Nurse Education Today 98 (2021) 104772

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Nurse Education Today

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Registered nurses and undergraduate nursing students’ attitudes to

performing end-of-life care
Sofi Fristedt a, b,*, Annika Grynne a, Christina Melin-Johansson c, Ingela Henoch d,
Carina Lundh Hagelin c, e, Maria Browall a, f
a
Jönköping University, School of Health and Welfare, Box 1026, 551 11 Jönköping, Sweden
b
Lund University, Medical Faculty, Department of Health Sciences, Lund, Sweden
c
Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Palliative Research Centre, Sweden
d
Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
e
Karolinska Institutet, Dept. Neurobiology, Care Sciences and Society, Stockholm, Sweden
f
Dep of Oncology, Inst of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden

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

Keywords: Registered Nurses (RNs) are in the immediate position to provide End-of-life (EOL) care and counselling for
Palliative care patients and families in various settings. However, EOL-care often creates feelings of uncertainty and inadequacy
Clinical experience linked to inexperience, lack of education, and attitude. To identify and describe factors associate d with RNs’
Nursing attitudes towards EOL-care, and to identify whether and how these attitudes differ from undergraduate nursing
Education
students’ (UNSs) attitudes, a descriptive and comparative, quantitative study was performed. The FATCOD-
instrument, focusing on attitude towards EOL-care, was used and the results analysed with descriptive and
nonparametric statistics. In total, 287 RNs in 14 different specialist programmes, and 124 UNSs participated. A
statistically significant difference (p = 0.032) was found in attitude towards EOL-care based on clinical expe-
rience. RNs in “Acute Care” and “Paediatric & Psychiatry Care” specialist programmes had a less positive attitude
towards EOL-care (compared to RNs in other specialist programmes), while RNs attending the Palliative Care
programme had the most positive attitudes. RNs and UNSs’ scores differed statistically significantly in 17 out of
30 FATCOD variables. Finally, the results imply that there is a need for greater emphasis on further continuing
education within EOL care for RNs working in all types of clinical specialities to encourage RNs talking about
death and to enhance attitudes towards EOL care.

1. Introduction complex (Lindqvist et al., 2012; Pask et al., 2018) and has an emotional
impact on both RNs and undergraduate nursing students (UNSs), who
Registered nurses (RNs) are in the immediate position for providing are exposed to patients’ trajectories of illness and death (Anderson et al.,
End-of-life (EOL) care and counselling for patients and their families, 2015; CroXon et al., 2018; Henoch et al., 2017; Jiang et al., 2019). RNs
whether death occurs in hospital wards or community settings. EOL care gain knowledge and clinical reasoning skills through clinical experience
constitutes an important part of palliative care and it refers to the sup- and it is feasible to assume that all types of clinical experience will
port and care given during the time surrounding death, which can be positively influence attitudes towards EOL care. However, little is
days, weeks, or even months (National Board of Health and Welfare, known regarding how the specific type of clinical experience might in-
2016; Radbruch et al., 2020; World Health Organization, 2002). In this fluence the RNs’ attitudes towards EOL care, whether there is a differ-
study, EOL care is associated with RNs’ everyday experiences of caring ence in attitude between them due to specific clinical experience, and
for dying patients. RNs play an important role in the EOL care of patients what distinguishes these differences from the attitudes of UNSs with
to reduce physical, psychological, psychosocial, and existential much less clinical experience. Increased knowledge on such differences
suffering, a role they must be prepared to take on (Browall et al., 2014; would be useful to guide undergraduate education as well as pro-
Losa Iglesias et al., 2013; Sekse et al., 2018). However, EOL care is grammes of continuing education for RNs whose work is focused on this

* Corresponding author at: Department of Rehabilitation, School of Health and Welfare, Jönköping University, BoX 1026, 551 11 Jönköping, Sweden.
E-mail address: sofi.fristedt@ju.se (S. Fristedt).

https://doi.org/10.1016/j.nedt.2021.104772
Received 3 August 2020; Received in revised form 4 December 2020; Accepted 10 January 2021
Available online 19 January 2021
0260-6917/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
complex area. education of palliative care, and experience of EOL care became indic-
ative (Hagelin et al., 2016; Henoch et al., 2017).
2. Background
3. Aim
Patients in EOL are cared for in various settings in specialised units,
in acute and general hospital wards, in community settings, and in The primary aim of the present study was to identify and describe
nursing homes (Harazneh et al., 2015; Håkanson et al., 2015). Hence, RNs’ attitudes to performing EOL care and to describe the factors
RNs in all types of specialities also need to be prepared to provide high- associated with these attitudes. The secondary aim was to identify
quality care in EOL situations (Martins Pereira et al., 2020). EOL care whether and how these attitudes differ from UNSs’ attitudes.
can be regarded as complex, covering several aspects of care, and can at
times be emotionally challenging, placing a great demand on profes-
sionalism and clinical knowledge as well as on personal maturity (Pask Research questions
et al., 2018; Sekse et al., 2018; Strang et al., 2014). Moreover, UNSs and
RNs often feel unprepared and anxious when providing EOL care and - To what extent are factors previously identified among UNSs, i.e.,
when communicating with patients and their relatives (CroXon et al., age, extent of education of palliative care, and previous experience of
2018; Ek et al., 2014; Garrino et al., 2017; Österlind et al., 2016) or fail EOL care, influential for RNs’ attitudes towards EOL care?
to understand the complexity in such situations (Balboni et al., 2013; - To what extent are RNs’ attitudes towards EOL care positively
Strang et al., 2014). The expressed uncertainty and feelings of in- influenced by clinical experience in different health care settings?
adequacy are often linked with inexperience and lack of education - How are RNs’ clinical experience and choice of clinical nurse
(Ablett and Jones, 2007; Balboni et al., 2013; Ek et al., 2014; Strang specialist education related to attitudes towards EOL care?
et al., 2014; Jiang et al., 2019) or busy and duty-orientated care envi- - Do RNs with clinical experience a more positive attitude towards
ronments (Lind et al., 2017; Zamanzadeh et al., 2014). Factors such as EOL care compared to UNSs? If so to what extent?
age, previous education in palliative care, and previous experience of
caring for dying patients are closely tied to attitudes towards and the 4. Research design
quality of EOL care provided by RNs and UNSs (Anderson et al., 2015;
Hagelin et al., 2016; Laporte et al., 2020; Park and Yeom, 2014). Henoch A descriptive and comparative, quantitative study design was used.
et al. (2017) explored the development of UNSs’ attitudes towards EOL
care during their undergraduate nursing education and found, in line
Setting and sample
with other research (Garrino et al., 2017; Laporte et al., 2020; Udo et al.,
2014), that a positive change in such attitudes was related to length of
RNs enrolled in different clinical nurse specialist education pro-
theoretical and clinical palliative care education.
grammes were invited to participate in the study. Specialist education
The total number of hours of EOL care education differs for under-
provides in-depth nursing knowledge about clinical evidence, research
graduate nursing education programmes between universities, even
methods and evaluation tools in a specific field of health care. Admission
nationally (Hagelin et al., 2016; National Board of Health and Welfare,
to specialist nurse education in a specific area of practice requires a
2006), with the possible consequence that UNSs are not being
bachelor’s degree in nursing (equivalent to the basic level of nursing
adequately trained for dealing with death (Garrino et al., 2017; Gillan
education in Sweden) and a minimum of one year of clinical experience.
et al., 2014; Paal et al., 2019). However, not only theoretical education
In the present study, a convenience sampling method was used, in that
but also clinical practice matters, as RNs construct their own under-
students admitted to 14 different specialist programmes, (Emergency
standing and develop the clinical reasoning skills necessary to guide
Care; Ambulance; Anaesthesiology; Intensive Care; Operation/Theatre;
their decisions and actions (Benner, 2001; Best et al., 2020; Henoch
Children and Youth; Psychiatric Care; Surgery Care; Oncology; Medical
et al., 2017). The novice nurse has limited clinical experience and
Care; Cardiac Care; District Nurse; Care of the Elderly; and Palliative
therefore has restricted knowledge in providing multiple types of care
Care) at four different universities were eligible for participation. Spe-
when compared with an RN with more clinical experience (Benner,
cifically, the RNs present at the course introductions of the 14 pro-
2001). The RN who has extensive clinical experience has progressed
grammes were, in line with research ethical guidelines, asked to respond
through the five stages of the Skill Acquisition model – from novice to
to a survey. A total of 287 RNs agreed to participate as part of our
expert nurse – and will be more confident and able to provide accurate
convenience sample. Additionally, UNSs (n = 124) in their final year,
actions (Benner, 2001). Browall et al. (2010) conclude that RNs con-
from siX different Swedish universities, were included. As part of their 3-
fronted with EOL care on a daily basis will learn to master appropriate
year education programme, these UNSs had clinical placements in
skills and will also have a positive attitude towards such care. However,
hospitals, nursing homes, and home care settings, as well as the provi-
Anderson et al. (2015) suggest that negative encounters with death and
sion of theoretical content to varying extent and length.
dying can potentially have a negative impact on the experience, which
may influence the choice of clinical speciality, job satisfaction, and at-
titudes to providing EOL care. There might also be a difference in atti- Ethical considerations
tudes, depending on previous clinical experience and in which current
clinical speciality the RN is working. Clinical experience is likely to in- The study was approved by the Regional Ethics Committee of the
fluence the particular clinical nurse specialist education programme in University of Gothenburg (DNR 997-15). The head of each university
which the RN actively and consciously chooses to further expand their and the students’ union approved the study. Participants received verbal
knowledge. More knowledge is needed regarding how clinical experi- and written information about the purpose of the study, the voluntary
ence has an impact on attitudes towards EOL care among different nature of their participation, their right to refuse and to withdraw their
groups of RNs through their professional career as they progress from participation at any time without providing any reason or explanation
being a novice to an expert nurse. Determining how RNs’ attitudes differ and without their grades being affected (Miller et al., 2012; Swedish
to those of final-year UNSs will provide an indication of the need for the Research Council, 2017). Questionnaires were anonymised and allo-
development of specific EOL care education within the undergraduate cated a participant code to ensure confidentiality. No compensation was
nursing programmes as well as in continual education programmes in offered to the participants. As issues around death can potentially raise
palliative care for RNs. The results from our previous studies as guidance uncomfortable feelings, the participants were encouraged to contact the
in shaping the purpose of this study, factors such as age, previous researchers in case of any concerns.

2
 Measurements 5. Findings

The survey packet consisted of the validated and reliable Swedish The demographic characteristics of the participants are presented in
version of the FATCOD-instrument (Henoch et al., 2014) and a brief Table 1. Participants were primarily women (89% of the RNs, 87% of the
demographic questionnaire encompassing socio-demographic- and work- UNSs). The mean age of the RNs was 35 (ranging from 22 to 59 years),
related characteristics, and variables related to personal experi- ence and among UNS, 23 years (ranging from 21 to 45 years). The majority of
(previous EOL care experience as RN, UNS or as a relative, previous the participants were born in Sweden.
education in palliative care), but no other information that could iden-
tify the participant. The FATCOD scale, form B instrument is a 30-item
tool using a 5-point Likert-type scale indicating respondents’ attitudes Differences in attitude towards EOL care among different groups ofRNs
towards EOL care, i.e., care of persons expected to survive siX months or
less. An equal number of positive items (1, 2, 4, 10, 12, 16, 18, 20–25, There was diversity in clinical experience among the RNs prior to
27, and 30) and negative items (3, 5–9, 11, 13–5, 17, 19, 26, 28, and 29) their commencing the specialist education programme. A statistically
are included in the instrument. Items are scored from one (strongly significant difference (p = 0.032) was observed in attitude towards EOL
disagree) to five (strongly agree). The possible total score ranges from 30 care between RNs who had worked clinically 1–5, 6–10, and more than
to 150; a higher FATCOD score indicates a more positive attitude to- 10 years. The RNs with 1–5 years’ clinical experience (n = 144) had a
wards EOL care. The reliability of the FATCOD has been tested and mean FATCOD score of 129.36 (SD=9.32), RNs with 6–10 years clinical
established in previous studies involving medical-surgical and oncology experience (n = 74) had a mean FATCOD score of 128.77 (SD = 9.85),
ward nurses (Dunn et al., 2005) and UNSs (Frommelt, 2003). The while RNs with clinical experience of more than 10 years (n = 69) had a
Swedish version of FATCOD has been translated and tested for appli- mean FATCOD score of 132.5 (SD 9.63).
=
cability in Swedish conditions (Henoch et al., 2014; Udo et al., 2014). When comparing groups based on choice of specialist programme,
The Cronbach’s alpha for FATOCD was earlier found to be 0.601 three of the five groups had a more positive attitude towards EOL care, i.
(Henoch et al., 2013), and, in the present study, the Cronbach’s alpha e., a higher total FATCCOD score on average, for example, Surgery and
was 0.612. Oncology (mean = 130.24, SD = 10.21); Medical Care (mean = 131.64,
SD 7.68); and Community Care (mean = 131.14, SD = 9.97). Conversely,
Data analysis the two remaining groups, based on specialist programmes, had a less
positive attitude: Acute Care (mean = 128.92, SD = 9.77) and other
Descriptive statistics were conducted to summarise demographic specialities (mean = 128.23, SD = 8.94). RNs enrolled in the speciality
characteristics and attitudes towards EOL care. Non-parametric methods
were used for group comparison. FATCOD scores were reversed for Table 1
negative items prior to analysis of the data and the total FATCOD score Participants’ demographic characteristics and their previous clinical experience.
was then calculated. Associations between the total FATCOD score, at-
titudes towards EOL care, and general characteristics were analysed Demographic characteristics and previous clinical UNS T6 (n = RN (n =
using analysis of variance (ANOVA). The FATCOD total score was experiences 124) 287)
calculated if a minimum of 27 questions in the FATCOD questionnaire Age group n (%)
were answered. The total FATCOD score was used as the dependent 21–30 105 (91) 86 (30)
variable in univariate linear regression analyses, where age, gender, 31–40 10 (9) 126 (44)
country of birth, clinical years as RN, previous palliative care education, 41–50 2 (2) 60 (21)
previous specialist education, and EOL care experience were used as 51–60 14 (5)

independent variables. P-values below 0.2 in the univariate linear Age in year
Mean (SD)
regression analyses were considered sufficient to include the respective 23.43 (5.03) 35.43
(8.06)
variables in multivariate linear regression analysis. In all other analyses, Median (range) 22 (24)
the results were considered significant when p-values were below 0.05. Age <35 n (%) 156 (55)
The mean and SD of total FATCOD score and per item were calculated Age >35 n (%) 130 (45)
and compared between the groups enrolled in specialist education, and Gender n (%)
between the groups of RNs and UNSs using non-parametric statistics Woman 108 (87) 256 (89)
(Mann-Whitney U test) as the data were not normally distributed ac- Man 14 (11) 31 (11)

cording to Kolmogorov-Smirnov’s test. The mean FATCOD score per Years’ working experience as RN n (%)
group (n = 14 groups) enrolled in specific speciality education was 1–5 years 143 (50)
compared using a parametric test (t-test), as total FATOCD is normally 5–10 years 74 (26)
>10 years
distributed (Frommelt, 2003). Based on similarities with respect to 69 (24)
1
occurrence of death in the respective clinical context, the RNs from the Missing
Previous education in health care n (%) 24 (19)
different clinical nurse specialist education programmes were merged Previous experience of clinical care n (%) 69 (56)
into five groups. The paediatrics and psychiatry groups were very small Previous experience of EOL-care n (%) 84 (68) 205(78)
and neither fit into any of the other groups and formed a bit of a “other Country of birth n (%)
group” 1) Acute Care (n = 98, including ambulance, anaesthesiology, Sweden 114(97) 254(89)
a
intensive care), 2) Surgery and Oncology Care (n = 41, including surgery, Nordic countries 1(0.5) 6(2)
Other European country b 2(2) 6(2)
oncology, theatre), 3) Medical Care (n = 31, including medicine, car-
Africac 4(1)
diac); 4) Community Care (n = 83, including district nurse, care of the Asiad 1(0.5) 11(4)
5(2)
diatrics, psychiatry). The data were analysed using IBM SPSS Statistics a
Denmark, Norway, and Finland are represented.
for Windows, Version 24.0 (SPSS Statistics for Windows, Armonk, NY: b
Iceland, Russia, former SFR Yugoslavia, Poland, Lithuania, Serbia, and
IBM Corp). Bosnia are represented.
c
South Africa, Ghana, Burundi, Ethiopia are represented.
d
Countries within central- south-, east- and west Asia are represented.
e
Colombia and Chile are represented.

elderly, palliative care) and 5) Other specialities (n = 34, including pae- 3 South Americae
programme of Palliative Care (n=10) (part of Community Care) had the relative (missing n = 23). However, 16 (women n = 14, men n = 2) had
highest mean (139.20) FATCOD score, signifying a more positive atti- no clinical experience of EOL care. The analysis revealed that neither
tude towards EOL care compared to the other groups. In fact, a statis- frequency of death at the workplace, nor the number of previous clinical
tically significant difference was noted in attitude towards EOL care work settings, had a statistically significant effect on RNs’ attitudes to-
between the RNs in the Palliative Care group and all other groups, wards EOL care. Most UNSs (n =116) had cared for a dying patient
except the Oncology, Cardiology and Elderly Care groups (Table 2). The during their clinical placement, and 79 had cared for a person who
number of participants per specialist education programme, including subsequently died during their programme of education.
their mean and SD values, are also presented in Table 2.
Among the 287 RNs, 26% (n = 75) had previous education in palli- Factors affecting EOL-attitudes among UNSs and RNs
ative care (ranging from short course within undergraduate education to
more in-depth postgraduate courses), while the rest had no such edu- Using univariate linear regression models, the factors previously
cation (missing n = 2). RNs with previous palliative care education had a identified as affecting the attitudes towards EOL care among UNSs were
more positive attitude towards EOL care (p = 0.002) than RNs without analysed (Hagelin et al., 2016) (Table 3). The p-values for the factors age
such education. While most participants without previous palliative care and previous experience of clinical health care were considered suffi-
education were found in the Acute Care group (n = 90), they were also ciently low (p < 0.2) to be included in a multivariate model, but only age
spread between all other groups; Community Care (n = 52), other spe- remained as a statistically significant factor associated with attitudes
cialties (n = 28), Medical Care (n = 24), and Surgery and Oncology Care (n towards EOL care among UNSs (Table 3).
= 16). Considering single items in the FATCOD questionnaire, most Also, for the RNs, the association between attitude towards EOL care
specialty education groups (n =13) had a high mean score (>3 e.g., and the same factors, respectively (univariate regression models), were
strongly agree) for item 23; Nurses should permit dying persons to have analysed. The statistically significant factors of age, gender, clinical
flexible visiting schedules. Most groups (n = 12) also had a low mean score years as RN, previous education in palliative care, and previous
(<3 e.g., strongly disagree) for item 17; As a patient nears death, the nurse specialist education, were then combined in a multivariate model where
should withdraw from their involvement with the patient, and item 19; The age, gender and previous education in palliative care remained signifi-
dying person should not be allowed to make decisions about their physical cant (Table 3).
care. The RNs admitted to the specialty programmes of Palliative Care,
Care of the Elderly, and Oncology had generally higher mean scores Comparison of EOL-attitudes in RNs and UNSs
(items 1, 2, 4, 10, 12, 16, 18, 20–25, 27, and 30) and lower mean scores
(items 3, 5–9, 11, 13–15, 17, 19, 26, 28, and 29), together indicating a We analysed the 5-point Likert-type questions at item level about
more positive attitude towards EOL care compared to the other groups. attitudes towards EOL care. The results for the RNs and the UNSs were
compared, and a statistically significant difference in mean score was
noted in 17 out of 30 FATCOD variables. After analysing the mean score,
General clinical experience, experience of EOL care and death at it was noted that there were differences between the two groups,
workplace among RNs and UNSs although the similarities were more frequent than differences. When
comparing which three items in each group had the highest (strongly
While most of the RNs, (n=205) had gained their experience of EOL agree) versus the lowest (strongly disagree) mean score, only a slight
care solely in their clinical role as an RN, 59 also had this experience as a disparity in most items was noted between the groups. The highest mean
for both groups was found for items 10, 22, and 23, and the lowest mean
Table 2 for items 6, 17, and 19. The greatest difference in mean scores between
Specialist education programme, number of participants per programme and the groups was found for items 24, 7, 3, and 2. There was only a slight
Mean FATCOD score and difference in FATCOD for each group compared to the variation in the mean score for items 14, 12, 20, and 5, while both
palliative care group. groups had the same mean core for item 11. The mean values and
Specialist education programme N Mean FATCOD (SD) T (df)/p-value standard deviation results are presented in Table 4.
Palliative care 10 139.20 (4.96)
Oncology 11 137.09 (6.06) —0.867(19)/ 6. Discussion
0.397
Cardiology 15 134.00 (7.68) —1.887(23)/ In the present study of RNs with clinical experience from different
0.072
Elderly 10 133.40 (9.37) —1.724(17)/
health care settings, we found that RNs who are older and have previous
0.103 education in palliative care have a more positive attitude towards EOL
Surgery 14 132.86 (7.03) —2.446(22)/ care. As we interpret it, age as a factor is difficult to influence but
0.023 important for how one experiences EOL. However, these findings are
Anaesthesia 10 130.90 (9.89) —2.371(18)/
likely to be related to experience and education that comes with age
0.029
Accident & emergency 34 129.59 (10.07)
(9.46) —3.073(42)0.004
rather than chronological age per se. The importance of palliative care
63 129.50
District nurses education is illustrated in CroXon et al.’s (2018) study about newly
—2.975(71)/
0.004 graduated nurses’ experiences of dealing with EOL care. Their findings
Medicine 16 129.43 (7.22) —3.741(24)/ suggest that placing a greater emphasis on education in communication
0.001
Ambulance 33 129.39 (8.92) —3.306(41)/
and in simulations are ways to enhance EOL care education within un-
0.002 dergraduate nursing programmes. The palliative care education for
Psychiatry 19 128.63 (10.18) —3.076(27)/ UNSs will form a significant base for their future role as professional
0.005 RNs. The National Board of Health and Welfare (2018) in Sweden states
Paediatrics 15 127.73 (7.41) —4.280(23)/
the importance of health care staff having good knowledge of EOL care
0.000
Intensive care 21 126.19 (11.54) —3.394(29)/ to meet the needs of patients and their relatives. Basic knowledge from
0.002 undergraduate nurse training and continuous training to develop clin-
Theatre/Op 16 123.25 (10.87) —4.342(24)/ ical competence is therefore a prerequisite for enabling RNs to provide
0.000 high-quality EOL care (McCourt et al., 2013).
The Mean FATOCOD scores are presented in order with the highest mean score Our findings show that RNs with clinical experience have a more
at the top and lowest score at the bottom. positive attitude towards EOL care compared to UNSs. The results from

4
Table 3
Univariate, and multivariable models for factors affecting RNs’ and UNSs’ attitudes towards EOL-care.a
Univariate Multivariate
2
R B (SE) (95% CI for B) Adj R2 (R2) B (SE) (95% CI for B)
p-value p-value

Undergraduate nursing students (UNSs)

Age 0.45 0.339 (0.146) (0.50, 0.629) 0.045 (0.036) 0.318 (0.146) (0.029; 0.606)
0.022 0.031
Gender 0.002 0.985 (2.312) (—3.592, 5.563) 0.671 – – –
Country of birth 0.000 0.706 (4.111) (—7.436, 8.848) 0.864 – – –
Previous health care education 0.12 —2.146 (1.837) (—5.803, 1.475) – –
0.241
Previous experience of clinical health care 0.029 —2.751 (1.488) (—5.698, 0.196) 0.067 0.069 (0.052) —2.541 (1.479) (—5.470, 0.388)
0.088
Previous experience of EOL-care 0.001 0.401 (1.642) (—2.852, 3.653) 0.808 – – –

Registered nurses (RNs)

Age 0.056 0.291 (0.071) (0.151, 0.431) 0.000 0.053 (0.056) 0.270 (0,085) (0.103–0.437)
0.002
Gender 0.020 4.341 (1.813) (0.772, 7.910) 0.017 0.066 (0.073) 3.870 (1753) (0.419–7.321)
0.028
Country of birth 0.010 —2.943 (1.773) (—6.434, 0.547) 0.098 – – –
Clinical years as RN 0.013 1.353 (0.688) (—0.001, —2.707) 0.050 0.063 (0.073) —0.103 (0.800) (—1.678–1.473)
0.898
Previous experience of EOL-care as RN 0.001 —1.266 (2.390) (—5.971, —3.439) 0.597 – – –
Previous education in palliative care as RN 0.033 —3.779 (1.210) (—6.160, —1.398) 0.002 0.084 (0.097) —3.223 (1.187) (—5.560 to —0.885)
0.007
Previous specialist education in nursing 0.000 —0.288 (1.980) (—4.186, 3.610) 0,884 – – –
a
Dependent variable: TOT_F.

this study are comparable to those of Benner (2001), which suggest that the death of a patient is viewed as a failure (Peters et al., 2013). Poor
there is a relationship between the development of clinical reasoning communication and avoidance of discussing death is related to the
skills, theoretical education, and clinical experience. The RNs with culture of avoiding death in acute hospitals and constitutes a compelling
extensive clinical experience can be viewed as expert nurses who possess barrier to providing EOL care (Reid et al., 2015; Lind et al., 2017). For
good communication skills and a superior awareness of the clinical sit- RNs who have yet to accrue significant experience in EOL care, attitudes
uation, compared to novice nurses and UNSs, who have very little or no about death and dying are likely to originate from what may be limited
clinical experience. In this case, it also seems that such experience also exposure to EOL care during undergraduate nursing training. Contrary
positively influences attitudes, at least those related to EOL care, as to the fact that EOL care is viewed as an important aspect of under-
supported by the findings of the present study. Surprisingly, when graduate nursing education, it is an area of practice that UNSs and RNs
comparing the FATCOD item mean score between RNs and UNSs, the are not adequately prepared for (CroXon et al., 2018). Our study found
mean values were similar. The results from the study revealed that the that most of the RNs had not received any training in palliative care.
RNs are not always comfortable talking about death with a dying person Greater emphasis is thus needed to enhance nurse education in this area,
(item 3) and, interestingly, both groups had the same mean value (1.97) as UNSs need both theoretical and clinical knowledge to encounter
on item 11, signifying that they would change subject to a more cheerful death and provide EOL care (Österlind et al., 2016). Employing theo-
topic if the patient should ask them whether he or she was dying. Pre- retical education in combination with simulation and guided reflection
vious research findings illustrating how RNs adopt a more positive on their experiences is one favourable way to prepare UNSs for their
attitude based on clinical experience (Browall et al., 2010; Park and clinical placements and future clinical practice (Garrino et al., 2017;
Yeom, 2014), may thus not apply to all RNs, especially if their clinical Österlind et al., 2016).
experience is in a clinical area with less exposure to EOL care. For groups
of RNs who do not gain any substantial experience in EOL care based on Methodological consideration
their clinical experience, continuing education programmes based on
EOL care that also take attitudes into consideration is nevertheless A descriptive, quantitative design was applied. The participants were
important, as they may come into contact with dying patients within predominantly women; although this may accurately reflect the situa-
their specific clinical area. Similarly, Lind et al. (2017) also noted a need tion of clinical settings in several healthcare environments, it provided
for placing a greater emphasis on EOL care education programmes
very few male RNs’ attitudes towards EOL care. RNs with a fear of death
within acute hospital settings.
and dying may have avoided participating in the study, while other RNs,
This is also supported by our finding that RNs with one to five years
those with an interest in the subject area, who were comfortable
of clinical experience had a higher mean FATCOD score compared to
reporting on their attitudes towards EOL care may have been more likely
RNs with siX to ten years of clinical experience. As most of the partici-
to agree to participate, which might bias the results. A convenience
pants in this group (6–10 years’ clinical experience) came from acute sampling procedure was applied, and all of the RNs who had
and psychiatric care, it could be assumed that RNs in these groups have commenced one of 14 specialist education programmes were
minimal contact with dying patients and their families. This suggests approached for participation, and all who were invited and agreed to
that having clinical experience from different health care settings does participate were included. Some limited data on ethnicity (place of
not always entail a positive attitude towards EOL care among RNs; birth) were collected, but no data on culture were collected, which
rather, the type of clinical experience, i.e., positive experiences of EOL possibly could decrease the generalizability of the findings to other
care, has a greater influence on having a positive attitude towards EOL cultural contexts. The groups were constructed based on the similarities
care (Anderson et al., 2015). This is likely to be related to the probability
with respect to exposure of death generally in the RNs’ clinical context.
that RNs working in acute care settings often see their patients for a There was a disparity in size between the different groups, which may
short period of time and their main focus is on curing disease, and where reduce the generalizability of the findings and may have had an effect of

5
Table 4 the outcomes of the study. It would have been interesting to use the RNs
Differences in mean (SD) between UNSs and RNs. within the palliative care group as a reference group, however, as the
FATCOD item numbers and items UNS RN (z-Value) group within this study consisted of only ten RNs, it was deemed too
Meana Meana p- value
b
small to be used as a reference group. It was noted that there was a
(SD) (SD) difference between RNs with different clinical experience; nonetheless,
1. Giving care to the dying person is a 4.83 4.71 (—2.44) our sample size was too small to power meaningful comparisons be-
worthwhile experience. (0.5) (0.6) 0.015 tween specific clinical areas and attitudes towards EOL care. However, it
2. Death is not the worst thing that can 4.17 3.86 (—3.779) was possible to see that attitudes towards EOL care are influenced by
happen to a person. (0.9) (1.2) >0.001
3. I would be uncomfortable talking about 2.60 2.26
factors such as age and previous experience of palliative care education.
(—1.717)
death with a dying person. (1.1) (1.2) 0.086 The participants came from a range of clinical settings and experience
4. Caring for the patient’s family should 4.83 4.65 (—2.338) levels, which supports the generalizability of the study findings. Our
continue throughout the period of grief (0.4) (0.7) 0.19 findings warrant further qualitative and quantitative study with larger
and bereavement.
samples, both within and across clinical specialists, to explore attitudes
5. I would not want to care for a dying 1.54 1.59 (—2.743)
person. (1.0) (1.0) 0.006 towards EOL care.
6. The nurse should not be the one to talk 1.36 1.46 (—3.336)
about death with a dying person. (0.7) (0.9) 0.001 7. Conclusions
7. The length of time required for giving 1.38 1.81 (—1.880)
care to a dying person would frustrate (0.7) (1.1) 0.060
me. This study concludes that age and previous education in palliative
8. I would be upset if the dying person I was 1.75 1.55 (—4.031) care, as well as type of clinical experience, are important influences on
caring for gave up hope of getting better. (1.0) (0.9) >0.001 attitudes towards EOL care. One might assume that RNs with extensive
9. It is difficult to form a close relationship 1.77 1.86 (—2.573) clinical experience have vastly more positive attitudes towards EOL care
with the family of a dying person. (1.0) (1.0) 0.011
10. There are times when death is 4.91 4.77 (—3.637)
compared to UNSs in their final semester. This study not only revealed
welcomed by the dying person. (0.3) (0.6) >0.001 that the RNs’ attitudes were not dissimilar to the attitudes of UNSs,
11. When a patient asks if they are dying, I 1.97 1.97 (—1.920) despite having more clinical experience, but that there was also a dif-
change the subject to something (1.0) (1.1) 0.055 ference between the RNs with different types (e.g., palliative vs acute
cheerful.
12. The family should be involved in the 3.57 3.59 (—0.784)
care) of clinical experience. Enhancing UNSs’ education by including
physical care of the dying person. (1.0) (1.0) 0.433 relevant theoretical and clinical contents in the curriculum and
13. I would hope the person I’m caring for 2.09 1.92 (—0.449) encouraging the UNSs to critically reflect on their clinical training as
dies when I am not present. (1.1) (1.1) 0.654 well as on their own life experiences will have a positive impact on their
14. I am afraid to become friends with a 1.66 1.67 (—2.932)
attitudes towards EOL care in their upcoming professional role as RNs.
dying person. (1.0) (1.0) 0.003
15. I would feel like running away when 1.55 1.33 (—3.334)
Furthermore, the results imply that there is a need for greater emphasis
the person actually died. (0.9) (0.7) 0.001 on further continuing education within EOL care for RNs working in all
16. Families need emotional support to 4.63 4.46 (—1.172) types of clinical specialities to encourage RNs talking about death and to
accept the behavior changes in the dying (0.6) (0.8) 0.241 enhance attitudes towards EOL care.
person.
17. As a patient nears death, the nurse 1.09 1.16 (—0.834)
should withdraw from their involvement (0.4) (0.6) 0.404 CRediT authorship contribution statement
with the patient.
18. Families should be concerned about 4.45 4.29 (—2.040)
Conceptualization: CMJ, IH, CLH, MB.
helping their dying family member make (0.6) (0.9) 0.041
the best of the remainder of their life. Data curation: CMJ, IH, CLH, MB.
19. The dying person should not be allowed 1.14 1.22 (—4.576) Formal analysis: SF, AG, MB.
to make decisions about their physical (0.4) (0.6) >0.001 Supervision: SF, MB.
care.
Writing - original draft: SF, AG, MB.
20. Families should maintain as normal an 3.84 3.82 (—3.130)
environment as possible for the dying (1.0) (1.1) 0.002
Writing - review & editing: SF, AG, CMJ, IH, CLH, MB.
family member.
21. It is beneficial for the dying person to 4.48 4.38 (—0.421)
verbalize their feelings. (0.7) (0.9) 0.674 Declaration of competing interest
22. Care should extend to the family of the 4.93 4.74 (—5792)
dying person. (0.3) (0.6) >0.001
23. Nurses should permit dying persons to 4.90 4.84 (—5.666)
There are no conflicts of interest.
have flexible visiting schedules. (0.4) (0.5) >0.001
24. The dying person and their family 3.90 3.41 (0.530)
Acknowledgements
should be the in-charge decision-makers. (1.1) (1.3) 0.596
25. Addiction to pain-relieving medication 1.80 1.5 (1.0) (—3.030)
is a problem when dealing with a dying (1.1) 0.002 We wish to thank Ms. Aileen Ireland for her excellent language re-
person. view of our manuscript.
26. I would be uncomfortable if the patient 2.03 1.75 (—3.739)
is crying. (1.1) (1.0) >0.001
27. Dying persons should be given honest 4.60 4.67 (—0.462) References
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7
Title : Registered nurses and
undergraduaten nursing students’
attitudes to performing end-of-life care

Research objective : RNs and the UNSs

Research method : A descriptive, quantitative

Participants/respondent : Specialist education programme, number of

participants per programme and Mean FATCOD score
and difference in FATCOD for each group compared to
the palliative care group

Sampling Technique : Univariate, and multivariable models for factors

affecting RNs’ and UNSs’ attitudes towards EOL-care.a

Data Collection : 14 specialist education programmes

Data Analisis : Descriptive statistics were conducted to

summarise demographic characteristics and
attitudes towards EOL care

Data findings : We analysed the 5-point Likert-type questions at

item level aboutattitudes towards EOL care. The
results for the RNs and the UNSs were compared,
and a statistically significant difference in mean
score was noted in 17 out of 30 FATCOD variables