Mun Leong Tang1, Chen Na Lee2, Hongli Sam Goh3*
1Nursing Administration, St Andrew’s Community Hospital 529895, Singapore
2Division of Nursing. Singapore General Hospital 168753, Singapore
3Open University Malaysia, Petaling Jaya, Selangor 47301, Malaysia
*Corresponding Author’s Email: nurghs@gmail.com
ABSTRACT
Introduction: The End-of-Life Nursing Education Consortium (ELNEC) international curriculum was developed in 2000 and translated into many different languages for nurses worldwide. Although death is a universal phenomenon, handling death and dying differs across cultures and countries. Limited studies are conducted to explore the impact of ELNEC on nursing practices in Asia.
Aim: This study explored palliative nurses' perception of the ELNEC and its impact on their nursing practices in Singapore long-term care setting
Methods: An exploratory qualitative design using individual face-to-face interviews was conducted at a community hospital in Singapore between 2018 and 2019. An interview guide comprising four open-ended questions was used to generate participants’ feedback.
Results: The overarching themes in this study demonstrated the benefits of the ELNEC program for palliative nurses working in the long-term care setting and illuminate ways on how the ELNEC reshaped practising nurses’ death attitudes and anxiety level by providing a platform for them to ventilate and share their experiences.
Conclusion: The study explored the nurses’ perception of ELNEC and found its benefits for improving death anxiety and attitudes among existing nurses working in a community palliative setting.
INTRODUCTION
Being at the forefront of caring for patients, nurses encounter death and dying situations frequently. Caring for a dying patient can be a worrisome but inevitable experience that creates distress and care apprehension for many healthcare professionals (Nia et al., 2016). Several systematic reviews report how death experiences could potentially create emotional burden and negative death attitudes among nurses (Jones et al., 2020; Shorey et al., 2017; Zheng et al., 2016). If not managed well, these nurses could face the risks of burnout, compassion fatigue, and adverse well-being. This situation is especially so for nurses working in a palliative care setting. Jones et al., (2020) reported that death anxiety could lead to nurses developing avoidance tactics and becoming professionally disengaged, adversely affecting the quality of death for the patients and family members. Therefore, it is important for nurses to increase their awareness, understanding, and competence in caring for terminally ill patients.
Palliative educational programs, such as the End-of-Life Nursing Education Consortium (ELNEC) curriculum, can equip nurses with the necessary skills and knowledge to cope with patients during end-of-life (EOL) situations and conduct a range of palliative education activities for nurses (Ferrell et al., 2015). The ELNEC international curriculum was developed in 2000 by palliative care experts in the United States. It consisted of eight core modules covering a wide range of topics that are central to EOL care (Malloy et al., 2018). The curriculum was translated into many different languages to increase their relevance to the other cultures (Malloy et al., 2018). Since its development, the ELNEC training material is constantly revised and updated for different care settings and sociocultural contexts. It has benefitted many nurses worldwide due to strong advocacy and support by leading palliative care nursing experts internationally (Gillan et al., 2014). Although the literature has collectively reported the potential benefits of palliative training for nursing students and nurses, several gaps were identified. First, most of these studies were mainly conducted on the nursing student population, who do not encounter death frequently (Gillan et al., 2014). The undergraduate ELNEC curriculum focuses on basic knowledge in palliative care that might not adequately prepare practising nurses, who experience different death and dying situations, which required person-centric approach and updated evidence-based strategies. Kav et al. (2018) proposed the need for continuing palliative education to address topics, such as culture-specific communication, emotional coping strategies, and EOL conversations. Second, there were limited studies that evaluated ELNEC impact on nurses in Asia. A recent systematic review that evaluated the effectiveness of palliative education found only six studies in Asia out of 39 studies (Li et al., 2021). Although death is a universal phenomenon, handling death and dying differs across cultures and countries (Tang et al., 2021). It remains unclear whether the ELNEC curriculum is contextualized to suit the local culture, religious beliefs, and death practices in Asia.
This study, therefore, aimed to explore palliative nurses' perception of the ELNEC and its impact on their nursing practices in Singapore long-term care setting. We focused on nurses working in a long-term palliative care setting because of the longer staff engagement with the patients and family members as compared to those in acute hospitals (Tang et al., 2021).
METHODOLOGY
Design
This study employed an exploratory qualitative design using face-to-face interviews to explore the palliative nurses' perception of the ELNEC program and its impact on their nursing practice, death attitudes, and anxiety. This method allowed participants’ views to be explored individually before attempting to seek a sense of universal experience
and compare differences, and finally refining emerging subcategories and themes (Polit & Beck, 2020).
Setting and Sample
The study was conducted at a community hospital in Singapore which serves an ageing population with concomitant increases of chronic, progressive, terminal diseases. There are approximately 400 nurses in the institution, including full-time and part-time nurses, of which 90 were working in the two palliative wards. Purposive sampling was utilized to select nurses from different job grades to ensure population representation. Inclusion criteria include nurses who had participated in the ELNEC program between 2018 and 2019 and worked at one of the two palliative wards at the hospital. Exclusion criteria were non-nursing personnel and those who did not encounter caring for the death and dying. A total of 16 nurses participated in this study.
An interview guide was developed based on the first author’s literature review and was designed to explore the nurses’ perceptions about the ELNEC program and its impact on them. A panel of three university professors validated the interview guide during the first author's doctoral proposal defence session. The individualized face-to-face interview was conducted to gather nurses’ responses to four open-ended questions using the interview guide: (i) Can you share with me your thoughts and feelings about the ELNEC program?; (ii) what were the positive and negative aspects of the program?;
(iii) How has this program impacted your work as a palliative nurse?; and (iv) What else do you think can be done to help you cope with the challenges in your work as a palliative nurse? The post interviews were conducted two weeks after the education program. All interviews will be tape-recorded and later transcribed for data analysis.
Ethical Considerations
Ethical approval was obtained from the Open University of Malaysia prior to data collection (OUM/2.7/400/2017(01)-CGS01134932) on 23 Feb 2018. Informed consent was obtained from participants, with their confidentiality and anonymity maintained at all times. Participants were also informed that they could withdraw from the study at any time without any penalty.
Data Analysis
Content analysis was conducted using the analytical approach by Miles et al., (2014), which comprises three steps – data reduction, data display, and conclusion drawing. Data reduction first involved two researchers familiarizing with the transcript and then making preliminary codes on the transcripts independently to ensure confirmability in the study findings. This step is followed by a data display where the researchers organize similar codes into categories or themes. Finally, conclusion drawing involved a final review and refinement of themes by the two researchers before getting a third researcher (CN) to confirm the themes. Any disagreement during the process was discussed with the third researcher to ensure the findings’ confirmability and accurate representation of the participants’ experiences and views (Miles et al., 2014).
RESULTS
The 16 participants were selected based on their job designations to ensure their population representation, with nine registered nurses, five enrolled nurses, and two nursing aides. Their age ranged from 23 to 50 years old, while their work experiences were between three and 28 years. Exploration of the themes forms the basis of this section, with each theme illustrated by verbatim extracts from the interviews, observations, and data sources. Three themes were generated from the content analysis and discussed in the following section (Table 1).
Themes | Subcategories | Paraphrased Examples |
Lack of basic and continuing nursing education on death-related subjects | Basic training on EOL care | "Part of the reason why we are not accepting death well is that there is a lack of this focus in this area palliative care in our nursing course...I still remember when I was pursuing my diploma, we are not taught palliative care, pain, and symptom management in the final hours…these are important stuff. Even breaking bad news…we are not taught…we only learn on the job. You could imagine how stressful it is when you do it live, and it is your first time." (P1). "Locally we lack training in this area…I receive much training and attend in-service overseas, for example, Hopis Malaysia…" (P5). "We did not learn all these during my nursing training in the 1980s. Nothing about palliative care and not even what to expect during the last hours. We are only taught to do the last office." (P14). "Traditionally, our nursing education in our schools has always focused on promoting health and preventive health. None was focused on death education. Because of that, when we face death or dying issues, we are at a loss." (P16). |
Themes | Subcategories | Paraphrased Examples |
“One thing for sure is that schools did not prepare us to manage these situations, grieving with patients and relatives when a patient is dying. It is through experience that we can ‘steel’ ourselves and handle these emotionally charged situations. Every patient journey is a lesson for us to learn to do better next time…” (P8). | ||
School-practice dichotomy in handling death | “In school, we are only taught of Kubler-Ross 5 stages of Grieving… in reality, no one teaches us anything to cope and handle people who are grieving.” (P7). “I had a ‘Communication’ module when I took my Diploma in Nursing many years ago. But it was nothing to do or related to palliative nursing or how to relate to patients during end of life.” (P3). "But it is so much more different when you experience it and when you're on your own and when it's your own patient. I was shielded from the reality of practice… in nursing school, I am so protected and separated from it, you know… Sometimes I reflect back, and I feel like I have learned so much more in the clinical area than I did in school.” (P 14). | |
Continuing nursing education on death-related subjects | The nursing curriculum has focused on how to treat a patient. But we are not taught how to do advance care planning for dying patients and their family members. Because of this, we lack the death competence and lack the necessary knowledge and skills, which unconsciously build up our death anxiety and negative perceptions of death and dying. I tried to find courses on this, but there are very few courses around for me." (P4). | |
Impact of ELNEC on nurses | Avenue for sharing experiences and feelings | “The ELNEC program was good. I would recommend my colleagues to attend as I personally benefit from it. The modules covered are relevant to my practice as a palliative nurse. Now I can say I am more confident and less |
Themes | Subcategories | Paraphrased Examples |
stressed in nursing and communicating with dying patients.” (P6). "I like the part of the program when we reflect on our values and death attitudes. It helps me align and be self-aware of my bias which could influence the care of the patient. That, of course, includes my death anxiety. Now I would say I am less anxious. Staff should regularly attend similar courses to refresh themselves and increase their death awareness of their own care for the dying patients." (P1). “I feel better when I share with my classmate about the incident during the class.” (P7) | ||
Reshape attitudes towards death | “I believe the public and the many healthcare professionals would continue to harbor this negative death attitude because we lack adequate death education and discussion of these topics openly. It becomes a Pandora box in which there is so much mystery, and everyone is so scared to open and approach. If we had courageously attended this course [ELNEC] in our earlier years, things would have been easier. Death acceptance will be greater, and of course, death anxiety will be lowered" (P8). "I like the part of the program when we reflect on our values and death attitudes. It helps me align and be self-aware of my bias which could influence the care of the patient. That, of course, includes my death anxiety. Now I would say I am less anxious. Staff should regularly attend similar courses to refresh themselves and increase their death competencies. (P1). “It made us aware of our death attitudes and important things we valued and what we should value. It should be part of the nursing curriculum in the nursing schools.” (P11). |
Themes | Subcategories | Paraphrased Examples |
Equip skills and competencies | “It is a program that all nurses should attend. The case studies and scenarios shared were all so real that made us feel we are in it. Through discussion and sharing, we learn about the best way to communicate… Silence, after all, might be good. This is one thing now I have learnt that I need not be stressed out or anxious when keeping silent when patients ask me about end-of-life issues." (P14). "The ELNEC program has taught me about many things… from technical skills to soft skills like pain management, communication skills, and how to convey bad news. One thing I feel is important is mindfulness, how to 'be with' with the patient. To learn to connect with the patient is important. Previously I avoided the sensitive conversation, now I am more comfortable in handling these conversations." (P9). “This (communication training) is an essential component of palliative care. It is one of the important ADLs that patients and we are doing every day. We should not limit ourselves and do less just because we feel anxious. In palliative care, all the nurses should receive some training in this aspect.” (P1). "The ELNEC module of Loss, Grief, and Bereavement was good. The scenarios that we have played let us experience how the relatives and the patient be feeling when approaching end- of-life.” (P7). | |
Perceived educational needs in palliative care | Knowledge deficit in pain management and standards | "I think there is this fear that giving all your PRN's (pro re nata – medication as needed) and giving all these medications like morphine that you know were taught suppresses the drive to breathe, and you know will essentially kill someone if given the dose high enough. There is a mentality that you're killing the patient. We are putting our licenses at stake…” (P1). |
Themes | Subcategories | Paraphrased Examples |
“He died like five minutes later, so I was like, a little nervous wondering, ‘Did the Morphine that I gave him kind of push him over the edge or cause him to die faster?” (P6). “I feel that I am just giving what the doctors have ordered and do not know the rationale why some drugs like Fentanyl and Oxycodone are ordered. I think having some lessons to understand the different classes of pain medication and pain management will help…” (P3). “Sometimes, patient has too many pain medications, which make us confused which one to give first when patient has intolerable pain. At times, I feel like withholding the medications due to my knowledge deficit.” (P8). “One area to improve could be to teach us how to use PCA pump and understand how to titrate breakthrough.” (P16). “Sometimes, patient has too many pain medications, which make us confused which one to give first when patient has intolerable pain. At times, I feel like withholding the medications due to my knowledge deficit.”(P8) | ||
Knowledge deficit in handling symptoms | “When patient is going to pass on, they experienced certain signs and symptoms. For those who are new, we might not know. Relatives will be anxious, and we will feel the same way too.” (P5). “Schools did not teach us how and what to expect and what to do during the final hours of the patient, for example, how to handle when patient is breathless, drowsy, nausea or vomiting…, this is important for us in the palliative setting.” (P8). |
Themes | Subcategories | Paraphrased Examples |
“ I am so worried and guilty when I think of Mr Tan’s suffering. I felt I am not doing enough. As much as possible, I want my patients to die of a good death rather than a bad death. This is something I need to learn… how to manage their sufferings and understand what the ultimate goal for them is.” (P12). | ||
EOL Communication | “I lack confidence in this area of communication…I tend to avoid having too much conversation and discussion with the family and patient as I do not want to be affected. I felt upset at times when I see the patient suffer…Would appreciate more training to develop myself in this area” (P6) "When the patient asks, "Am I dying?". What can I say? It is a difficult situation and schools do not teach us how to answer this when patient asks this type of question. Many times, I avoid the question and try diverting and start talking about other positive things and refer to the doctor. On one hand, you know the patient is dying, and we should not lie. On the other hand, I do not want to hurt the patient emotionally. This is the worst feeling, and keeping silent is so uncomfortable. The best is just don't talk and carry on do things and move on." (P4). | |
Handling loss, grief, and bereavement | “When I see relatives or patient crying or grieving, I do not know how to approach them to console them and to tell them. Training in such area needs to be done to let us understand grief and loss.” (P15) “In the palliative ward, we often are exposed to patients dying, people crying and grieving over their loss. My training in the School of Nursing did not cover this aspect in depth. I believe this type of training should be provided for the nurses.” (P14). |
Themes | Subcategories | Paraphrased Examples |
As a nurse, we have the duty to comfort and counsel the patients as long as their well-being is affected. It would be good that the MSW (medical social worker) or pastoral team can come in to support the patient. Not all hospitals have such services, hence often patients do not receive adequate support when they are in despair. When the patient is helpless and does not receive adequate support, I believe even he dies, he would not be happy, and this type of death is very bad…"(P3). | ||
Imparting death literacy to patients and family | "We need more training and education in this area. Getting more people involved in end-of-life care and having more end-of-life conversations can help build our death competence and lower our death anxiety." (P4). "By creating a more death literate society, people and communities have the practical know-how needed to plan well for end-of-life and prepare for death…which lowers the death anxiety. I think we nurses have a part to play in educating them." (P11). | |
Juggling between ethical dilemma in EOL situations. | "At the final hours, patient's death rattle is the most miserable and horrifying experience for both the relatives and nurses. The rattling sound behind the throat is often loud and irritating, and it makes the relatives worried that the patient can be choked by his secretions and not breathe properly. However, we know that if we suction the patient, the patient could potentially die faster. We are caught in a dilemma. Seeing the dying patient rattling with his secretions makes us also feel bad and the patient seems to be choking on his pool of secretions. I felt guilty when the relative are grieving and begging us to do something, and yet we could not do anything." (P6). "I felt guilt at times when I see patient dying in pain, and I can't help. I wanted to help as I can't |
Themes | Subcategories | Paraphrased Examples |
bear to see him suffer. At times, I feel like giving him an extra dose of morphine to let him go and relieve his suffering since he is suffering badly and having a painful and terrible death process. Now I hope you understand why some nurses are fearful in handling dying patients and why some nurses avoid the patients" ( P4). "Sometimes I feel not confident and do not know what to do to give patient a good death. When a patient dies, I sometimes feel very guilty as though I have not done enough. Perhaps more training in palliative could help me enhance my competence and confidence". ( P14) |
Most participants lamented the lack of basic training in palliative and EOL care. As a result, many new nurses expressed an inability to provide quality and holistic care for this group of patients.
“Part of the reason why we are not accepting death well is that there is a lack of this focus in this area palliative care in our nursing course...I still remember when I was pursuing my diploma, we are not taught palliative care, pain and symptom management in the final hours…these are important stuff. Even breaking bad news…we are not taught…we only learn on the job. You could imagine how stressful it is when you do it live, and it is your first time.” (P1).
“Traditionally, our nursing education in our schools has always focused on promoting health and preventive health. None was focused on death education. Because of that, when we face death or dying issues, we are at a loss.” (P16).
Additionally, even when some nurses had some form of palliative education during their basic nursing training, there is a lack of application of such knowledge in their nursing practice. One participant (P7) said: “In school, we are only taught of Kubler-Ross 5 stages of Grieving… in reality, no one teaches us anything to cope and handle people who are grieving”, while another (P3) mentioned: “I had a ‘Communication’ module when I took my Diploma in Nursing many years ago. But it was nothing to do or related to palliative nursing or how to relate to patients during end of life.”
Another participant expressed that she encountered the school-practice dichotomy in handling death, resulting in her heightened death anxiety levels. There is a distinct gap between the school and reality, especially when a novice nurse handles death in the clinical area. Some participants also lamented the lack of continuing education on specific death-related subjects, like advance care planning, living will, and cultural aspects of palliative care, which could help them improve their ability to manage palliative patients and their family members better.
“The nursing curriculum has focused on how to treat a patient. But we are not taught how to do advance care planning for dying patients and their family members… I tried to find courses on this, but there are very few courses around for me." (P4).
All the nurses acknowledged that the ELNEC program helped decrease their death anxiety levels and improve their perceptions of EOL care. The ELNEC provided the avenue for the nurses to share and ventilate their experiences and feelings about caring for the dying, which resulted in less anxiety level.
“I like the part of the program when we reflect on our values and death attitudes. It helps me align and be self-aware of my bias which could influence the care of the patient….” (P1).
One participant also shared that the ELNEC helped to reshape her attitudes towards dying patients and become more open to approaching the patients and family members to discuss palliative care management.
"I like the part of the program when we reflect on our values and death attitudes. It helps me align and be self-aware of my bias which could influence the care of the patient. That, of course, includes my death anxiety. Now I would say I am less anxious. Staff should regularly attend similar courses to refresh themselves and increase their death competencies.” (P1).
The nurses also expressed that the ELNEC educational program consists of various modules that equipped them with the necessary skills and competencies in their daily practice. Modules like symptom management, communication, loss, grief and bereavement and final hours have covered the possible daily challenges the nurses will encounter and provided solutions that the nurses could use. Equipped with this knowledge, this has decreased their death anxiety when faced with similar situations or nursing patients facing EOL situations.
“The ELNEC program has taught me about many things… from technical skills to soft skills like pain management, communication skills and how to convey bad news. One thing I feel is important is mindfulness, how to ‘be with’ with the patient. To learn to connect with the patient is important. Previously I avoided the sensitive conversation; now, I am more comfortable in handling these conversations." (P9).
Despite the ELNEC training, most participants agreed that there were areas that could be enhanced further to equip them with the knowledge, skills, and confidence to manage palliative patients in long-term care settings. Some participants responded that they have knowledge deficits in pain management and difficulty treating a dying patient's pain and were not equipped to decipher therapeutic doses of opiates. This unique skill set was typically acquired through practice and witnessing first-hand the adverse effects of overdosing.
“I feel that I am just giving what the doctors have ordered and do not know the rationale why some drugs like Fentanyl and Oxycodone are ordered. I think having some lessons to understand the different classes of pain medication and pain management will help…” (P3).
Not being familiar with standards for palliative care made the nurses feel powerless, incapable, and anxious of relieving the patient’s pain and suffering. The issue was compounded when the nurse was also not acquainted with what the patient actually needed, limiting the nurse’s parameters for pain management. The nurses also reported a knowledge deficit in handling symptoms during the patient's final hours as a perceived educational need.
“When patient is going to pass on, they experienced certain signs and symptoms. For those who are new, we might not know. Relatives will be anxious, and we will feel the same way too.” (P5).
Another perceived educational need was in the area of communication. Many nurses expressed communication apprehension and were ill-prepared in their previous training to handle end-of-life conversations and challenging questions. Understanding loss, grief and bereavement was another important area that the nurses had reported as a perceived educational need in palliative care. Participants expressed that their previous education lacks training in this aspect.
“When the patient asks, “Am I dying?”. What can I say? It is a difficult situation, and schools do not teach us how to answer this when patient asks this type of question. Many times, I avoid the question and try diverting and start talking about other positive things and refer to the doctor. On one hand, you know the patient is dying, and we should not lie. On the other hand, I do not want to hurt the patient emotionally. This is the worst feeling and keeping silent is so uncomfortable. The best is just don't talk and carry on do things and move on.” (P4).
Two nurses emphasized the role of nurses in imparting death literacy to the patients and loved ones in lowering death anxiety. They felt that good education about death and raising public awareness would help promote positive mindsets and address cultural misunderstanding about death as taboo or negative. Such subjects include advance care planning, living will, last office rites, and ethical balance between prolonging life versus prolonging suffering. By advocating for more open discussion about death in a more positive light, nurses would feel more confident in engaging patients in these taboo subjects rather than engaging in death avoidance behaviours.
“By creating a more death literate society, people and communities have the practical know-how needed to plan well for end-of-life and prepare for death…which lowers the death anxiety. I think we nurses have a part to play in educating them.” (P11).
DISCUSSION
The overarching themes in this study demonstrated the benefits of the ELNEC program for palliative nurses working in the long-term care setting and illuminate ways on how the ELNEC reshaped practising nurses’ death attitudes and anxiety level by providing a platform for them to ventilate and share their experiences. A systematic review by Draper et al., (2018) found that education that focused on death and dying have improved the physicians’ perceived ease and lowered their death anxiety when treating patients during EOL situations. Our study finding was consistent and parallel with previous studies on EOL education in reducing nurses’ death anxiety (Gillan et al., 2014; Li et al., 2021). Hence the findings suggested the importance of both basic and continuing education in moderating the level of death anxiety among nurses. The ELNEC provides basic palliative knowledge and a platform for palliative nurses to share their experiences caring for the death and dying.
The study also confirmed the effectiveness of ELNEC in improving nurses’ knowledge and skills in EOL care. Most nurses in the study reported acquiring technical and soft skills, from pain management to breaking bad news to patients and family members. Previous research has suggested that the ELNEC program has been beneficial and have increased the nurses’ competence and confidence in delivering effective EOL care (Kozy et al., 2017; Mitrea et al., 2017). This finding confirmed the benefits of the ELNEC program for practising nurses as part of continuing nursing education. In addition, during the ELNEC sessions, simulation was frequently utilized to ensure that participants had the hands-on opportunities to role-play realistic case scenarios and received feedback on their care. This study adds to the evidence by Gillian, Jeong & van der Riet (2014), who reported using palliative simulation to improve death competency among nursing students.
One key theme from the study revealed how several nurses expressed inadequacies in providing EOL care despite having some training. Their inadequacies include communication skills, pharmacological pain titration, handling grief, loss, and bereavement. This finding concurred with similar studies that report how nurses faced difficulties applying their palliative training to different death and dying situations, where there is no fixed protocol for EOL practices (Barrere & Dunkin, 2014; Teleshova, 2020). Albeit spending time with the dying patients, the nurses expressed their inadequacies and difficulties in supporting dying patients and their families competently and holistically. Many nurses have expressed the need to be better prepared to care for dying patients and deal with patient death and their grieving families. These findings have suggested that ELNEC can be enhanced to improve existing nurses’ ability to manage the dying process accordingly based on the patient’s wishes, preferences, comfort, unanticipated emotional, cognitive, or physical responses.
Based on the third theme, we identified opportunities to enhance the ELNEC program in several areas for nurses in Singapore as follows: practical knowledge in pain and symptom management, initiating EOL discussion and advance care planning, facilitate ethical-decision-making in EOL situations, handling bereavement and grief, and imparting death literacy to patients and family members. Similar educational needs were observed in the systematic reviews by Donne et al., (2019) and Li et al., (2021).
Limitations
Three limitations were identified from our study. First, the small sample size and non- random nature of purposive sampling might not represent palliative care nurses in Singapore. Second, the study was conducted at a single site, which limited its transferability to nurses working in other care settings, such as acute hospitals and hospices. Finally, we did not determine any potential respondent bias due to participants’ acquiescence or social desirability bias. Nevertheless, we sought to mitigate this effect by validating our findings with the other authors (Polit & Beck, 2020).
Implications for Practice
These findings have many implications for nursing education in palliative care. Historically, EOL issues had not held a pivotal place in nursing schools and the nursing curriculum in Singapore. In recent years, the palliative movement in Singapore has gained better visibility, emphasizing the need for palliative care education (Cheong et al., 2020). In general, nurses are inadequately prepared to address end of life issues resulting in poor and possibly horrible outcomes, and there is considerable evidence that current training in this field is lacking and inadequate (Cheong et al., 2020). The national nursing curriculum should be reviewed to integrate palliative care components.
The study findings also demonstrated the importance of communication, and interpersonal skills training for the nurses working in the palliative care settings as advance care planning and handling end-of-life conversations could be challenging when approached by the patients and families. Besides that, emphasizing soft skills and personal characteristics like warmth, compassion, mindfulness, and empathy are also important in increasing the death competence and resilience of the nurses. According to Gerhart et al., (2016), emphasis on these aspects are often lacking in many of the nursing training and education and should be made mandatory as part of a postgraduate or graduate program, in palliative care or as standalone courses for those who wish to enter to work in this specialized field of practice. Additionally, education and training of pain and symptom control and management should also be tempered with equal focus on the psychosocial role of the palliative nurse and effective communication and caring characteristics. Besides that, education emphasizing grief and bereavement should also not be neglected. The qualitative findings from the participants have also indicated the need for education and training of nurses in handling difficult relatives and family conflicts, especially during the final hours of the patient, as the nurses have expressed that they experienced high death anxiety levels during that period or when facing such circumstances.
CONCLUSION
As the growth of the ageing population continues to increase, the demand for nurses to develop expertise in providing care for dying patients will also increase. Caring for EOL patients is emotionally taxing and demanding for the nurses and may lead to death anxiety. The study explored the nurses’ perception of ELNEC and found its benefits for improving death anxiety and attitudes among existing nurses working in a community palliative setting. Specific educational needs were also identified as potential areas for enhancing the ELNEC for the Singapore palliative context.
Conflict of Interests
The authors declare that they have no conflict of interests.
ACKNOWLEDGEMENT
The authors are thankful to the institutional authority for completion of the work.
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