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Understanding the educational needs of undergraduate nursing students regarding end-of-life care: a qualitative content analysis

BMC Research Notes volume 18, Article number: 129 (2025) Cite this article

Abstract

Background

Although nurses have a fundamental role in end-of-life care, nursing curricula have not paid enough attention to this area. This research aimed to understand the educational needs of undergraduate nursing students regarding end-of-life care.

Methods

This study was a qualitative content analysis conducted in 2023 in which 16 participants, including faculty members, nurses, head nurses, nursing educational supervisors, nursing service managers, PhD and MSc students, were selected purposefully. Individual in-depth semi-structured interviews were used face-to-face and over the phone to collect information. The data was analyzed using Elo and Kyngas’ inductive content analysis approach with the help of MAXQDA 2020 software. Also, Elo et al.‘s checklist was used to check the rigor of the data.

Results

After coding the interviews, 773 initial codes were generated, which were reduced to 679 after several revisions. These codes were placed into 46 subcategories, 17 categories, and six themes, including the principles of end-of-life care, physical care, psycho-social care, spiritual care, ethical challenges, and after-death care.

Conclusion

This study determined the educational needs of undergraduate nursing students regarding end-of-life care. Therefore, it is suggested that the results of this study be considered when designing related educational programs for nursing students and nurses.

Peer Review reports

Introduction

In recent years, as the average age of patients has increased and the social and cultural conditions of societies have changed, the support and care provided by families to dying patients has decreased. So now, more than two-thirds of deaths occur in healthcare settings [1]. In this challenging period, the pressure from patients’ needs and requests and caregiver stress can lead to dissatisfaction among care workers, possible inattention to details of care, and a decline in the quality of patient care [2]. Hence, receiving sustainable and high-quality end-of-life care has become one of the most important concerns of policymakers and health managers [3].

End-of-life care is a part of palliative care that specializes in caring for patients whose disease has progressed and are nearing the end of their lives [4]. These cares often include a range of interventions, including managing pain and other symptoms and providing emotional, social, and spiritual support and medical measures [5]. Caring for a dying patient and comforting his family is one of the most challenging nursing experiences [6]. Since most body systems are affected in the final stages of life and show abnormal performance, nursing care interventions in these patients are complex and require high theoretical knowledge and practical skills. This is even though many nurses, especially in developing countries, do not receive such training during their studies and work [3, 7]. This weakness in providing educational programs on palliative and end-of-life care has led many nursing organizations to call it a historical deficiency in nursing education curricula [8]. The results of studies conducted in this field also indicate nurses’ low knowledge level [9, 10], especially nursing students [11, 12], about end-of-life care. For example, according to the results of a systematic review, the average score of nursing students’ knowledge about this care was 8 out of 20 [13].

In Iran, ethical guidelines have recently been compiled on the issue of supportive palliative care for patients in the final stages of life [14], and the provision of this type of care has been stated as one of the essential duties of different levels of nursing [15]. Also, according to the Charter of Patients’ Rights in Iran, receiving care in the final stages of life to maintain comfort is mentioned as one of the fundamental rights of patients [16]. However, a review of nursing curricula at different educational levels shows that sufficient attention has not been paid to this issue [17]. This is while Iran’s population is moving towards old age at a rate five times higher than the world average, and according to statistics, in 2050, one-third of the country’s population will be older adults [18]. Moreover, the majority of Iranian people are Muslims, and they expect to receive care based on their religious and belief needs and moral values, especially in the difficult stages of the end of life. Therefore, paying more attention to end-of-life care and strengthening the necessary foundations for providing this care is essential [19].

Since no native end-of-life nursing care program fits the cultural, religious, and social context in Iran, the first step to designing such a program is to assess the educational needs of the learners. Qualitative content analysis is the best approach to discovering people’s perspectives and experiences and interpreting their subjective information on a specific topic [20]. Therefore, the researchers decided to conduct this study using this approach to understand the educational needs of undergraduate nursing students regarding end-of-life care.

Materials and methods

Study design and sampling

This research is a qualitative content analysis that was conducted from September to November 2023. The participants of this study included faculty members, nurses, head nurses, nursing educational supervisors, nursing service managers, PhD and MSc students from all over Iran, who were selected purposefully (selecting participants rich in information). Also, informed consent, at least five years of teaching experience in theory, practice, and internships related to the research topic for faculty members, at least five years of clinical experience in special wards, and multiple experiences in caring for dying patients for nurses, head nurses, nursing educational supervisors, nursing service managers, PhD, and MSc students were considered as inclusion criteria. The exclusion criterion was withdrawal from the study at any stage.

Data collection

The research team developed in-depth, semi-structured individual face-to-face and phone interviews to collect information. The participants determined the time and place of the interviews, and most face-to-face interviews were conducted at Shahid Beheshti School of Nursing and Midwifery and two hospitals, Razi and Poursina, in Rasht, Iran.

At the beginning of each interview and after obtaining consent, the participants were asked to introduce themselves briefly and then asked questions about demographic characteristics, including age, level, degree of education, and clinical and educational work experience. The interview form included two categories of open and main questions.

Each interview started with these open questions:

  • Have you encountered patients passing the last moments of their lives during your years of work and life?” What are your experiences in this field?

Then, the main questions included:

  • Are undergraduate nursing students prepared during the training program to play a role in providing end-of-life care?

  • What components would you consider if you were asked to design an educational program on end-of-life care?

  • According to ethical, cultural, and religious values, what are the differences between the care provided in our country and other countries?

The mean and standard deviation of the interview time were 45.68 ± 8.28. All interviews were conducted by the corresponding author over three months. With the participants’ permission, the interviews were recorded immediately after the completion of the interview; after listening several times, it was typed word for word as soon as possible to provide the necessary feedback for the subsequent interviews or the adequacy of the data. Then, data analysis was done with the help of MAXQDA 2020 software. Sampling continued until data saturation, and after analyzing 15 interviews, the researchers reached saturation, so no new subcategories and categories were formed. However, one more interview was conducted to ensure saturation and confirm the findings [21].

Data analysis

In order to analyze the findings, the inductive content analysis approach of Elo et al. was used. According to this method, open coding, coding sheets, grouping, categorization, and abstraction are used in order to achieve the model and system or conceptual map of the subject in question [22]. At first, the written interview was read several times to get a general feeling and immerse in the data. The initial ideas were extracted from the textual data and listed in coding sheets in the open coding stage. After reading each text word by word and line by line several times and pausing enough on the interviews, all the codes related to the research purpose were noted in the margins of the text. Then, the interviews were listened to again, and the possibly forgotten points were written down. This process continued continuously from the extraction of the codes to their placement in the respective classes. The extracted codes were compared in terms of differences and similarities, and after determining the label, they were categorized into subclasses. Then, information was grouped in order to reduce the number of classes. More specific labels were used to categorize the data in the next step. In the last stage, i.e., abstraction, the researcher achieved a general description of the phenomenon based on the codes and content in the classes and subclasses. It should be noted that all the steps mentioned during the research were carried out several times, back and forth.

Trustworthiness

To ensure the trustworthiness of the data, the checklist developed by Elo et al. was utilized. This checklist consists of three sections: preparation (which includes data collection methods, sampling strategies, and selection of the unit of analysis), organization (covering categorization and abstraction, interpretation, and representativeness of findings), and reporting (encompassing the reporting of results and the analysis process). It contains a total of 29 questions [23]. In this study, efforts were made to enhance the trustworthiness of the findings by addressing all these questions.

Results

In this research, 16 participants, including eight faculty members, one nurse, two head nurses, two nursing educational supervisors, one nursing service manager, one Ph.D student, and one MSc student with an age range of 33 to 61 years and work experience of 9 to 33 were years. Also, five of them had an international certificate of palliative care. The participants worked and studied in two educational and therapeutic hospitals affiliated with the Guilan University of Medical Sciences and nursing schools in Rasht, Dezful, Baqiyatullah, Birjand, and Ahvaz. Table 1 provides more information about the demographic characteristics of the participants.

Table 1 Demographic characteristics of participants
Full size table

After coding the interviews, 773 initial codes were created, reaching 679 after several revisions, using experts’ opinions, and reduction, deletion, and mergers at different stages. Finally, these codes were placed in 44 subcategories, 17 categories, and six themes (Table 2).

Table 2 Codes, subcategories, categories and themes raised regarding the educational needs of Iranian undergraduate nursing students in end-of-life care
Full size table

According to the participants of this study the educational needs of undergraduate nursing students in end-of-life care include six main themes: the principles of end-of-life care, physical care, psychosocial care, spiritual care, challenges of end-of-life care, and after-death care.

Principles of end-of-life care

This topic included two categories of definitions and indicators. In the definition section, the participants believed that nursing students must be familiar with concepts such as the death process, dignified death, grief and loss.

“The problem of our students now is that the concept of death is not open to them at all. That is why they are afraid of death. We must teach them that death is part of evolution and must happen. Just as we are excited about the birth of a baby, we are obliged to see people off at the end of their lives in a very calm condition as much as possible” (P 4).

According to the participants, end-of-life care is guided by six key indicators: evidence-based, culture-based, holistic, team-centered, family-centered, and patient-centered.

“End-of-life care is complicated, and I believe it can have several characteristics. For example, the patient must be in the care center, and our care covers all dimensions. According to these different dimensions, I think we need a team. Well, the role of the family is also vital here” (P 13).

Physical care

The second part of the educational needs of nursing students was related to physical care. According to the participants, in this section, there is a need to focus on education such as care of the eyes, pain management, nutrition, respiration, excretion, and skin in the patient.

“Well, a major part of the care of these patients is related to the physical aspect. For example, how to control their pain with medicinal or non-medicinal methods; we should pay attention to them in terms of nutrition, we should take care of them in terms of pressure ulcers, their breathing, and that most of them have urinary and fecal incontinence or, on the contrary, they have constipation and retention. We have to pay attention to this” (P 1).

Psycho-social care

According to the participants, one of the most essential parts of the students’ educational needs in end-of-life care was related to the psychosocial dimension, which included three categories of patients, caregivers, and nurses. In the area of ​​psychosocial care of patients, the participants believed that students should have the necessary knowledge to establish effective communication with the patient, provide respectful care, maintain maximum patient independence, and create an appropriate care environment. They should also have the necessary knowledge and skills to manage anxiety and depression in these patients.

“A dying patient has a series of psychological needs that our students need to know. For example, our students should learn to create a comfortable and peaceful atmosphere in the patient. Respect the patient, especially in those difficult situations. Communicate with the patient. In my opinion, our biggest problem is related to lack of communication. If we establish a proper relationship with the patient, a mental and even physical peace will be created in him” (P 3).

The participants also believed that nursing students should have the necessary knowledge to communicate effectively with patient caregivers and manage their anxiety in this dimension. Also, they should know about the possibility of the nurse’s colleagues suffering from mental disorders.

Another important discussion here is the psychological care of sick companions and how to communicate with them. Well, they are stressed and worry about their patients. Our students must learn how to communicate and talk with them” (P 12).

Spiritual care

According to the findings, the fourth part of the educational needs of undergraduate nursing students in end-of-life care was related to the spiritual dimension. In this dimension, learning two topics was emphasized more. First, nursing students should acquire the necessary knowledge regarding identifying the patient’s and family’s spiritual needs. Secondly, while fully respecting the patient and family’s beliefs, they should provide spiritual care based on spiritual beliefs.

“Our students as nurses should know something about spiritual care. They should respect the patient’s religious and spiritual issues. Maybe this is very important for some patients. They should be able to determine the patient’s religious and spiritual resources and provide care accordingly” (P 9).

End-of-life care challenges

Participants believed that providing optimal end-of-life care was challenging. These challenges were categorized into two categories: family economic problems and ethical and legal challenges. In their opinion, the most important ethical and legal challenges were patient and family desires and preferences, surrogate decision-making, withholding and withdrawing treatment, do-not-resuscitate (DNR), brain death, autopsy, and organ donation.

“There are a series of legal and ethical dimensions in these cares. For example, the patient’s friends and family members may say not to give this medicine to the patient or, for example, not to resuscitate him. Do they have the right to decide for the patient or not? Another example is patients who have brain death and want to donate their organs. Our students should learn what to say and do in these situations” (P 14).

After-death care

The last theme from the participants’ statements was the need to familiarize students with After-death care. Their opinion was that end-of-life care does not end with the patient’s death. Therefore, the nursing student must have information about the care of the corpse and support for the family.

“One part of the care of the dying patient goes back to the care after his life. How to deal with the patient’s body after death, the manners of dealing with the dead, and how to support his family in those difficult mental conditions” (P 15).

Discussion

This study aimed to understand undergraduate nursing students’ educational needs regarding end-of-life care. Based on the study’s findings, these educational needs were classified into six general themes. In fact, despite the differences in the cultural, social, and spiritual backgrounds of countries, the main elements of end-of-life care are common in most programs. The difference is that, based on some legal and religious considerations of societies, more emphasis is placed on education of some components of this care, or some content, such as euthanasia, is excluded [24].

The first theme was the necessity of familiarizing students with end-of-life care principles, which were placed in two parts: definitions and indicators. In the definition section, Ozturk Birge et al. stated that there are many questions in the minds of nursing students regarding the philosophy of palliative and end-of-life care. So, they like to talk about the death process and subsequent mourning [25]. In the indicators section of the studies conducted, different indicators were defined for end-of-life care. However, reviewing these studies, three patient-centered, family-centered, and team-centered indicators are their common point. In this context, Bijnsdorp et al. explained the role of caregivers in providing this care while pointing to the patient-centeredness and team nature of end-of-life care. From their point of view, the caregivers of these patients are the invisible workforce who spend many hours a week in care and bear a significant part of the burden of care [26].

Providing optimal physical care to the dying patient was the second part of the educational needs of undergraduate nursing students, which was categorized into six categories. In the physical dimension, most reviewed studies focused on patient pain management, which was also assigned a category in this study. However, Haavisto et al. criticized this excessive focus. They stated that although more than 90% of these patients experience severe pain at the end of life, they have other critical physical needs, such as skin, excretory, and respiratory problems that require special attention [27]. Another concern in this field was excessive attention to physical care and neglecting other dimensions of care in these patients. For example, Kim et al. stated in their study that the objective and tangible aspect of physical care has made nursing lecturers and students consider the care of the dying patient as providing this care. This is even though the inherent approach of end-of-life care is comprehensive, and in providing this type of care, instead of focusing on a part of the care needs, attention should be paid to the totality of the person’s existence [28].

The necessity of familiarizing nursing students with psycho-social and spiritual care in dealing with dying patients were two other themes obtained from the findings of this study. Mills et al. believed that psycho-social care of the patient and family is the primary basis of end-of-life care [29]. Rosenberg et al. also stated that the focus of end-of-life care programs in this dimension is on the management of anxiety, depression, and emotional suffering of the patient and family [30]. One of the other points emphasized in this section was the need to learn proper communication skills with the patient and family. The importance of communication in end-of-life care is so great that it has been mentioned as a central theme in some programs [24]. In the same context, Goode et al. also stated in their study that nurses should be able to establish appropriate therapeutic communication to manage the situation in cases of increased stress and emotional tensions [31].

Another dimension of the educational needs of nursing students was related to spiritual care. Even though spirituality is a dimension of human existence, it is a neglected part of most care programs [32]. According to King et al., this dimension is strongly influenced by the patient’s and his family’s cultural background [7]. Also, Dobrowolska et al. pointed out in their study that spiritual care is an inherent aspect of end-of-life care and potentially impacts the quality of care. However, nursing students and nurses are weak in providing this care, and this has caused an increase in the unestimated spiritual needs of these patients [33].

The fifth theme obtained from the findings of this study was related to end-of-life care challenges, which were categorized into family economic problems and ethical and legal challenges. Regarding economic problems, Chan et al. stated that allocating government funds to palliative and end-of-life care is a global challenge. This part is a lower priority in receiving financial support in almost all countries [34]. The second part of the care challenges was related to ethical and legal issues at the end of life. Jak et al. mentioned that most nurses need more time to feel confident fulfilling their ethical obligations in this field and more training [35]. The two main problems of this department were surrogate decision-making and withholding and withdrawing treatment. Akdeniz et al. stated that some family members want “everything” to be done to keep their loved ones alive.In contrast, others cannot decide to limit treatment and may want medical and nursing staff to make these decisions for them, and in this situation, the care team will face a difficult challenge [36]. Another thing that should be considered is that the legal and ethical issues of the end of life are strongly affected by the laws and policies of societies and countries. Hence, as O’Shea et al. have emphasized, these issues should be considered in the design of relevant educational programs [37].

According to the findings, After-death care was identified as the last recommended component of end-of-life care education programs. In this regard, Mota-Romero et al. mentioned that nurses should have the necessary preparation for events after the patient’s death and be able to manage the situation appropriately [38]. Also, Hao et al. stated that since the patient’s condition worsens, the patient and especially his family become involved in loss and mourning, which is the peak of this phenomenon after the patient’s death. Therefore, nurses should provide the necessary support to the family to pass this stage [39].

Strengths and limitations

Conducting in-depth interviews, leading the interviews by the correspondence author, and the involvement of all research group members in the data analysis process were among the most obvious strengths of this study. Another strength of the study was that four participants had experienced caring for a dying relative in recent months, and their perspective added to the richness of the study. The most important limitation of the study was the impossibility of dealing with the extracted themes in detail due to their extensiveness. Therefore, it is suggested that in future studies, the educational needs of students in each theme should be identified and extracted more precisely by interviewing experts in that field.

Conclusion

Based on the results of this study, the educational needs of Iranian undergraduate nursing students about end-of-life care were identified and classified into six main themes. Given that end-of-life care is context-based and that there is no indigenous end-of-life care program in Iran and many other countries, educational planners and policymakers in our country, and especially in other Muslim societies, can consider the themes, categories, and subcategories described in this study when designing educational programs for nurses and nursing students.

Data availability

All data generated or analyzed during this study are included in this published article.

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Acknowledgements

We would like Thanks and appreciation to the dear participants.

Funding

Guilan University of Medical Sciences, Iran.

Author information

Authors and Affiliations

  1. Department of Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

    Zahra Taheri-Ezbarami, Fateme Jafaraghaee & Seyed Kazem Mousavi

  2. Department of Philosophy, University of Guilan, Rasht, Iran

    Ali Karimian Sighlani

  3. Department of Nursing, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran

    Seyed Kazem Mousavi

Authors
  1. Zahra Taheri-Ezbarami
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Contributions

ZTE, SKM, and AKS helped design the study. SKM collected the data. SKM, FJ, and ZTE analyzed and interpreted the data. All the authors helped write the manuscript and read and approved the final version.

Corresponding author

Correspondence to Seyed Kazem Mousavi.

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Taheri-Ezbarami, Z., Jafaraghaee, F., Sighlani, A.K. et al. Understanding the educational needs of undergraduate nursing students regarding end-of-life care: a qualitative content analysis. BMC Res Notes 18, 129 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13104-025-07180-9

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BMC Research Notes

ISSN: 1756-0500

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