Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Jennifer Pierce

Bon Secours Memorial College of Nursing

NUR 4122: Nursing Research

Christine Turner, PhD

April 22, 2018

I pledge
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Abstract

Purpose: The purpose of this integrative review is to identify the relationship between

education on end-of-life (EOL) care and nurses’ perceived comfort and confidence in caring for

dying patients.

Background: Caring for dying patients is an essential aspect of the nursing role and nurses are

likely to encounter end-of-life patients regardless of their practice setting. Many nurses

experience anxiety and feel unprepared to provide end-of-life care.

Method: This is an integrative review of five articles identified through the EBSCO database.

The articles were filtered with criteria set by the researcher and had to be in reference to a study

that examined an educational intervention related to nurses and end-of-life care.

Results and Findings: The results and findings of the articles clearly identify a positive

correlation between end-of-life care education and nurses’ perceived comfort and confidence in

caring for the dying. The results were consistent regardless of the teaching strategy utilized.

Limitations: Limitations included the researcher’s lack of experience in conducting an

integrative review and limited knowledge about end-of-life nursing education.

Implications for Practice: A variety of teaching strategies designed to provide students with

education on EOL have been shown to improve knowledge and attitudes about caring for dying

patients. Nursing schools and health care organizations should integrate more education about

end-of-life care into their curricula and/or continuing education programs.

Recommendations for Future Research: Further research related to standardizing EOL care

education is recommended.
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Integrative Literature Review

The purpose of this integrated review is to identify the relationship between education on

end-of-life (EOL) care and nurses’ perceived comfort and confidence in caring for dying

patients. Caring for dying patients is an essential aspect of the nursing role and nurses are likely

to encounter end-of-life patients regardless of their practice setting. According to the World

Health Organization (2018), between the years 2000 and 2050, the proportion of the world's

population over 60 years will double from approximately 11% to 22%. The absolute number of

people aged 60 years and over is expected to increase from 605 million to 2 billion over the same

period. With this significant increase in the elderly population, nurses across the health care

system can expect to care for dying patients at some point in their careers. Yet, many nurses

experience anxiety and feel unprepared to provide end-of-life care. (McCourt, Power, & Glackin,

2013).

According to a literature review undertaken by Corcoran (2016), there is inconsistency in

how nursing schools are preparing nurses to provide EOL care. Oftentimes, nursing schools do

not provide adequate EOL education and new graduate nurses are consequently ill-prepared to

care for dying patients when they begin their careers. Corcoran (2016) also found that even

experienced nurses, including those working in oncology or critical care where patients

oftentimes are dying, have unmet educational needs related to providing EOL care. Teaching

strategies designed to provide students with education on EOL have been shown to improve

knowledge and attitudes about caring for dying patients (Gillan, van der Riet, & Jeong, 2013).

The aim of this review is to examine and discuss published data related to the researcher’s

PICOT question: Does end-of-life care education improve nurses’ perceived comfort and

confidence in caring for dying patients?

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Design and Methods

The research design is an integrative review focused on five research articles. The search

for research articles was conducted utilizing EBSCO’s Nursing Reference Center database. The

search terms included end-of-life education, ELNEC, preparation for end-of-life care, and

nurses’ comfort with end-of-life care. The initial search results yielded thousands of articles.

The articles were filtered to peer-reviewed nursing journals published in English between the

years 2013 and 2018.

The articles were then chosen based on their relevance to the PICOT question: Does end-

of-life care education improve nurses’ perceived comfort and confidence in caring for dying

patients? The articles had to be in reference to a study that examined an educational intervention

related to nurses and end-of-life care. Also, the researcher focused on articles that examined

nurses’ perceived comfort and confidence in providing end-of-life care rather than nurses’

knowledge or clinical skills. The researcher purposefully looked for articles that included a

variety of educational interventions, such as classroom-based, simulation and distance learning.

After narrowing the results according to the above criteria, the researcher identified five articles

to include in the integrative review.

Findings

The results and findings of the articles clearly identify a positive correlation between

EOL care education and nurses’ perceived comfort and confidence in caring for the dying.

(Barrere & Durkin, 2014; Corcoran, 2016; Lippe & Becker, 2015; Venkatasalu, Kelleher, &

Shao, 2015; and Wheeler et al., 2014). A summary of the five research articles is located in

Table 1 – Article Evaluation in the Appendix. The following is a brief overview of each articles’

findings.
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In a study conducted by Barre and Durkin (2014), the researchers sought to explore the

lived experiences of new graduate nurses who had participated in EOL education and who cared

for a dying patient during their first year of practice as a nurse. The theoretical framework used

was Transformative Learning Theory. A phenomenological descriptive methodology was used in

the study, including open-ended semi-structured questions with study participants. A

convenience sample of 12 recent nurse graduates participated in the study.

Barre and Durkin (2014) conducted open-ended semi-structured interviews with new

nurses who had participated in EOL education and who cared for a dying patient during their

first year of practice as a Registered Nurse. The researchers utilized Colaizzi’s method of

content analysis to identify themes from the interviews. Findings suggest that EOL education

can help nurses feel more prepared to care for dying patients.

In a study conducted by Corcoran (2016), researchers developed and evaluated an EOL

workshop for professional caregivers at a community hospital. The framework utilized was

Lewin’s Framework for Change Model. The intervention examined was an EOL workshop. The

sample consisted of 55 interdisciplinary caregivers at a 206 bed community hospital in the

northeast United States. Data was collected using the End of Life Professional Caregiver

Survey, which was administered three weeks before and three weeks after the workshop. A

matched-pairs t-test was used to compare pretest-posttest data about nurses’ comfort with EOL

care. Findings suggest that educational interventions with professional caregivers increase their

comfort level during EOL care. Also, the researchers suggested that nurses who are provided

with tools and resources for self-care while caring for dying patients have reduced compassion

fatigue.
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Lippe and Becker (2015) conducted a study to assess learning outcomes from a

simulation on providing care to a dying patient. The theoretical framework was Bandura’s four

stage process of observational learning in social cognitive theory. The study design was a

simulation evaluated by a pretest-posttest tool to compare perceived competence and attitudes in

caring for dying patients before and after the intervention. Perceived competence was measured

using the Perceived Competence in meeting the End-of Life Nursing Education Curriculum

Standards survey. Attitudes were measured with the Concerns About Dying scale and the

Frommelt Attitudes Toward Care of the Dying Scale. Factor analysis was used to analyze the

Perceived Confidence data. A 2x3 mixed design ANOVA was conducted to assess the

differences between pretest and posttest scores for students within the different cohorts.

Findings were that subjects had significantly improved scores on the perceived confidence and

attitude measures following the simulation.

In another study examining simulation, Venkatasalu, Kelleher, and Shao (2015) sought to

design, use and assess the effectiveness of high-fidelity simulation teaching versus classroom-

based EOL care teaching for first year nursing students. The framework used was

phenomenography. The study was conducted at a university in England that delivers

undergraduate nursing education. A purposeful sample of 187 students was included in the

teaching and twelve students participated in interviews. Data was collected through face-to-face

semi-structured individual interviews with students who attended either simulation-based or

classroom-based intervention. Data was analyzed using framework analysis. Findings were that

both strategies improved students’ knowledge of EOL care but simulation-based EOL care

education was perceived as better in terms of enhanced practical skills and improved emotional

experience.
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Wheeler, Anstey, Lewis, Jeynes, and Way (2014) conducted a study to develop, deliver

and evaluate a distance-learning education module focused on the principles of EOL care. The

sample included 100 community nurses who completed the module. Data was collected through

pretest-posttest self-assessment questionnaires. Comparisons between pretest Likert and posttest

Likert scales were analyzed. Findings indicate that nurses completing the module showed

significant and measurable improvement in their confidence, competence and knowledge related

to EOL care.

Discussion and Implications

The articles selected for review indicate that EOL education has a positive effect on

nurses’ perceived comfort and confidence in caring for dying patients. The researcher framed

the review according to the following categories; nurses’ anxiety about providing EOL care;

nurses’ perceived confidence in caring for dying patients; and educational interventions. The

following is a discussion on the implications of the articles; it is organized by these common

themes and their relevance to the PICOT question.

Anxiety (personal experience of the nurse)

Previous research has demonstrated that nurses experience significant stress related to

their first experience of providing EOL care. (CITE). Some of this anxiety comes from not

knowing what to expect or how to interact with the dying patients’ family members. All of the

studies reviewed support use of EOL care training to increase nurses’ comfort and reduce anxiety

related to caring for dying patients. For example, Corcoran (2016) found that ELNEC training

increased comfort with EOL care by 21% as measured by the End of Life Professional Caregiver

Survey tool. Personal coping, grief loss.

Preparedness (perceived confidence/skill)

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Wheeler et. al. found that nurses increased their confidence in providing EOL care after

participating in a distance learning program. Areas of confidence examined included the nurses’

ability to address patients’ physical, psychosocial and spiritual needs. This included dealing with

family members. (examples of measures). Venkatasalu et. al. (2015) found that participants

who attended simulation-based teaching felt more prepared for their clinical placements.

Educational Interventions

All of the studies reviewed found positive outcomes for the intervention under

investigation. Barre and Durkin (2014) found that the most meaningful learning experiences

occurred in clinical practice. Corcoran (2016) found that a workshop format also improved

nurses comfort levels with delivering EOL care. Similarly, Wheeler et. al.(2014) achieved

positive outcomes with a distance learning program (description). Venkatasalu et. al 2015), on

the other hand, found that simulation-based learning was more effective than classroom-based

education

The implications of the findings from this literature review suggest that EOL education

has a positive effect on nurses perceived comfort and confidence regardless of the setting or

delivery mechanism. The studies examined classroom-based education, simulation, and distance

learning.

Recommendations for future research are to standardize EOL content, using ELNEC as a basis

and then develop a variety of delivery methods that can be implemented depending on the

learning environment. For example, nursing students may be more able to participate in

simulations during their academic careers. Working nurses, however, may benefit more from a

distance learning course of workplace based training that can be completed while they are on the

job.
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Limitations

The limitations of this integrative review were as follows. The first limitation was the

researcher’s lack of experience in conducting an integrative review, including lack of confidence

in conducting database searches. The second limitation was the researcher’s lack of expertise in

the subject area. The third limitation was the small number of articles included in the literature

review. Study limitations were varied among the studies. For example, the phenomenological

studies had small sample sizes. Although typical in phenomenology, a small sample can

decrease the generalizability of the results. The other studies had a mix of sample sizes. Another

limitation of the studies is that for each study the researchers developed their own EOL content,

although much of it was derived from the ELNEC.

Conclusions

The evidence compiled from this integrative review supports EOL education as an

important strategy to help prepare nurses to care for dying patients. Interestingly, the evidence

supports multiple learning modalities, including classroom-based education, simulation, and

distance learning. One study suggests that simulation is more effective than classroom-based

learning but all five studies found significant improvements in nurses’ perceived comfort and

confidence in caring for dying patients. As nursing students prepare to enter the workforce,

nursing schools can help them feel more prepared to care for dying patients by providing

education on end-of-life care. Similarly, nurses already working in health care can benefit from

continuing education related to end-of-life care. As the elderly population continues to grow,

nurses will increasingly encounter dying patients across a multitude of health care settings.

Appropriate education can help relieve nurses’ anxiety about providing end-of-life care and

increased their preparedness. Simultaneously, preparedness will reduce compassion fatigue and
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caregiver burnout at a time when there’s a looming nursing shortage. In regards to the

researcher’s PICOT question, does EOL care education improved nurses’ perceived comfort and

confidence in caring for dying patients, the literature reflects a positive correlation between EOL

care education and nurses’ perceived comfort and confidence in caring for the dying.
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References

Barrere, C. & Durkin, A. (2014). Finding the right words: The experience of new nurses after

ELNEC education integration into a BSN curriculum. MEDSURG Nursing, 23, 35-43.

Corcoran, K. (2016). Evaluation of an educational workshop to increase comfort levels of

professional caregivers with end-of-life care. MEDSURG Nursing, 25, 103-109.

Gillan, P., van der Riet, P., & Jeong, S. (2013). End of life care education, past and present: A

review of the literature. Nurse Education Today, 34(3), 331-342.

Lippe, M. & Becker, H. (2015). Improving attitudes and perceived competence in caring for

dying patients: An end-of-life simulation. Nursing Education Perspectives, 36(6), 372-

378.

McCourt, R., Power, J., & Glackin, M. (2013). General nurses’ experiences of end-of-life care

in the acute hospital setting. International Journal of Palliative Nursing, 19(10), 510-

516.

Venkatasalu, M., Kelleher, M. & Shao, C. (2015). Reported clinical outcomes of high-fidelity

simulation versus classroom-based end-of-life care education. International Journal of

Palliative Nursing, 21(4), 179-186.

Wheeler, W., Anstey, S., Lewis, M., Jeynes, K., & Way, H. (2014). The effect of education on

community nursing practice in improving the patient-carer experience at the end of life.

British Journal of Community Nursing, 19(6), 284-290.

World Health Organization (2018). Facts about aging. Retrieved from

http://www.who.int/ageing/about/facts/en/
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TABLE 1 – ARTICLE EVALUATION

First Author Barrere, C. & Durkin, A. (2014). Finding the right words: The
(Year)/Qualifications experience of new nurses after ELNEC education integration
into a BSN curriculum. MEDSURG Nursing, 23, 35-43.
Background/Problem • End-of-life care is an essential aspect of nursing role
Statement • New graduate nurses feel unprepared for end-of-life care
• The End-of-Life Nursing Education Consortium (ELNEC)
developed a program of teaching care of the dying to nurses and
nursing students
• The purpose of the study was to explore the lived experiences of
new graduate nurses who had participated in ELNEC education
and who cared for a dying patient during their first year of practice
as nurse
Conceptual/theoretical • Transformative Learning Theory
Framework
Design/ • Phenomenological descriptive methodology
Method/Philosophical • Researchers wanted to understand the lived experiences of study
Underpinnings participants
• The researchers used open-ended semi-structured questions to
conduct interviews with study participants
Sample/ • A convenience sample of 12 recent nurse graduates
Setting/Ethical • Criteria included age 21 or older, prior ELNEC education, one
Considerations year of nursing experience, and experience caring for a dying
patient.
• Nursing students in the northeastern United States who were in
their final semester of school and about to graduate
• The researchers received study approval from the institutional
review board prior to contacting potential subjects. Also,
individuals participating in the study signed consent forms prior to
being interviewed.
Major Variables • Researchers explored the lived experiences of new graduate nurses
Studied (and their who had participated in End-Of-Life Nursing Education
definition), if Consortium (ELNEC) education and who cared for a dying patient
appropriate during their first year of practice as a Registered Nurse (RN).
Measurement • The interviews included open-ended questions that prompted
Tool/Data Collection participants to describe their lived experiences.
Method
Data Analysis • The researchers utilized Colaizzi’s method of content analysis to
identify themes from the transcribed narratives.
Findings/Discussion • Data analysis identified four themes from the transcribed
narratives. The themes were 1) facilitating a good death; 2)
experiencing intrinsic rewards; 3) learning through impressionable
experiences; and 4) maintaining a balance.
• New nurses face challenges when caring for dying patients and
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that they oftentimes feel unprepared for the experience.

• ELNEC education as one opportunity to prepare nurses to navigate
these challenges. The researchers also suggested that new nurses
can build upon their ELNEC education and engage in
transformative learning once they are in clinical practice.
Appraisal/Worth to • ELNEC education as one opportunity to prepare nurses to navigate
practice these challenges.
• Health care organizations need to provide additional support to
new nurses once they are on-the-job and providing end of life care.

First Author Corcoran, K. (2016). Evaluation of an educational workshop to

(Year)/Qualifications increase comfort levels of professional caregivers with end-of-
life care. MEDSURG Nursing, 25, 103-109.
Background/Problem • Educational gaps and lack of comfort by nurses in providing EOL
Statement care
• Nurses experience high stress in caring for dying patients
• EOL care critical aspect of nursing role
• Researchers developed and evaluated an ELNEC workshop for
professional caregivers at a community hospital
Conceptual/theoretical • Lewin’s Framework for Change Model
Framework
Design/ • EOL workshop consisting of three modules of the ELNEC training
Method/Philosophical was delivered
Underpinnings
Sample/ • 55 interdisciplinary caregivers
Setting/Ethical • 206-bed community hospital in northeast United States
Considerations

Major Variables 28 items from the End-of-Life Professional Caregiver Survey,

Studied (and their including comfort with end-of-life care, comfort with ethical issues
definition), if related to end-of-life care, comfort interacting with families during
appropriate EOL, knowledge of palliative care and hospice

Measurement • End-of-Life Professional Caregiver Survey, pre/post test three

Tool/Data Collection weeks before and three weeks after workshop
Method
Data Analysis • Matched-pairs t-test used to compare comfort with EOL care
before and after the intervention
Findings/Discussion • The difference between comfort with EOL care before and after
the intervention was statistically significant
• EOL education topics should be integrated into new employee
training
• ELNEC modules should be offered as continuing education to
staff
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• Promote train-the-trainer programs to facilitate ongoing

dissemination of EOL education
Appraisal/Worth to • Educational interventions with professional caregivers increase
practice their comfort level delivering EOL care
• Nurses provided with tools and resources for self-care have
reduced compassion fatigue
• ELNEC is a resource for hospitals and/or nurses that want to
implement ELNEC methodology

First Author Lippe, M. & Becker, H. (2015). Improving attitudes and perceived
(Year)/Qualifications competence in caring for dying patients: An end-of-life
simulation. Nursing Education Perspectives, 36(6), 372-378.
Background/Problem • Nursing students have anxiety and low perceived competence for
Statement caring for dying patients
• The purpose of the study was to assess learning outcomes from a
simulation on providing care to a critically ill patient
Conceptual/theoretical • Bandura’s four-stage process of observational learning in social
Framework cognitive theory informed the development of the simulation
Design/ • Simulation
Method/Philosophical • Pretest-posttest design compared perceived competence and
Underpinnings attitudes in caring for dying patients
Sample/ • Three cohorts – cohort 1 had 19 subjects; cohort 2 had 53 subjects
Setting/Ethical and cohort 3 had 56 subjects
Considerations • Simulation was conducted in the simulation lab and a classroom in
the school of nursing at a large public university
• The university’s IRB approved an exempt status for the study
Major Variables • Perceived competence – measured with the Perceived Competence
Studied (and their in Meeting ELNEC Standards survey
definition), if • Attitudes – measured with the Concerns About Dying scale and
appropriate the Frommelt Attitudes Toward Care of the Dying Scale

Measurement • Pretest-posttest
Tool/Data Collection
Method
Data Analysis • Factor analysis using principal components and varimax rotation
was conducted for the Perceived Confidence
• 2x3 mixed-design ANOVAs were conducted to assess the
differences between pretest and posttest scores for students within
cohorts
Findings/Discussion • Subjects had significantly improved scores on the perceived
competence and attitude measures following the simulation
Appraisal/Worth to • Simulation is a robust teaching strategy for improving nursing
practice students’ attitudes and perceived competence in caring for dying
patients
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First Author Venkatasalu, M., Kelleher, M. & Shao, C. (2015). Reported clinical
(Year)/Qualifications outcomes of high-fidelity simulation versus classroom-based
end-of-life care education. International Journal of Palliative
Nursing, 21(4), 179-186.
Background/Problem • Nursing students experience anxiety, lack of clinical skills and
Statement poor coping mechanisms when dealing with EOL care for the first
time
• The purpose of the study was to design, use and assess the
effectiveness of high-fidelity simulation teaching versus
classroom-based EOL care teaching for first-year nursing students
Conceptual/theoretical • Phenomenography – how people experience a given phenomenon
Framework • Researchers wanted to explore perceived clinical outcomes of
teaching method
Design/ • Qualitative phenomenography
Method/Philosophical • Subjects were randomly assigned to receive either classroom-
Underpinnings based or high-fidelity simulation-based EOL teaching
Sample/ • Study was conducted at a university in England that delivers
Setting/Ethical undergraduate nursing education
Considerations • A purposeful sample from one cohort of first-year full-time
nursing students was included
• 187 students were divided into eight groups for teaching purposes
• 12 students participated in interviews
• Study was approved by the Institutional Ethical Committee of
Northumbria University
Major Variables • How students experience EOL care
Studied (and their
definition), if
appropriate
Measurement • 12 face-to-face semi-structured individual interviews were
Tool/Data Collection conducted with students who attended either simulation-based or
Method classroom-based intervention
• Interview topic guide was used
Data Analysis • Framework analysis
Findings/Discussion • Four themes: 1) recognizing death and dying; 2 knowledge into
practice; 3) preparedness for clinical eventualities; and 4)
emotional preparedness
• Both strategies improved students’ knowledge of EOL care, but
simulation-based EOL care education was perceived as better in
terms of enhanced practical skills and improved emotional
experience
Appraisal/Worth to • Both classroom-based and simulation-based teaching impart
practice knowledge on EOL care
• Incorporating simulation-based teaching in to the undergraduate
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nursing curriculum would help students feel more prepared

• Promoting simulation-based EOL care training should be
encouraged in clinical practice and nursing education

First Author Wheeler, W., Anstey, S., Lewis, M., Jeynes, K., & Way, H. (2014).
(Year)/Qualifications The effect of education on community nursing practice in
improving the patient-carer experience at the end of life.
British Journal of Community Nursing, 19(6), 284-290.
Background/Problem • Inequity within the community in terms of accessing the
Statement appropriate education for nurses to gain the knowledge and skills
needed to provide EOL care
• When appropriate education is provided, a significant
improvement in nurses’ ability to deliver EOL care is
demonstrated
• The purpose of the study was to develop, deliver and evaluate a
distance-learning education module focused on the principles of
EOL care
Conceptual/theoretical
Framework
Design/ • Module uses a distance-learning and practice-focused approach
Method/Philosophical • Pretest-posttest questionnaires
Underpinnings
Sample/ • 100 community nurses across seven cohorts
Setting/Ethical • Ethical considerations not addressed (study conducted in Wales)
Considerations

Major Variables • Perceived confidence

Studied (and their
definition), if
appropriate
Measurement • Self-assessment questionnaires – one pre-module and one post-
Tool/Data Collection module
Method • Questions were related to perceived confidence
Data Analysis • Shifts in Likert scale
Findings/Discussion • Data from nurses completing the module indicate significant and
measurable improvement in the confidence, competence and
knowledge relating to EOL care
• Increased confidence
• Self-reported increased knowledge in the management of EOL
care
• Greater confidence in recognizing needs of EOL patients
Appraisal/Worth to An appropriate practice-based education module can positively affect
practice the knowledge, competence and confidence of community nurses in
the principles and practices of EOL care
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