% within (no follow- A subgroup analysis of intervention delivery method showed statis­
26–30 years up) tically non-significant subgroup differences (I2 = 0%, p = 0.85). The
old
C:
face-to-face subgroup reported a statistically non-significant small effect
42.8% within while the online subgroup which only comprised of one study, reported
26–30 years a statistically significant medium effect (Supplemental File 2, Fig. S2c).
old
Henoch 2 arm RCT 102 nurses 90 min × 5 1. No
3.6. Narrative synthesis
et al., 1. Intervention from hospice, sessions 2. Yes
2013 2. Control oncology clinic within 8
(Sweden) and palliative weeks Henoch et al. (2013) was the only study that conducted follow-up
home care (5–6 months) assessment of nurses’ attitude toward care of dying patients in both
I intervention and control groups. It reported a statistically non-
Age: 44.4
(11.4)
significant small effect favoring the intervention group at 5–6 months
C follow-up (Henoch et al., 2013).
Age: 47.6 Mallory (2003) conducted follow-up assessment of attitude toward
(10.5) care of dying patients for the intervention group only. Nursing students
Hwang 2 arm RCT 99 nursing 2 h × 13 1. Yes
from the intervention group reported a statistically non-significant
et al., 1. Life and students sessions 2. No
2005 death studies I weekly higher mean score compared to their immediate post-intervention
(Taiwan) program Age: 18.79 (no follow- score at 1 month follow-up (Mallory, 2003).
2. Control (1.16) up) Johnson (1986) was the only study that conducted follow-up
C assessment of attitude toward death. Nursing students from the inter­
Age: 19 (0.7)
Jo et al., 2 arm CCT 47 nursing 16 weeks 1. Yes
vention group reported a statistically non-significant higher mean score
2009 1. EOL care students (no follow- 2. No compared to that of the control group at 3 months follow-up (Johnson,
(Korea) education Age: NS up) 1986).
program
2. Control
4. Discussion
Johnson, 2 arm RCT 37 nursing 50 min × 5 1. Yes
1986 students sessions 2. No
(US) 1. Intervention Age: 19–44 (3 months) This meta-analysis examined the effectiveness of end-of-life educa­
2. Control years old tional interventions in improving nurses and nursing students’ attitude
Mallory, 2 arm CCT 104 nursing 6 weeks 1. No toward death and care of dying patients and results suggest that they are
2003 1.ELNEC students (1 month) 2. Yes
(US) education Age: NS
effective in doing so. Similar improvement in attitude toward the care of
package dying patients among nurses and nursing students was reported by a
2.Control previous review (Degner and Gow, 1988), while no previous examina­
Zargham- 2 arm RCT 56 pediatric 3 weeks 1. No tion of attitude toward death was conducted. The current findings
Boroujeni 1. Palliative nurses (no follow- 2. Yes
validate the transformative learning theory which states that education
et al., care training I up)
2011 course Age: 33.74 has the ability to transform one’s attitude (Mezirow, 1991). This is
(Iran) 2. Control (7.19) encouraging because the attitudes of nurses and nursing students affect
C their behavior (Boroujeni et al., 2009; Peters et al., 2013). Hence,
Age: 31.59 improvement in attitude toward death and care of the dying among
(4.43)
nurses and nursing students would improve their nursing care (Lange
C: Control; CCT: Controlled Clinical Trial; ELNEC: End of Life Nursing Education et al., 2008; Peters et al., 2013).
Consortium; EOL: End-of-life; I: Intervention; NS: Not Stated; RCT: Randomized Current results suggest that end-of-life educational interventions are
Controlled Trial; US: United States. more effective in improving nurses and nursing students’ attitude

5
J.Y.X. Chua and S. Shorey Nurse Education Today 101 (2021) 104892

Fig. 2. Risk of bias graph.

Fig. 3. Forest plot of attitude toward death at post-intervention among five included studies.

Fig. 4. Forest plot of attitude toward care of dying patients at post-intervention among five included studies.

toward care of dying patients compared to their attitude toward death.
The effect size of the attitude toward care of dying patients was greater
than that of the attitude toward death and also showed statistical sig­
nificance, unlike that of the attitude toward death. An included study
that examined both outcomes reported greater improvement in attitude
toward care of dying patients compared to attitude toward death among
nursing students (Conner et al., 2014), suggesting that attitude toward
death is more resistant to change compared to attitude toward care of
dying patients. This could be due to stronger religious beliefs among
nurses and nursing students being positively associated with having a
better attitude toward death (Braun et al., 2010; Conner et al., 2014;
Tranter et al., 2016), but not on attitude toward care of dying patients
(Braun et al., 2010; Cevik and Kav, 2013; Conner et al., 2014). The in­
fluence of one’s personal religious beliefs on attitude toward death
makes it more resistant to change via secular educational interventions
compared to attitude toward care of dying patients. Hence, future trials
could consider incorporating more spiritual components to enhance the
impact of educational interventions on attitude toward death.
Results from subgroup analyses of intervention duration suggests
that interventions lasting more than 2 months were more effective in
improving attitude toward death among nurses and nursing students.
Conversely, it also revealed that a shorter intervention lasting up to 1
month and a longer intervention lasting more than 2 months were more
effective in improving nurses and nursing students’ attitude toward care
of dying patients. These results suggest that longer interventions (more
than 2 months) may be needed to improve nurses and nursing students’
attitude toward death compared to attitude toward care of dying pa­
tients, thus reinforcing that the attitude toward death is more resistant to
change, and future trials should heed this suggestion. However, as this
review’s subgroup analyses of intervention duration was limited by the
lack of studies in each subgroup, future trials would be needed to vali­
date current findings.
The similar improvements to nurses as well as nursing students’
attitude toward death and care of dying patients indicate that both
nurses and nursing students have benefitted from the end-of-life
educational interventions, therefore validating the need to conduct
such interventions for both nurses and nursing students (Braun et al.,
2010; Bush and Shahwan-Akl, 2013; Cui et al., 2011; Tüzer et al., 2020).
All included studies conducted educational interventions on nurses and
nursing students separately but did not pool them together. Conducting
interventions on nurses and nursing students together could be benefi­
cial; students could learn from nurses’ firsthand experiences dealing
with dying patients (Ruiz-Pellón et al., 2020) while nurses could learn
fresh perspectives from students who have not experienced patient-
induced stress (Capella University, 2019). Hence, future trials should
conduct some combined sessions for nurses and nursing students.

6
J.Y.X. Chua and S. Shorey
Existing evidence suggests that both online and face-to-face methods
of delivering end-of-life educational interventions are effective. In this
review, Conner et al. (2014) conducted an online educational course
with asynchronous group discussions and presentations while the rest of
the studies conducted group-based interactive interventions. Group-
based learning was the common feature in all trials and it has been
regarded as an important teaching strategy for nurses (Ulrich and
Glendon, 2005). The interaction among participants helps them to learn
from each other’s experiences and perspectives and encourage reflective
learning (van der Wath and du Toit, 2015), which could help change
their past attitudes toward death and care of dying patients into more
positive ones. Conner et al. (2014) has shown that group-based learning
in an online asynchronous manner could be effective hence future trials
should consider conducting similar educational interventions to provide
nurses the much-needed flexibility and convenience to accommodate
their erratic shift schedules. Moreover, more studies conducting online
based learning would be needed to evaluate the relative effectiveness of
online learning compared to face-to-face interventions.
Only two included studies conducted follow-up assessments for
attitude toward care of dying patients; Mallory (2003) reported sus­
tainability of attitude improvement at 1 month follow-up while Henoch
et al. (2013) reported attitude decline at 5–6 months follow-up. Only
Johnson (1986) reported an attitude decline toward death at 3 months
follow-up. The cause of attitude decline after 1 month post-intervention
could be due to nurses and nursing students’ poor grief management,
which could lead to compassion fatigue – a common problem faced by
palliative nurses (Abendroth and Flannery, 2006; Coetzee and Klopper,
2010). Compassion fatigue occurs when nurses become overly exhaus­
ted from accumulated stress and prolonged intense patient contact,
resulting in their inability to alleviate their patients’ sufferings (Coetzee
and Klopper, 2010; Ledoux, 2015). As excessive empathy is a risk factor
for compassion fatigue (Abendroth and Flannery, 2006), nurses and
nursing students could have inadvertently over-exerted themselves post-
intervention in their eagerness to provide care for dying patients hence
leading to compassion fatigue. This review only had three included
studies which addressed nurses’ grief management (Alvaro, 2009;
Conner et al., 2014; Johnson, 1986); future trials should focus more on
the topic to prevent compassion fatigue. Moreover, as only three studies
conducted follow-up assessments, future trials would be needed to
investigate the sustainability of nurses and nursing students’ improved
attitude toward death and care of dying patients more closely.
5. Implications for future research and practice
Future trials should be conducted across more regions, such as in
Africa and South America to understand the attitude of nurses and
nursing students toward death and care of dying patients in other cul­
tures. As attitude toward death may require more time to improve and is
associated with religious beliefs, future interventions should be longer
than 2 months and include spiritual segments to improve this attitude.
Encouraging collaborative learning between nurses and nursing stu­
dents could be explored as they may benefit from learning different
perspectives and experiences. Group-based learning, both face-to-face
group discussions and asynchronous online group discussions, should
be encouraged as they have proven to be feasible and effective. Online
components could also be introduced to facilitate participation from
busy nurses and the topic of grief management should be addressed to
prevent compassion fatigue. Moreover, follow-up assessments should be
conducted to examine the sustainability of nurses and nursing students’
improved attitude toward death and care of dying patients. Lastly,
further research is required to determine if the improvement in nurses
and nursing students’ attitude toward death and care of dying patient
following educational interventions can be translated into better nursing
practices.
7
Nurse Education Today 101 (2021) 104892
6. Limitations
Publication bias may be incurred due to the inclusion of English
language studies only. All studies utilized the self-report method to
assess nurses and nursing students’ attitude toward death and care of
dying patients thus contributing to social desirability bias. Due to the
limited number of overall included studies (n = 9), and the fact that not
all studies assessed attitude toward death and care of dying patients,
some subgroup analysis only had one or two studies in each subgroup.
This could have compromised the results’ reliability and validity.
Conclusive findings regarding the durability of the intervention effects
could not be made due to insufficient studies that conducted follow-up
assessments. As only endpoint data was extracted for meta-analysis,
disparities of baseline scores between the intervention and control
groups were not considered. Moreover, as both review outcomes were
rated as very low quality via the GRADE approach, there is very little
confidence in the effect estimated in this review.
7. Conclusion
This review showed that end-of-life educational interventions are
able to improve nurses and nursing students’ attitude toward death and
care of dying patients at immediate post-intervention. Sustainability of
this improvement at any follow-up timepoint could not be determined
due insufficient data and thus warrant future investigation. Improving
nurses and nursing students’ attitude toward death is challenging hence
interventions are recommended to be longer than 2 months and include
spiritual components. Future trials should promote combined learning
sessions for nurses and nursing students, as well as group-based and
online segments to improve participants’ learning experience. Grief
management is another critical topic that should be discussed. More­
over, future research would be required to examine how an improve­
ment in attitude toward death and care of dying patients among nurses
and nursing students is translated into clinical practice. Lastly, due to
this review’s limitations and uncertainties, future research is needed to
corroborate current findings.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statements
Joelle Chua: Data curation; formal analysis; writing-original draft
Shefaly Shorey: Conceptualization; data curation; writing - review &
editing
Declaration of competing interest
The authors declare that they have no conflict of interest.
Acknowledgements
The authors would like to thank the National University Health
System, Research Support Unit, for assistance in the language editing of
this manuscript.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.nedt.2021.104892.
J.Y.X. Chua and S. Shorey Nurse Education Today 101 (2021) 104892

References Glaser, B.G., Strauss, A.L., 2017. Awareness of Dying. Taylor and Francis. https://doi.
org/10.4324/9781351327923.
Goris, S., Tasci, S., Ozkan, B., Ceyhan, O., Kartin, P.T., Celiksoy, A., Elmali, F., Eser, B.,
Abendroth, M., Flannery, J., 2006. Predicting the risk of compassion fatigue: a study of
2017. Effect of terminal patient care training on the nurses’ attitudes toward death in
hospice nurses. J. Hosp. Palliat. Nurs. 8 (6), 346–356. https://doi.org/10.1097/
an oncology hospital in Turkey [Professional Education & Training 3410]. J. Cancer
00129191-200611000-00007.
Educ. 32 (1), 65–71. https://doi.org/10.1007/s13187-015-0929-6.
Abu-El-Noor, N.I., Abu-El-Noor, M.K., 2016. Attitude of Palestinian nursing students
GRADEpro, 2015. GRADEpro. https://gradepro.org.
toward caring for dying patients: a call for change in health education policy.
Hainsworth, D.S., 1996. The effect of death education on attitudes of hospital nurses
J. Holist. Nurs. 34 (2), 193–199. https://doi.org/10.1177/0898010115596492.
toward care of the dying. Oncol. Nurs. Forum 23 (6), 963–967.
A’la, M.Z., Setioputro, B., Kurniawan, D.E., 2018. Nursing students’ attitudes towards
Harrefors, C., Sävenstedt, S., Axelsson, K., 2009. Elderly people’s perceptions of how
caring for dying patients. Nurse Media: Journal of Nursing 8 (1), 25–34. https://doi.
they want to be cared for: an interview study with healthy elderly couples in
org/10.14710/nmjn.v8i1.17270.
northern Sweden. Scand. J. Caring Sci. 23 (2), 353–360. https://doi.org/10.1111/
Alvaro, A.W., 2009. Critical Care Nurses’ Attitudes towards the Care of the Dying: An
j.1471-6712.2008.00629.x.
Educational Intervention. M.S., Western Carolina University]. ProQuest
Haugan, G., 2014. Nurse-patient interaction is a resource for hope, meaning in life and
Dissertations & Theses Global.
self-transcendence in nursing home patients. Scand. J. Caring Sci. 28 (1), 74–88.
Ay, M.A., Öz, F., 2018. Nurses attitudes towards death, dying patients and euthanasia: a
https://doi.org/10.1111/scs.12028.
descriptive study. Nurs. Ethics 26 (5), 1442–1457. https://doi.org/10.1177/
Heliker, D., Nguyen, H.T., 2010. Story sharing: enhancing nurse aide-resident
0969733017748481.
relationships in long-term care. Res. Gerontol. Nurs. 3 (4), 240–252. https://doi.org/
Bekelman, J.E., Halpern, S.D., Blankart, C.R., Bynum, J.P., Cohen, J., Fowler, R.,
10.3928/19404921-20100303-01.
Kaasa, S., Kwietniewski, L., Melberg, H.O., Onwuteaka-Philipsen, B., Oosterveld-
Henoch, I., Danielson, E., Strang, S., Browall, M., Melin-Johansson, C., 2013. Training
Vlug, M., Pring, A., Schreyögg, J., Ulrich, C.M., Verne, J., Wunsch, H., Emanuel, E.J.,
intervention for health care staff in the provision of existential support to patients
for the International Consortium for End-of-Life, R., International Consortium for
with cancer: a randomized, controlled study [Professional Education & Training
End-of-Life, R., 2016. Comparison of site of death, health care utilization, and
3410]. J. Pain Symptom Manag. 46 (6), 785–794. https://doi.org/10.1016/j.
hospital expenditures for patients dying with cancer in 7 developed countries.
jpainsymman.2013.01.013.
JAMA: the Journal of the American Medical Association 315 (3), 272–283. https://
Higgins, J.P., Green, S., 2011. Cochrane Handbook for Systematic Reviews of
doi.org/10.1001/jama.2015.18603.
Interventions. John Wiley & Sons.
Bolmsjö, I., Tengland, P.-A., Rämgård, M., 2018. Existential loneliness: an attempt at an
Howie, P., Bagnall, R., 2013. A beautiful metaphor: transformative learning theory. Int.
analysis of the concept and the phenomenon. Nurs. Ethics 26 (5), 1310–1325.
J. Lifelong Educ. 32 (6), 816–836. https://doi.org/10.1080/
https://doi.org/10.1177/0969733017748480.
02601370.2013.817486.
Boroujeni, A.Z., Mohammadi, R., Oskouie, S.F.H., Sandberg, J., 2009. Iranian nurses’
Hwang, H.L., Lin, H.S., Chen, W.T., 2005. Evaluation of life and death studies course on
preparation for loss: finding a balance in end-of-life care. J. Clin. Nurs. 18 (16),
attitudes toward life and death among nursing students. Kaohsiung J. Med. Sci. 21
2329–2336. https://doi.org/10.1111/j.1365-2702.2008.02437.x.
(12), 552–560. https://doi.org/10.1016/s1607-551x(09)70207-4.
Bovero, A., Gottardo, F., Botto, R., Tosi, C., Selvatico, M., Torta, R., 2019. Definition of a
Inci, F., Oz, F., 2009. Effects of death education on nurses’ death anxiety, depression
good death, attitudes toward death, and feelings of interconnectedness among
regarding death, and attitudes towards the dying patient. In: CUMHURIYET UNIV
people taking care of terminally ill patients with cancer: an exploratory study. Am. J.
Tip FAK PSIKIYATRI ANABILIM Dali.
Hosp. Palliat. Med. 37 (5) https://doi.org/10.1177/1049909119883835,
Jo, K., Doorenbos, A.Z., An, G.J., 2009. Effect of an end-of-life care education program
104990911988383-104990911988349.
among Korean nurses. J. Hosp. Palliat. Nurs. 11 (4), 230–238.
Braun, M., Gordon, D., Uziely, B., 2010. Associations between oncology nurses’ attitudes
Johnson, E.L., 1986. Attitudes Toward Death and Dying Among Student Nurses AS
toward death and caring for dying patients. Oncol. Nurs. Forum 37 (1), E43–E49.
Affected BY A Specialized Curriculum. Ph.D., Oregon State University]. ProQuest
https://doi.org/10.1188/10.onf.e43-e49.
Dissertations & Theses Global.
Broad, J.B., Gott, M., Kim, H., Boyd, M., Chen, H., Connolly, M.J., 2012. Where do people
Kempler, L., Sharpe, L., Miller, C.B., Bartlett, D.J., 2016. Do psychosocial sleep
die? An international comparison of the percentage of deaths occurring in hospital
interventions improve infant sleep or maternal mood in the postnatal period? A
and residential aged care settings in 45 populations, using published and available
systematic review and meta-analysis of randomised controlled trials. Sleep Med. Rev.
statistics. International Journal of Public Health 58 (2), 257–267. https://doi.org/
29, 15–22. https://doi.org/10.1016/j.smrv.2015.08.002.
10.1007/s00038-012-0394-5.
Lamppu, P.J., Pitkala, K.H., 2020. Staff training interventions to improve end-of-life care
Brudek, P., Sękowski, M., Steuden, S., 2020. Polish adaptation of the death attitude
of nursing home residents: a systematic review. J Am Med Dir Assoc. https://doi.
profile-revised. Omega (Westport) 81 (1), 18–36. https://doi.org/10.1177/
org/10.1016/j.jamda.2020.09.011.
0030222818754670.
Lange, M., Thom, B., Kline, N.E., 2008. Assessing nurses’ attitudes toward death and
Bush, T., Shahwan-Akl, L., 2013. Palliative care education - does it influence future
caring for dying patients in a comprehensive cancer center. Oncol. Nurs. Forum 35
practice? Contemporary Nurse: a Journal for the Australian Nursing Profession 43
(6), 955–959. https://doi.org/10.1188/08.onf.955-959.
(2), 172–177. https://doi.org/10.5172/conu.2013.43.2.172.
Ledoux, K., 2015. Understanding compassion fatigue: understanding compassion. J. Adv.
Capella University, 2019. What nurses of different generations can learn from each other.
Nurs. 71 (9), 2041–2050. https://doi.org/10.1111/jan.12686.
Capella University. Retrieved 13 December, 2020, from. https://www.capella.
Mallory, J.L., 2003. The impact of a palliative care educational component on attitudes
edu/blogs/cublog/different-generations-in-nursing/.
toward care of the dying in undergraduate nursing students. J. Prof. Nurs. 19 (5),
Centeno, C., Rodríguez-Núñez, A., 2015. The contribution of undergraduate palliative
305–312. https://doi.org/10.1016/s8755-7223(03)00094-2.
care education: does it influence the clinical patient’s care? Curr Opin Support
Matsui, M., Braun, K., 2010. Nurses’ and care workers’ attitudes toward death and caring
Palliat Care 9 (4), 375–391. https://doi.org/10.1097/spc.0000000000000169.
for dying older adults in Japan. Int. J. Palliat. Nurs. 16 (12), 593–598. https://doi.
Cevik, B., Kav, S., 2013. Attitudes and experiences of nurses toward death and caring for
org/10.12968/ijpn.2010.16.12.593.
dying patients in Turkey. Cancer Nurs. 36 (6), E58–E65. https://doi.org/10.1097/
McClatchey, I.S., King, S., 2015. The impact of death education on fear of death and
ncc.0b013e318276924c.
death anxiety among human services students. Omega (Westport) 71 (4), 343–361.
Chen, Y.-C., Del Ben, K.S., Fortson, B.L., Lewis, J., 2006. Differential dimensions of death
https://doi.org/10.1177/0030222815572606.
anxiety in nursing students with and without nursing experience. Death Studies 30
Mezirow, J., 1991. Transformative Dimensions of Adult Learning, 1st ed. Jossey-Bass.
(10), 919–929. https://doi.org/10.1080/07481180600925351.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., 2009. Preferred reporting items for
Coetzee, S.K., Klopper, H.C., 2010. Compassion fatigue within nursing practice: a
systematic reviews and meta-analyses: the PRISMA statement. Ann. Intern. Med. 151
concept analysis. Nursing & Health Sciences 12 (2), 235–243. https://doi.org/
(4), 264–269.
10.1111/j.1442-2018.2010.00526.x.
National Center for Health, S, 2011. Health, United States (Health, United States, 2010:
Cohen, J., Bilsen, J., Addington-Hall, J., Löfmark, R., Miccinesi, G., Kaasa, S.,
With Special Feature on Death and Dying). National Center for Health Statistics (US).
Onwuteaka-Philipsen, B., Deliens, L., 2008. Population-based study of dying in
Nevis, I., 2014. Educational intervention in end-of-life care: an evidence-based analysis.
hospital in six European countries. Palliat. Med. 22 (6), 702–710. https://doi.org/
Ont Health Technol Assess Ser 14 (17), 1–30.
10.1177/0269216308092285.
Organization for Economic Cooperation and Development, 2004. The definition and
Conner, N.E., Wochna Loerzel, V., Uddin, N., 2014. Nursing student end-of-life care
classification of educational programmes. In: The Practical Implementation of
attitudes after an online death and dying course. J. Hosp. Palliat. Nurs. 16 (6),
ISCED. OECD Publishing, pp. 77–120.
374–382. https://doi.org/10.1097/NJH.0000000000000080.
ÖSterlind, J., Hansebo, G., Andersson, J., Ternestedt, B.-M., HellstrÖM, I., 2011.
Cui, J., Shen, F., Ma, X., Zhao, J., 2011. What do nurses want to learn from death
A discourse of silence: professional carers reasoning about death and dying in
education? A survey of their needs. Oncol. Nurs. Forum 38 (6), E402–E408. https://
nursing homes. Ageing Soc. 31 (4), 529–544. https://doi.org/10.1017/
doi.org/10.1188/11.onf.e402-e408.
S0144686X10000905.
Degner, L.F., Gow, C.M., 1988. Evaluations of death education in nursing: a critical
Peters, L., Cant, R., Payne, S., O’Connor, M., McDermott, F., Hood, K., Morphet, J.,
review. Cancer Nurs. 11 (3), 151–159.
Shimoinaba, K., 2013. How death anxiety impacts nurses’ caring for patients at the
Dwyer, L.-L., Nordenfelt, L., Ternestedt, B.-M., 2008. Three nursing home residents speak
end of life: a review of literature. The Open Nursing Journal 7, 14–21. https://doi.
about meaning at the end of life. Nurs. Ethics 15 (1), 97–109. https://doi.org/
org/10.2174/1874434601307010014.
10.1177/0969733007083938.
Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., Chochinov, H.,
Eues, S.K., 2007. End-of-life care: improving quality of life at the end of life. Professional
Handzo, G., Nelson-Becker, H., Prince-Paul, M., Pugliese, K., Sulmasy, D., 2009.
Case Management 12 (6), 339–344. https://doi.org/10.1097/01.
Improving the quality of spiritual care as a dimension of palliative care: the report of
PCAMA.0000300408.00325.1c.
the consensus conference. Journal of Palliative Medicine 12 (10), 885–904. https://
Frommelt, K.H., 1991. The effects of death education on nurses’ attitudes toward caring
doi.org/10.1089/jpm.2009.0142.
for terminally ill persons and their families. Am J Hosp Palliat Care 8 (5), 37–43.
https://doi.org/10.1177/104990919100800509.

8
J.Y.X. Chua and S. Shorey
Ruiz-Pellón, N., Sarabia-Cobo, C., Amo-Setién, F., Fernández-Peña, R., Abajas, R.,
Martín, R., Ortego-Mate, C., 2020. Experiences of nursing students participating in
end-of-life education programs: a systematic review and qualitative metasynthesis.
Nurse Educ. Today 90, 104442. https://doi.org/10.1016/j.nedt.2020.104442.
Sawilowsky, S.S., 2009. New effect size rules of thumb. J. Mod. Appl. Stat. Methods 8 (2),
597–599. https://doi.org/10.22237/jmasm/1257035100.
Sedgwick, P., 2013. Meta-analyses: heterogeneity and subgroup analysis. BMJ: British
Medical Journal 346, f4040. https://doi.org/10.1136/bmj.f4040.
Steinhauser, K.E., Christakis, N.A., Clipp, E.C., McNeilly, M., McIntyre, L., Tulsky, J.A.,
2000. Factors considered important at the End of Life by patients, family, physicians,
and other care providers. JAMA: the journal of the American Medical Association
284 (19), 2476–2482. https://doi.org/10.1001/jama.284.19.2476.
Sterne, J.A., Sutton, A.J., Ioannidis, J.P., Terrin, N., Jones, D.R., Lau, J., Carpenter, J.,
Rücker, G., Harbord, R.M., Schmid, C.H., 2011. Recommendations for examining
and interpreting funnel plot asymmetry in meta-analyses of randomised controlled
trials. BMJ 343, d4002. https://doi.org/10.1136/bmj.d4002.
Tranter, S., Josland, E., Turner, K., 2016. Nurses’ bereavement needs and attitudes
towards patient death: a qualitative descriptive study of nurses in a dialysis unit.
J Ren Care 42 (2), 101–106. https://doi.org/10.1111/jorc.12147.
Tüzer, H., Kırca, K., Özveren, H., 2020. Investigation of nursing students’ attitudes
towards death and their perceptions of spirituality and spiritual care. J. Relig. Health
59 (4), 2177–2190. https://doi.org/10.1007/s10943-020-01004-9.
Nurse Education Today 101 (2021) 104892
Ulrich, D.L., Glendon, K.J., 2005. Interactive Group Learning: Strategies for Nurse
Educators. Springer.
van der Wath, A.E., du Toit, P.H., 2015. Learning end-of-life care within a constructivist
model: undergraduate nursing students’ experiences. Curationis (Pretoria) 38 (2),
1537. https://doi.org/10.4102/curationis.v38i2.1537.
Wessel, E.M., Rutledge, D.N., 2005. Home care and hospice nurses’ attitudes toward
death and caring for the dying: effects of palliative care education. J. Hosp. Palliat.
Nurs. 7 (4). https://journals.lww.com/jhpn/Fulltext/2005/07000/Home_Care_
and_Hospice_Nurses__Attitudes_Toward.12.aspx.
William, L., 2014. Non-palliative care staff need to deliver generalist end of life care.
BMJ: British Medical Journal 348 (may20 9). https://doi.org/10.1136/bmj.g3426
g3426-g3426.
Wong, P., Reker, G., Gesser, A., 1994. The Death Attitude Profile Revised: a
Multidimensional Measure of Attitudes Towards Death, pp. 121–148.
Xu, F., Huang, K., Wang, Y., Xu, Y., Ma, L., Cao, Y., 2019. A questionnaire study on the
attitude towards death of the nursing interns in eight teaching hospitals in Jiangsu,
China. Biomed. Res. Int. 2019, 3107692. https://doi.org/10.1155/2019/3107692.
Zargham-Boroujeni, A., Bagheri, S.H., Kalantari, M., Talakoob, S., Samooai, F., 2011.
Effect of end-of-life care education on the attitudes of nurses in infants’ and
children’s wards. Iran. J. Nurs. Midwifery Res. 16 (1), 93–99.