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Third-year Australian nursing students’ attitudes, experiences, knowledge, and education concerning end-of-life care Oluwatomilayo Adesina, Anita DeBellis, Lana Zannettino

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ll human beings will experience death, but despite the inevitability of this experience it has become a topic that is largely not discussed, especially in Western cultures (Mooney, 2005; Iranmanesh et al, 2008a; Chaves and Massarollo, 2009; Huang et al, 2010). A death experienced in the place of one’s choice, surrounded by loved ones, and with adequate pain relief has been suggested to be a ‘good’ death (Ferrand et al, 2003). However, in recent times the death and dying process has become institutionalised and a large proportion of patients experience death in settings such as hospitals (Levy et al, 2005; Braun et al, 2010; Huang et al, 2010). Changes in family and social structures, such as the ageing population and the medicine-oriented model of treatment, are some of the reasons for the increasing institutionalisation of death in both Western and non-Western cultures (Huang et al, 2010). Provision of quality end-of-life care (EoLC) relies on an interdisciplinary health team working collaboratively to provide optimal care (Mutto et al, 2010). Members of this interdisciplinary team, particularly nurses—who have the most contact with patients—need to possess strong interpersonal communication skills, EoLC knowledge, practical expertise, and respect for the dying patient and their family’s wishes (Mutto et al, 2010). It is also important for each member of the multidisciplinary team to possess skills informed by current evidence and to have either personal or professional experience relating to death and dying (Wessel and Rutledge, 2005; Mutto et al, 2010). Experience not only helps to provide the required skills and knowledge, it may also help to increase a person’s ability to empathise with patients and families (Barrera et al, 2008). In addition, members of the multidisciplinary team need to have no unresolved negative issues and feelings associated with such experience, as these may have a detrimental impact on their ability to provide effective EoLC (Wessel and Rutledge, 2005; Mutto et al, 2010).

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Abstract

Background: Nurses have a vital role in providing end-of-life care to patients and their families, and it is important that nursing students are adequately prepared for this role. Aim: This article reports on qualitative findings from research that explored a cohort of third-year undergraduate Australian nursing students’ attitudes, experiences, knowledge, and education concerning end-of-life care. Methods: The study used open-ended questions in a purpose-designed, self-administered questionnaire and thematic analysis of the responses. Findings: Five themes emerged from the analysis: the importance of the students’ values and beliefs, the influence of experience, their views on what constitutes a good or bad death, their knowledge of ethics and legislation surrounding end-of-life care, and how they perceived their level of education and knowledge. Conclusion: The need for more education on end-of-life care has implications for curriculum development in undergraduate nursing programmes, which need to provide graduating nurses with the necessary knowledge and skills to deliver quality care to patients who are dying and their families. Key words: Nursing l Undergraduate education l End-of-life care l Death and dying l Euthanasia

Mooney (2005) suggested that education around death is effective in reducing death anxiety, particularly when it is conducted in a manner that allows the individual to examine and resolve their attitudes and beliefs over time rather than through a short, intensive programme. Mooney (2005) and Barrere et al (2008) examined the influence of end-of-life education programmes on the attitudes of nursing students and found that a 13-week death education programme decreased death anxiety and positively affected participants’ attitudes toward EoLC. These studies recommend that death education theory in nursing classes, coupled with opportunities to gain clinical experience and reinforce concept application at the bedside, could promote a positive change in attitude toward end-of-life issues (Mooney, 2005; Barrere et al, 2008). Nursing students are often involved in the care of terminally ill patients during their clinical

Oluwatomilayo Adesina, Registered Nurse, The Queen Elizabeth Hospital, and Lecturer, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide SA 5001, Australia; Anita DeBellis, Senior Lecturer in Nursing, School of Nursing and Midwifery, Flinders University; Lana Zannettino, Senior Lecturer (Sociology), School of Nursing and Midwifery, Flinders University Correspondence to: Oluwatomilayo Adesina ades0009@ flinders.edu.au

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rotation. For those undergraduates who have had little or no exposure to death, dying, and providing EoLC, these experiences can lead to feelings of anxiety and emotional distress (Leighton and Dubas, 2009). Students’ attitudes, experiences, knowledge, and education concerning EoLC are crucial because such care can be intensive and confronting for nursing students, patients, and their families. The literature suggests that many registered nurses (RNs) and nursing students feel inadequately prepared by their nursing education to provide EoLC and emphasises the need for continuing education in this area of nursing (Hughes et al, 2006; Dickinson et al, 2007; Leighton and Dubas, 2009; Mutto et al, 2010). These and other studies question whether undergraduate nursing education is adequately preparing nursing students to provide EoLC. Additionally, studies have indicated that the lack of EoLC education in nursing curricula also affects nurses’ ability to deal with the ethical dilemmas encountered in relation to caring for dying patients (Hamric and Blackhall, 2007; Erdil and Korkmaz, 2009). For example, nurses may feel distressed at giving care they perceive as unwarranted if they have less impact on end-oflife decision making than physicians (Hamric and Blackhall, 2007; Erdil and Korkmaz, 2009). Much of the literature has examined nurses’ perceptions of death and dying in a palliative care context, i.e. one in which EoLC is provided that neither hastens nor postpones death but aims to achieve a good quality of life until the end of life (Pastrana et al, 2008). However, many nursing students experience death and dying outside the palliative care setting, such as in the acute and critical care environments (Lange et al, 2008; Huang et al, 2010). These experiences are not well documented in the current literature. Also, it appears that there may still be a significant gap in knowledge concerning nursing students’ practices pertaining to the care of people who are dying. Therefore, research into nursing students’ attitudes, experiences, knowledge, and education concerning caring for people who are dying is an important first step in an effort to improve the education and practice of undergraduate nursing students.

Aim This paper reports on research undertaken as part of a larger study that broadly aimed to explore a cohort of third-year undergraduate nursing students’ attitudes, experiences, knowledge, and education concerning EoLC through a survey design. The study aimed to identify: ●●The attitudes, beliefs, feelings, values, and dispositions that may influence nursing students

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to act in certain ways when providing EoLC ●●Nursing students’ personal and professional experiences of death and dying that may influence their provision of EoLC in their nursing practice ●●Whether nursing students feel adequately prepared by their undergraduate nursing programme to provide quality EoLC.

Methodology The study used a mixed-method survey approach. A combination of open-ended qualitative and closed quantitative questions was developed to survey a single cohort of final-year undergraduate nursing students. This article reports on the qualitative data generated by the questionnaire.

Ethical approval Ethical approval for the project was gained from the ethics committee of the university at which the survey cohort was enrolled (project number 5300), and consent was given by the dean and curriculum coordinator of the nursing school to approach all third-year undergraduate nursing students.

Survey instrument The questionnaire was developed from the literature, experts in the field, and two previously validated questionnaires. It was designed to obtain information on participants’ current attitudes, experiences, knowledge, and education regarding EoLC. The two previously validated questionnaires were the Frommelt Attitude Toward Care of the Dying (FATCOD) scale and the Death Attitude Profile–Revised (DAP-R) scale (Frommelt, 1991; Wong et al, 1994). The questionnaire included 12 open-ended questions (Box 1). These questions enabled the generation of qualitative data replete with participants’ subjective experiences and meanings of death and dying. A pilot study of the questionnaire was conducted to establish whether the survey questions were intelligible and unambiguous. The questionnaire was piloted by third-year nursing students (n=25) enrolled in elective palliative care study. From this pilot study, the researcher was able to ascertain that the questionnaire was userfriendly and provided sufficient information for data analysis. A minor amendment to a question on cultural background was made because it was missed or misinterpreted in the pilot study.

Sampling and recruitment Participants were sampled from a cohort of third-year undergraduate nursing students enrolled in the Bachelor of Nursing degree

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programme in an Australian university. This cohort had undertaken several clinical placements as part of their nursing studies and consequently had a range of clinical experience. Third-year nursing students were chosen as they were in the final year of their degree and it was expected that they would have had some clinical experience of death and dying at this stage of their nursing education. EoLC content was threaded through several topics in the curriculum but on an informal basis; there were no topics or modules that specifically covered EoLC. Potential participants were drawn from approximately 200 nursing students. The lecturers in all of the tutorial classes in one week were given a script to read that provided information about the study. The students were entirely free to decide whether to participate and were assured of anonymity and confidentiality. It was also stated that participation would not form any part of the requirements for the course and that the students would be neither advantaged nor disadvantaged by their decision about whether to participate. The students were informed that they could withdraw from the study at any time without consequence and could refuse to answer any questions in the survey.

Box 1. Survey questions ●

Can you please describe your own values and beliefs about death and dying—your personal perspective?



Can you please describe any thoughts and reflections on your own mortality?



Did your nursing education influence your attitudes about death and dying and your own mortality? (No/yes) If yes, can you please describe how you were influenced?



Can you please describe what you consider to be a ‘good’ death and can you give an example from your clinical practice?



Please describe what you consider to be a ‘bad’ death and can you give an example from your clinical practice?



Have you experienced nursing a dying person? (No/yes) If no, go to question 4.4



Have you had any negative experience(s) of death and dying while providing nursing care during your clinical practice? (No/yes) If yes, please give a brief summary of what happened



Have you had any positive experience(s) of death and dying while providing nursing care during your clinical practice? (No/yes) If yes, please give a brief summary of what happened



Have you had personal experience(s) of death and dying of friends or relatives in your life? (No/yes) If yes, please describe how this experience has influenced your nursing practice



Please name any principles you know of that guide your practice in end-of-life care or death and dying of patients



Please identify any ethical issues that may arise in end-of-life care or death and dying of patients



Please identify any legislation pertaining to end-of-life care or death and dying that you know of

Data collection The questionnaire was distributed to the students in class along with an introductory letter, information sheet, and reply paid envelope. The students were also informed that the introductory letter, information sheet, and survey were available online. They could then freely choose to complete the survey and return their response in the supplied envelope. Alternatively, they could choose to send the completed electronic survey to the provided email address. Participants choosing the latter option were made aware that email was not a secure medium. The students could also print the completed survey and post it to the research supervisor or return it via the chute box at a specific campus location.

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Data analysis The qualitative data from the open-ended questions was analysed using six levels of analysis. The first level involved transcribing the data and reading over it to note down initial ideas. Numerous potential themes were coded at this stage. Subsequently, all the different codes were sorted into potential themes. The themes were then refined to determine what the different themes were and how they fitted together. A thematic map of the data was generated and further refinements were made by identifying the essences of each theme and determining what

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aspect of the data each theme captured. This generated a thematic map of five main themes and further refinements were made to these themes by identifying the essence of what each was describing (Braun and Clarke, 2006).

Findings A total of 62 survey responses were obtained, giving a response rate of 31%. Owing to the small response rate the data from the nursing students who piloted the survey was also included in the analysis, resulting in a total of 87 participants for the study. Although this article focuses on the open-ended questions, some descriptive statistics are provided to contextualise the responses. Of the 87 participants, 85% were female and 13% male (2% unspecified). Analysis of the demographic data found that participant gender did not significantly affect the attitudes expressed toward death and dying. Fifty nine per cent of the students reported having had some experience with nursing a dying person either personally or professionally (e.g. through enrolled nursing, aged care work, and/or the death of a family member). In contrast to gender, participants’ age had a significant association with their attitudes toward EoLC: older participants were significantly more confident in some areas regarding death and dying.

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The thematic analysis of the participants’ responses identified five major themes concerning death and dying: the importance of the students’ values and beliefs, the influence of experience, their views on what constitutes a good or bad death, their knowledge of ethics and legislation surrounding EoLC, and how they perceived their level of education and knowledge.

The importance of values and beliefs The majority of the students’ values and beliefs about death and dying were related to their personal belief systems (e.g. religious, scientific, spiritual). Some had religious or supernatural views of death, some viewed death and dying as a mystery, and others related death to the ideology of science and believed that death is ultimately the end of life as opposed to believing in an afterlife: ‘I know that I’m not going to live forever. I accept that someday I’m going to die. I just have to enjoy life and hope to be ready when my death comes.’ (Participant 25)

Some of the students appeared to accept the inevitability of their own death. A non-religious, humanistic view of life lent itself to a philosophical interpretation of the death and dying process, which helped the students to face their mortality and accept it. As a result they reported being able to focus on other issues while enjoying life. Participants who stated they had religious beliefs showed no fear of death at all and appeared to be assured and confident about their own death. The crucial point of this theme was that those students with a belief system in place, irrespective of what that belief system was, reported feeling more secure and less fearful about the inevitability of their own death and the deaths of others.

Personal and professional experience The students’ experience of death and dying was classified as either personal (death of a loved one or friend) or professional (aged care and enrolled nursing). Professional experience was not often related to the ongoing nursing education, being more likely to stem from previous experience of working in the health-care sector as either aged care workers or as enrolled nurses. A significant number of students also reported that their personal experience had a positive influence on their EoLC nursing practice: ‘Grandma and grandpa died—it was the first time I had heard about palliative care, and it sparked my interest. Death of a friend has also made me think about how I would address

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these issues with the patient and their family— what would you say to ease the hurt and pain.’ (Participant 3)

The students believed that their knowledge of death and dying had been obtained from their own personal, private, individual, and professional experiences rather than their university education. This implies that there may be a gap in the nursing curriculum of this university regarding death and dying.

Good death vs bad death The participants’ descriptions of what they considered good and bad deaths illustrated the values and beliefs that the students viewed as being crucial to providing quality EoLC. Pain management and control appeared to be key factors: ‘A good death is one without pain and is not drawn out with no or very low quality of life. I believe a ‘bad’ death is the opposite—a long, drawn out or low quality of life with immense pain.’ (Participant 36)

The circumstances and contexts in which death occurs were also thought to affect whether a death was considered good or bad. Deaths occurring during sleep, with dignity, and without pain were described as good deaths, whereas deaths in which the person suffered pain, was unprepared, or lacked dignity were described as bad deaths. The mechanism of death and age at which death occurs were also considered instrumental in constituting a good or bad death. Most of the participants emphasised the importance of achieving a good death experience for patients and their families.

Ethics and legislation Although not directly asked about in the survey, the most common ethical issue raised by the students was euthanasia, particularly in relation to the legal and moral role of health professionals. Euthanasia is currently illegal in all states in Australia. One student attempted to understand the issue of euthanasia from the perspective of the patient and from a legal perspective: ‘We cannot go against the law by helping them [a dying patient] commit euthanasia. But then are we only thinking about ourselves? If we were in that patient’s place, how would we feel?’ (Participant 33)

The statement implies the importance of the patient having a level of control in relation to

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how and when their life will end, irrespective of the legal framework governing such issues. Although euthanasia remains illegal in Australia, most of the students viewed it as an ethical issue, requiring reflection and examination by all heath-care providers. Moreover, the students’ perspectives on euthanasia were polarised, with some viewing it as a way of providing comfort and peace to the dying patient and others viewing it as an act of murder. Several of the students suggested that healthcare providers perform passive euthanasia by hastening death with opioids used for pain relief. There were some inaccuracies in the participants’ knowledge relating to euthanasia, particularly regarding legislation. There was no mention of the Consent to Medical Treatment and Palliative Care Act 1995 (South Australian Government, 1995), which protects health professionals who are managing EoLC and pain in the South Australian context. The legislation was apparently not well understood or recognised. Those nursing students in favour of legalised euthanasia tended to be motivated by a desire to not be a ‘burden’ on their loved ones. Some of the students expressed views on euthanasia in relation to their own death: ‘I personally would like a choice if euthanasia was available. I would prefer not [to] be a burden to family and have a dignified pain free demise.’ (Participant 51)

Education and knowledge Some of the students saw their nursing education as having benefitted and influenced them in relation to providing EoLC. The students’ nursing education appeared to have instilled in some of them the importance of the concepts of self-determination and advocacy: ‘I have learnt how important it is to not impose my beliefs upon patients, but rather to try and be accepting and accommodate the needs of my patients, even though I personally may not agree.’ (Participant 3)

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For some students, their nursing education caused them reflect on their own mortality: ‘More than influence I am educated and was forced to think of thoughts I wouldn’t normally enjoy pondering upon.’ (Participant 6) ‘Nursing education has given me a greater understanding of what care I would like to receive if I were to be in EoLC, and that I

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would much rather pass away than be kept on a ventilator etc with very little quality of life.’ (Participant 16)

However, some of the participants indicated that they needed more EoLC education. Several stated that EoLC or palliative care should be a core subject rather than an elective subject in the curriculum: ‘A topic to cover end of life but also include multicultural aspects & religion. This will give more guidance and improve confidence. Senior nurses in a local hospital are even shy about this topic. It really needs to be added into university curriculum!’ (Participant 83)

The participants recognised that nurses provide EoLC in a multitude of contexts and settings, such as acute and critical care, not just palliative care. Although their nursing education had given some students the confidence and skills required to provide EoLC, 63% of the students indicated that they did not feel adequately prepared to care for a dying patient:

❛The students believed that their knowledge of death and dying had been obtained from their own personal, private, individual, and professional experiences rather than their university education.❜

‘Only after doing this survey, I realized that I have no knowledge of caring for a dying patient, although I have always felt that caring for a dying patient is a privilege that we may encounter in our nursing career.’ (Participant 33)

For those students who had not experienced EoLC in their clinical placement, their own personal and professional experiences were their only sources of knowledge in relation to death and dying because, according to them, such content was not available in the curriculum.

Discussion The participants’ attitudes toward death, dying, and providing EoLC were influenced by various beliefs. Whether religious, atheist, or humanist, a strong belief system was an important factor in approaching death and dying without fear and accepting its inevitability. Other studies have also found that participants who had a particular belief or view of death and dying (whether as a gateway to an afterlife or as a natural part of life) had a more positive attitude toward people who were dying (Wessel and Rutledge, 2005; Iranmanesh et al, 2008a; Mutto et al, 2010). Studies by Braun et al (2010) and Iranmanesh et al (2008b) found that attitudes toward EoLC influence the behaviour of nurses and caregivers.

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❛Several students stated that end-of-life care or palliative care should be a core subject rather than an elective subject in the curriculum ...❜

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For some of the students, personal and professional experience of death and dying provided context for their learning and improved their EoLC knowledge and confidence. For example, the nursing students with experience identified a positive change such as a reduction in fear and anxiety relating to the dying process. These positive changes included an ability to empathise with the experiences of patients and their families and increased knowledge in areas of EoLC. The importance of having personal or professional experience of death and dying has also been highlighted in previous studies (Barrere et al, 2008; Iranmanesh et al, 2008a; 2008b). Similar to the findings of the current study, these studies concluded that participants with previous experience of death and dying had better knowledge, had fewer anxieties, and felt better prepared to provide EoLC. The findings suggest that nursing students’ personal and professional experience may be more influential than their education in determining their attitudes and practices in relation to EoLC. However, the knowledge of participants without personal or professional experience of death and dying had been garnered through education. The participants believed that for a death to be ‘good’, it had to be what the individual wanted it to be and, most importantly, pain-free. The students considered a good death to be one that occurs during sleep, at an old age, with time for preparation, and with as much dignity as possible. Ultimately, the findings revealed that the students had a strong sense of achieving a death experience that respects the wishes of the dying patient. They had negative views of interventions not tailored to patients’ own personal requirements. What constitutes a good or bad death is an aspect of death and dying theory and practice that has been under-examined in the literature. This current study supports Costello’s (2006) findings that the context and circumstances surrounding the death of an individual determine whether a death is considered to have been good or bad. Euthanasia was a key issue in participants’ responses in relation to the legal and ethical context of death and dying. Some of the students viewed euthanasia as an act that could be undertaken to respect the wishes of a dying patient or relieve pain, whereas others believed that euthanasia should not be considered even if a patient has expressed a wish to die. Interest in the issue of euthanasia has attracted strong debate among both the lay public and health professionals in Australia. Johnstone (2011) indicated that the issue of euthanasia may have been over-emphasised by the media, with the general public not viewing it as a main concern.

However, it is important that nurses participate in these debates (Johnstone, 2011). Comments by some of the students indicated that they had a general misunderstanding of the Australian legislation that protects health professionals if treatment should hasten death as a secondary effect. These findings are concerning. Under the Consent to Medical Treatment and Palliative Care Act of 1995 (South Australian Government, 1995), the administration of medical treatment for the relief of pain or distress in accordance with proper professional standards of palliative care and without negligence does not constitute an intervening cause of death. All major religions, legislation, and palliative care standards acknowledge that, regardless of whether narcotic pain relief may hasten a person’s death, the ethical intention is beneficence and the relief of suffering, not death. However, little is known about the actual experiences and practices of nursing students in regard to deliberately hastening death through the provision of opioids. In one study, a survey of 943 Australian nurses found that 23% reported being asked by a physician to engage in passive euthanasia and, of these, 85% reported complying with the request (Kuhse and Singer, 1993). In another survey of 278 Australian nurses, 19% reported taking active steps to bring about the death of a patient through the provision of opioids, often without being asked to do so by the patient or the patient’s family (Asch, 1996). The findings of this study indicate that the undergraduate nursing programme may not adequately prepare nursing students for providing EoLC. Although some students reported that the nursing curriculum provided them with the skills and confidence to care for dying patients, others expressed that it did not adequately prepare them to do so and that they had to rely on their own personal and professional experience of death and dying to inform their practice. Overall, the findings indicate that there is a dire need for a greater focus on EoLC in the undergraduate nursing curriculum. Similar findings were reported by Brajtman et al (2007) and Leighton and Dubas (2009). This research adds to the body of knowledge on nursing students’ beliefs and attitudes toward death and dying and EoLC practices. It has explored areas where there has been a significant gap in Australian knowledge, such as how nursing students define a good or bad death and their views on issues such as euthanasia. Of paramount importance is the finding that many of the students perceived the EoLC education in their undergraduate degree as inadequate.

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Limitations The findings reported here are not generalisable as this was a qualitative study conducted with participants from one university; however, other undergraduate programmes are similar. Moreover, the survey design did not give participants the opportunity to probe or seek clarification on the questions asked, as would be the case in face-toface or focus group interviews.

Future research An in-depth study using qualitative methodology and interviews to provide richer data would usefully expand on and explore these findings. Furthermore, there is a significant gap in the literature on what constitutes a good or bad death, and this also requires further research.

Conclusion The ability of nursing students to provide quality EoLC is influenced by a number of elements, including their values, beliefs, education, knowledge, and experiences concerning death and dying. The participants’ descriptions of what they considered good and bad deaths illustrated the values and beliefs that they viewed as being crucial and influential to providing quality EoLC. However, many of the students reported that there was inadequate EoLC content in the nursing curriculum. For some this resulted in a lack of knowledge about death and dying; other students’ knowledge was not solely acquired or based on their nursing education but was influenced by their experience of death and dying. Efforts by educators and curriculum designers to improve the quality of patients’ death and dying experiences depend on understanding the needs of student nurses in this area. I● JPN

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Declaration of interests This work had no external sources of funding. The authors have no conflicts of interest to declare. Asch DA (1996) The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 334(21): 1374–9 Barrere CC, Durkin A, LaCoursiere S (2008) The influence of end-of-life education on attitudes of nursing students. Int J Nurs Educ Scholarsh 5: 11. doi: 10.2202/1548923X.1494 Brajtman S, Fothergill-Bourbonnais F, Casey A, Alain D, Fiset V (2007) Providing direction for change: assessing Canadian nursing students learning needs. Int J Palliat Nurs 13(5): 213–21 Braun M, Gordon D, Uziely B (2010) Associations between oncology nurses’ attitudes toward death and caring for dying patients. Oncol Nurs Forum 37(1): E43–9. doi: 10.1188/10.ONF.E43-E49 Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3: 77–101 Chaves AA, Massarollo MC (2009) Perception of nurses

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about ethical dilemmas related to terminal patients in intensive care units. [In Portuguese] Rev Esc Enferm USP 43(1): 28–34 Costello J (2006) Dying well: nurses’ experiences of ‘good and bad’ deaths in hospital. J Adv Nurs 54(5): 594–601 Dickinson GE, Clark D, Sque M (2007) Palliative care and end of life issues in UK pre-registration, undergraduate nursing programmes. Nurse Educ Today 28(2): 163–70 Erdil F, Korkmaz F (2009) Ethical problems observed by student nurses. Nurs Ethics 16(5): 589–98. doi: 10.1177/0969733009106651 Ferrand E, Lemaire F, Regnier B et al (2003) Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 167(10): 1310–5 Frommelt KH (1991) The effects of death education on nurses’ attitudes toward caring for terminally ill persons and their families. Am J Hosp Palliat Care 8(5): 37–43 Hamric AB, Blackhall LJ (2007) Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med 35(2): 422–9 Huang XY, Chang JY, Sun FK, Ma WF (2010) Nursing students’ experiences of their first encounter with death during clinical practice in Taiwan. J Clin Nurs 19(15–16): 2280–90. doi: 10.1111/j.1365-2702.2009.03090.x Hughes PM, Parker C, Payne S, Ingleton MC, Noble B (2006) Evaluating an education programme in general palliative care for community nurses. Int J Palliat Nurs 12(3): 123–31 Iranmanesh S, Savenstedt S, Abbaszadeh A (2008a) Student nurses’ attitudes towards death and dying in south-east Iran. Int J Palliat Nurs 14(5): 214–9 Iranmanesh S, Dargahi H, Abbaszadeh A (2008b) Attitudes of Iranian nurses towards caring for dying patients. Palliat Support Care 6(4): 363–9. doi: 10.1017/ S1478951508000588 Johnstone MJ (2011) Public opinion and ethics. Aust Nurs J 19(1): 25 Kuhse H, Singer P (1993) Voluntary euthanasia and the nurse: an Australian survey. Int J Nurs Stud 30(4): 311–22 Lange M, Thom B, Kline NE (2008) Assessing nurses’ attitudes toward death and caring for dying patients in a comprehensive cancer center. Oncol Nurs Forum 35(6): 955–9. doi: 10.1188/08.ONF.955-959 Leighton K, Dubas J (2009) Simulated death: an innovative approach to teaching end-of-life care. Clin Simulation Nurs 5(6): 223–30 Levy CR, Ely EW, Payne K, Engelberg RA, Patrick DL, Curtis JR (2005) Quality of dying and death in two medical ICUs: perceptions of family and clinicians. Chest 127(5): 1775–83 Mooney DC (2005) Tactical reframing to reduce death anxiety in undergraduate nursing students. Am J Hosp Palliat Care 22(6): 427–32 Mutto EM, Errázquin A, Rabhansl MM, Villar MJ (2010) Nursing education: the experience, attitudes, and impact of caring for dying patients by undergraduate Argentinian nursing students. J Palliat Med 13(12): 1445–50. doi: 10.1089/jpm.2010.0301 Pastrana T, Jünger S, Ostgathe C, Elsner F, Radbruch L (2008) A matter of definition--key elements identified in a discourse analysis of definitions of palliative care. Palliat Med 22(3): 222–32. doi: 10.1177/0269216308089803 South Australian Government (1995) Consent to Medical Treatment and Palliative Care Act 1995. http://bit. ly/1jTsZ5K (accessed 22 July 2014) Wessel EM, Rutledge DN (2005) Home care and hospice nurses’ attitudes towards death and caring for the dying: effects of palliative care education. J Hospice Palliat Nurs 7(4): 212–8 Wong PTP, Reker GT, Gesser G (1994) Death attitudes across the life span: the development and validation of the Death Attitude Profile (DAP). Omega 18(2): 113–28

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Third-year Australian nursing students' attitudes, experiences, knowledge, and education concerning end-of-life care.

Nurses have a vital role in providing end-of-life care to patients and their families, and it is important that nursing students are adequately prepar...
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