Study: Nursing Student Beliefs About Death and Dying Can Affect End-of-Life Care

Nurses across all specialties frequently care for patients who are approaching death. While nursing education tends to emphasize physical comfort in end-of-life care, many nurses and nursing students feel unprepared to provide emotional and spiritual support.

In a 2023 study in the Journal of Nursing Education, co-authors Pam Stephenson, Ph.D., RN, and Dana Hansen, Ph.D., APRN, ACHPN, FPCN, investigated nursing and medical students’ beliefs about death and dying. They concluded that misconceptions about death can affect end-of-life care, particularly the spiritual aspects of this care.

“Our findings indicate a need for improved education regarding spiritual care and end-of-life care,” Stephenson told NurseJournal.

The term refers to the final stage of caring for people who are nearing the end of life. End-of-life nursing care may occur over a period of days, weeks, or longer, depending on each individual case.

End-of-life care differs from palliative care, which focuses on people with serious illnesses and emphasizes managing symptoms alongside treatments intended to cure the illness. When a patient’s palliative care team believes they have fewer than six months to live, they may transfer the patient to hospice care. In a hospice setting, care teams provide comfort and support, including dedicated end-of-life care. However, end-of-life nursing care can occur outside the hospice setting as well.

During end-of-life care, nurses focus on the patient’s physical comfort, mental and emotional needs, and spiritual needs. As the National Institute on Aging explains, “For people nearing the end of life, spiritual needs may be as important as their physical concerns.”

Broadly defined, spirituality touches on meaning, beliefs, values, and connections. Spiritual needs can include connecting with loved ones, resolving unsettled issues, and making peace with death and dying. Patients may also turn to faith for comfort or guidance.

This is where nurses and nursing education sometimes fall short, according to the 2023 study. Study authors pointed out that previous studies have shown that physicians and nurses often report that their education does not equip them to provide spiritual care. Yet by examining their own views about death, nurses can strengthen support skills that improve patient outcomes.

Examining how nursing students approach questions of death and dying reveals broader lessons for end-of-life care nursing.

The 2023 study explored attitudes toward death among 156 nursing and medical students. By asking participants to reflect on their own wishes around death, the study determined that students naturally approach death with a spiritual perspective.

Participants considered issues of meaning, value, and connection in their self-reflection. While many nurses report discomfort with spiritual care, self-reflection can help build confidence for this role.

When reflecting on the dying process through a personal lens, the participants revealed misconceptions about death. In particular, many assumed that they would have time to plan their death and say goodbye to loved ones.

Students focused on tasks they would want to accomplish before dying, including connecting with loved ones and reflecting on their life. For example, one participant emphasized leaving messages for loved ones, so that, “Whenever they miss me, they can just look back at those videos or letters.”

Similarly, participants romanticized the process of dying. Some indicated a desire to die in a meaningful location, while others discussed being at the center of attention. One participant, for instance, related a desire to “spend my last couple days with my family discussing the high points of my life.”

However, the reality of end-of-life care differs from many of the participants’ perceptions of death.

“The problem for students in healthcare is that death is rarely romantic, pretty, or under human control,” the study concluded,

The study also revealed how examining death and dying raised existential concerns and discomforts for students. Nurses who fear death are less likely to provide spiritual care, according to a 2021 study. This can leave patients and their families feeling disconnected from their care team.

Many nursing students have limited experience with death. For instance, participants in the 2023 study had an average age of 21. As a result, nursing students “may not have experienced the death of anyone significant to them, let alone considered their own deaths.”

By exploring attitudes toward death, nursing education can help students recognize their discomforts and help prepare them for the reality of death in healthcare settings.

How can nurses and nursing students challenge their assumptions about death and develop their end-of-life care skills? Changes to nursing education can play a central role.

“We are hopeful that we have found an educational intervention that has a tremendous impact on our students’ learning,” Stephenson said. The use of online cognitive tools and live simulations allows nursing students to anticipate the needs of patients and their own discomforts or fears around death.

Yet while nursing students benefit from integrating spiritual care into the curriculum, this goal poses challenges. “Many educators report that they themselves were poorly trained in spiritual care and, therefore, lack the skills to teach it — let alone know what to do when spiritual care discussions uncover old wounds for students and educators,” said Stephenson.

When care providers feel uncomfortable delivering spiritual care, it can negatively impact patients. “Presence, listening, and empathy are spiritual care interventions that are lost opportunities when providers avoid spiritual care,” the study stated. Nurses who withdraw because of a discomfort with spiritual care can leave patients and their families feeling unsupported.

Fortunately, providing spiritually sensitive end-of-life care draws on skills that nurses apply in many other areas of their practice.

“Use your observational skills to assess your patient and their family’s needs,” Stephenson recommended. “Are relational conversations or spiritual care important for them and how do you feel about that? If you are uncomfortable addressing these needs, who can you turn to for help?”

Nurses and nursing students can also commit to examining their personal relationship with death, understanding that their growth as an individual and a care provider will continue long after leaving nursing school.

“Remember that everyone has a story to share,” Stephenson advised, “and the power of being a nurse lies in the ability to connect with others on a human level to hear those stories.”

Page last reviewed on January 6, 2024