Palliative and end-of-life care from an education lens. An international systematic review of undergraduate medical and nursing students’ knowledge, perceptions, and orientation towards palliative and end-of-life care

Abstract

Introduction:

Nursing and medical schools and universities are increasingly integrating palliative and end-of-life care education in their curricula. However, research on the impacts of training and education on future nurses and physicians remains sparse.

Aim of the review:

The aim of this review was to systematically appraise existing research evidence on undergraduate nursing and medical students’ knowledge, perception, and orientation towards palliative and end-of-life care.

Methods:

This international systematic review was conducted between April and May 2021 and was updated in May 2024. A systematic search was conducted in four databases: Hinari ‘Research4Life’, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Google scholar and PubMed. Methodological quality of the included studies was assessed using the Mixed-Methods Appraisal Tool. A data extraction sheet was developed for this review. A convergent integrated approach to mixed-method data synthesis and integration was used to analyse and report the evidence. Braun and Clarke’s inductive and deductive thematic analysis approach was used to identify main themes.

Results:

A total of 64 peer-reviewed research articles met eligibility criteria and were included in the review. Of the 64 eligible research articles, 34 employed a descriptive quantitative cross-sectional design, 11 studies were qualitative, 14 used a quantitative non-randomised design and 5 were mixed methods. The review identified three major thematic categories: (1) students’ knowledge of palliative and end-of-life care, (2) attitude, perception and orientation towards palliative and end-of-life care and (3) predictors of knowledge, orientation, attitude and perception towards palliative and end-of-life care.

Conclusion:

Findings suggest inadequacy and variability in knowledge levels, self-efficacy, willingness, perception and orientation towards palliative care and end-of-life care. Surprisingly, this is common across studies, including those from high-resource countries. Inadequate, limited and/or inconsistent curricula and training content about palliative and end-of-life care is a common theme in the literature.

Plain language summary

A systematic review examining international published research on undergraduate nursing and medical students’ understanding, views and attitudes towards caring for people with life-limiting illness

Why was the study done? Globally, many nursing and medical training schools and universities are now integrating teaching and training on how to care for people facing life-limiting illnesses in their curricula. However, the distribution and nature of research evidence about future nurses’ and medical doctors’ understanding, views, attitudes, willingness and ability to care for those facing serious illness and the dying remains under reported. What did the researchers do? The researchers searched four online databases which store research publications on healthcare. These were-: Hinari ‘Research4Life’, CINAHL, Google scholar, and PubMed. The search was conducted between April and May 2021 and was updated in May 2024. Retrieved articles were screened against an established eligibility criterion and were assessed for scientific quality using the Mixed Methods Appraisal Tool (MMAT). A sheet was designed for data extraction. Data extracted from eligible studies were analysed, combined and reported using main topics derived both from the study aims and the data. What did the researchers find? 64 research articles were found eligible for inclusion. Of these, 34 reported findings using statistics, 11 studies reported findings in narrative form, 14 involved experimentation, and four used mixed methods. Three main themes emerged-: student’ views and understanding, students’ attitudes and orientation, and factors that influence students’ understanding and attitudes regarding caring for people with life-limiting illness. What do the findings mean? Findings suggest inadequacy and variability in views and understanding, perceived ability, willingness, and attitudes towards working with people with life-limiting illnesses. Inadequate teaching and training and lack of and/or limited real-life and problem-based learning opportunities, particularly interaction with the dying is a common finding in this study.

Introduction

Over the last few decades, there has been significant palliative care (PC) development in countries across the globe, including integration of PC training and education into nursing and medical undergraduate curricula. However, PC and end-of-life care (EOLC) are still considerably underappreciated in many parts of the world.^1,2 Most of the studies reporting PC development are based in resource-rich regions of the world, mainly Europe^3–7 and in Asia.^8,9

Education and training in PC are recognised as a core component of the WHO Public Health Model for increasing equitable access to PC.^10–12 This is consistent with the 67th World Health Assembly resolution ‘Strengthening of palliative care as a component of comprehensive care throughout the life course’ which mandates governments to ensure PC training is integrated routinely in undergraduate medical and nursing curricula and professional education, and as part of in-service training (continuing professional development) of primary health caregivers. ¹³ The goal is to ensure trainees acquire knowledge, skills and positive attitudes towards providing appropriate PC and EOLC. Thus, it is important to review and appraise existing literature to understand whether, and to what extent, training and teaching in medical and nursing schools are realising this goal.

The benefit of PC and EOLC, particularly for patients with life-limiting illness, cannot be overemphasised. Research shows that good quality basic as well as specialised PC not only improve patients’ quality-of-life but also reduce costs and spending on healthcare.^14–16 In her early grounded theoretical model of death education, experiential and transformative learning in nursing students, Quint ¹⁷ reported the positive role of education in influencing students’ attitudes towards caring for seriously ill and dying patients. She found that students who lacked death education held negative attitudes towards the provision of PC and EOLC, and they eventually abandoned caring for dying patients.

Sadly, literature indicates significant deficiencies in knowledge and negative attitudes towards PC among undergraduate nursing students (UNSs) and undergraduate medical students (UMSs).^7,18 Inadequate knowledge is cited as one of the commonest barriers to the provision of supportive and PC to patients.^19–22 As a result, nursing and medical students continue to graduate from training schools with negative attitudes and lacking basic knowledge, skills and confidence about PC and EOLC, and as a result are often unprepared to provide PC and EOLC to patients and their families.^23–26 Inadequate education and deficient curricula in training schools are cited as predominant reasons for this phenomenon.^9,27

Furthermore, low to poor knowledge levels and negative perceptions and orientation towards PC and EOL are a growing concern in the general population, patients, and among healthcare professionals (HCPs).^{10,12,22,28,30,31} Surprisingly, inadequate and/or lack of attention to PC in universities and clinical education has also been cited as one of the main possible factors explaining low/inadequate levels of knowledge of PC among health professionals in high-income countries (HICs) and also in many African countries.^22,32,33

The main purpose of this international review is therefore to systematically appraise the available evidence on undergraduate medical and nursing students’ knowledge and perceptions of and orientation towards PC and EOLC and their correlates. The review has the potential to examine crucial insights about the nature, extent, distribution, strengths and gaps in existing evidence and generate actionable recommendations for practice, policy and future research. The review was performed as part of a mixed-methods study that examined UNSs and UMSs knowledge and perceptions of and orientation towards PC in Uganda. The review questions were:

• (1) What are final-year medical and nursing undergraduate students’ level of knowledge of PC and EOLC?

• (2) What are final-year UMSs and UNSs’ perceptions and orientation towards PC and EOLC?

• (3) What are the predictors of knowledge and perceptions of final-year UMSs and UNSs’ towards PC and EOLC?

• (4) What factors predict UMSs and UNSs’ orientation towards PC and EOLC?

Methods

Registration

This systematic review is registered on PROSPERO-international register of systematic review, registration number CRD420251171843.

Design and data collection methods

This was an international systematic review of empirical literature on at least one of the three main variables: knowledge, perception and orientation towards PC and EOLC among UNSs and UMSs. A data extraction sheet was developed for this review, including authors’ names, year of publication, country, aims, design, data collection tool, sample and summary of the main findings.

Literature search and search strategy

An iterative and rigorous systematic literature search was conducted by the lead author (G.N.) in trusted databases, that is, Hinari ‘Research4Life’, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Google Scholar and PubMed for rich literature to inform this review. An additional online search was conducted on Google for relevant articles.

The search integrated key free text and of Medical Subject Headings (MeSH) search terms across the databases (Figure 1). Boolean connectors ‘OR’ to widen the search and capture as many relevant articles as possible and ‘AND’ to narrow the search to include articles with literature relevant to the aims of this study were utilised. Key search terms used were: (Undergraduate) AND ((nursing) OR (nurses) OR (medical)) AND (students) AND ((knowledge) OR (attitudes) OR (perceptions) OR (orientation)) (Self-efficacy)) AND ((Palliative Care) OR (end-of-life-care)).

Figure 1.

PRISMA flow chart showing search strategy for studies included in the review.

Source: Adapted from Page et al. ³⁵

Eligibility criteria

The inclusion and exclusion criteria for this review were underpinned by the PICOST framework ³⁴ as outlined in Table 1:

Table 1.

The PICOST framework for the review question.

Criteria	Description of inclusion criteria	Description of exclusion criteria
Population/setting	Studies involving UNSs and UMSs at any stage of their training programme as study participants. These include: UMSs pursuing a first degree in medicine and surgery, UNSs pursuing: a first degree, diploma or certificate in nursing or nursing and midwifery	Studies reporting about: postgraduate/qualified healthcare professionals (nurses and medical doctors) and other cadres, e.g. social workers, psychologists, etc.
Phenomenon of Interest	PC and EOLC	Excluding articles reporting about similar outcomes, not about UNSs and UMSs
Comparator	Any of the outcomes of interest
Outcomes	Knowledge, attitudes, perception and orientation towards PC and EOLC. We included articles reporting data on PC and EOLC outcomes, such as communication, difficult or challenging conversations, pain and symptom management, self-efficacy	Studies that do not report any of the outcomes of interest
Study type	Any primary research of any study design, including quantitative descriptive, qualitative, mixed method, non-RCTs, interventional (RCTs, non-RCTs, quasi-experimental studies), case-control studies, outcome-evaluation studies, longitudinal studies, retrospective studies, case series, cohort studies and dissertations Only peer-reviewed full-text articles, published in English	Conference or poster abstracts for which full-text manuscripts could not be retrieved Opinion pieces, letters or editorials
Time frame	We searched for articles published between 2011 and 2024 (for up-to-date literature). The search was conducted between April and May 2021 and updated in May 2024 (phase II)

EOLC, end-of-life care; PC, palliative care; RCT, randomised controlled trials; UMSs, undergraduate medical students; UNSs, undergraduate nursing students.

Screening of the articles for inclusion

A preliminary screening based on the titles and abstracts of all the search results (n = 860 articles) was conducted by GN. At this stage, 764 articles were excluded as it was obvious they were either not about the topic of interest or the papers were not research based or were duplicates. Full-text screening was then performed independently by GN and PE on each of the remaining (n = 96) articles, and an additional 32 papers were excluded as these were either about knowledge, attitudes, or experiences of working or active nursing and/or medical professionals rather than undergraduate students. To note, there were two disagreements on full-text screening, and these were resolved through consensus. The two papers were excluded as these were about qualified nurses/medical doctors but not undergraduate students, leaving 64 articles that met the inclusion criteria (see Figure 1).

The review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for conducting and reporting systematic reviews. ³⁵

Methodological quality of included studies critiqued using Mixed-Methods Appraisal Tool

The remaining 64 articles were screened for methodological quality using the Mixed-Methods Appraisal Tool (MMAT). ³⁶ The MMAT includes criteria for appraising the methodological quality of five broad categories of study designs: (i) qualitative studies, (ii) randomised controlled trials, (iii) non-randomised studies, (iv) quantitative descriptive studies and (v) mixed-methods studies. MMAT was deemed the most appropriate tool as this is a mixed-methods systematic review involving qualitative, quantitative and mixed-methods studies. The screening and critiquing of articles were independently conducted by the first author (G.N.) and second author (P.E.), and disagreements were resolved by consensus.

Each of the studies was appraised using an appropriate MMAT category with seven screening questions. The first two screening questions assessed whether an individual study met basic eligibility criteria – a clear research question and relevance and suitability of the data in answering the research question. Studies that passed initial screening were further subjected to category-specific screening for suitability of the study design, data collection methods, analysis and findings. Each of the seven screening items was assessed against three main responses ‘Yes’, ‘Can’t tell’ and ‘No’. All the papers had an acceptable level of methodological quality on critiquing. Detailed results are presented in Supplemental File.

Synthesis approach

A convergent integrated approach to data synthesis and integration was used. ³⁷ Data extracted from quantitative studies (including data from the quantitative component of mixed-methods studies) and qualitative studies (including data from the qualitative component of mixed-methods studies) were combined and transformed.

Narrative synthesis was utilised for quantitative studies. Quantitative findings were summarised using tables and text, which were later integrated and analysed thematically using Braun and Clarke’s framework. ³⁸

Thematic synthesis integrated both deductive-predetermined themes based on the review aims and inductive approaches, identifying themes from the data. The synthesis followed a four-stepwise approach. (1) Data extraction: GN and PE extracted data from the eligible studies and summarised them in a table (Table 2). (2) Data transformation: Quantitative data was qualitised-converted into qualitative or textual descriptions, categories, typologies, narratives or themes. (3) Integration: Here, qualitised data were compared, combined and pooled with the qualitative data extracted from qualitative studies. The pooled data were read and re-read to identify homogenous data segments that overlapped in meaning to generate broad-based categories or themes. Furthermore, emergent themes were iteratively compared with predetermined themes to generate final master themes. (4) Interpretation: Discussion of the results of the synthesis of qualitative and quantitative evidence in the context of the study aims. The discussion was constructed in such a way that it identified, compared and accounted for areas of convergence (similarities), divergence (differences and contradictions) and complementarity between evidence in the studies, while placing the evidence in the context of the aims of the review (Figure 2).

Table 2.

Summary of findings from eligible articles included in the review.

S. no.	Authors (year)	Country	Design, aim	Instruments	Sample	Summary of main findings
1.	Abu-El-Noor and Abu-El-Noor (2016) 24	Palestine	Cross-sectional. To assess Palestinian UNSs attitudes towards death and caring for dying patients and their families	FATCOD	141 UNSs	UNSs predominantly demonstrated negative attitudes towards caring for dying patients and families. No significant differences between students who attended death cases and those who did not
2.	Abuhammad et al. (2021) 47	Jordan	A quantitative cross-sectional study. To examine UMSs knowledge regarding PPC and determine the predictors of knowledge towards PPC	PCQN	326 UMSs	Participants had inadequate knowledge about PPC. A quarter of the participants didn’t have an idea about the meaning of PPC. Only gender predicted students’ knowledge of PPC
3.	Adesina et al. (2014) 60	Australia	Qualitative study. To explore a cohort of third-year undergraduate Australian UNSs attitudes, experiences, knowledge and education concerning EOLC	Self-administered questionnaire using open-ended questions	87 third-year UNSs	Majority of the students reported inadequate EOLC content in the nursing curriculum, with 63% indicating they felt inadequately prepared to care for a dying patient
4.	Al-Khawaldeh et al. (2013) 39	Jordan	A descriptive cross-sectional study. To explore knowledge and attitudes regarding pain management among UNSs and the factors that might influence such knowledge and attitudes, and UNSs perceived barriers to adequate pain management during clinical practice	- Participant information form - The revised 38-item self-administered KASRP questionnaire Researcher-developed a seven-item structured question (to measure students’ perceived barriers to pain management)	240 UNSs in three nursing schools in three governmental universities	Participants had inadequate knowledge and attitudes related to pain and its management, with a lack of knowledge and training and failure of working nurses to use pain assessment tools reported as common barriers.
5.	Al Khalaileh & Al Qadire (2013) 40	Jordan	Cross-sectional survey. To evaluate UNSs knowledge and attitudes regarding pain management.	Demographic data sheet Researcher-developed 40-item KAS questionnaire	Fourth-year UNSs	Students had low knowledge scores of PC (11.1%–64%). They showed negative attitudes towards pain management; 48% reported patients’ pain could be managed with a placebo rather than medication
6.	Alwawi et al. (2022) 51	Palestine	A descriptive cross-sectional quantitative study. To investigate the level of knowledge about PC and attitudes towards the care of dying patients and their influencing factors among Al-Quds University UNSs	The 20-item PCQN English version questionnaire, 9-item FATCOD-B Scale	410 UNSs	The overall knowledge mean score was 7.42 ± 2.93 (range 0–20), indicating inadequate knowledge about PC. However, they had a positive attitude 25.94 ± 4.72 (range 9–45) towards care for a dying person. Training about PC, having cared for a relative in their last days of life, gender and year of study were independently associated with students’ knowledge and attitudes about PC and care of dying patients
7.	Argyra et al. (2015) 42	Greece	Cross-sectional online survey. To assess whether an elective undergraduate course on chronic pain offered in Greek medical schools influences the knowledge and attitudes of UMSs about chronic pain and helps them clarify pain-related concepts	An electronic questionnaire comprising 6 demographic and 21 pain-related items was uploaded to Survey Monkey	321 UMSs	Participants had good knowledge about the definition and consequences of pain and believed chronic pain should not be left untreated. Those who attended the pain course had better knowledge about chronic pain classification and treatment compared to those who did not. All expressed concerns regarding addiction to opioids
8.	Bailey and Hewison (2014) 72	United Kingdom	A mixed-methods pre- and post-intervention survey. To evaluate the impact of an educational workshop on UNSs attitudes to caring for dying patients	FATCOD supplemented with free-text response sections	21 third-year UNSs	Found a significant increase in positive attitudes towards EOLC amongst the respondents. Free-text responses confirmed that the students developed positive attitudes and expressed that the workshop was a learning opportunity
9.	Bassah et al. (2014) 62	Cameroon	Qualitative evaluation. To examine the impact of a PC course on UNSs practice in Cameroon	Focus groups and individual critical incident interviews	Three focus groups with 23 nursing participants and 10 individual critical incident interviews	Participants who received PC education can transfer their learning to practice. Perceived barriers to knowledge transfer pertained to students themselves, qualified nurses, the practice setting, or family caregivers and patients
10.	Berndtsson et al. (2019) 76	Sweden	Descriptive study with a pre and post-design combining data from a questionnaire and qualitative open-ended questions. To examine UNSs attitudes towards care of dying patients before and after a course in PC.	Data were collected before and after a PC course using FATCOD and qualitative open-ended questions.	73 UNSs enrolled in a mandatory palliative course in the nursing programme.	Mean scores showed a statistically significant change towards a more positive attitude towards care of the dying. Those with the lowest pre-course scores showed the highest mean change. Qualitative analysis revealed knowledge development, deepened understanding and increased perceived self-confidence through the course
11.	Camara et al. (2024) 67	United Kingdom	Descriptive qualitative study. Experiences of UNSs providing EOLC for CYP	Open-ended focus group discussion (4–5 participants per group)	Nine undergraduate student children’s nurses participated in two focus groups	Children’s nursing students felt unprepared to care for a CYP at EOL but recognised EOLC for CYP as a sad but important part of the job role, and that it requires education and support to do it
12.	Cao et al. (2022) 65	China	A descriptive qualitative study. Perceptions on the current content and pedagogical approaches used in EOL education among UNSs	Face-to-face semi-structured interviews	Purposive sample of 15 fourth-year UNSs	Participants’ perceptions emerged in three main themes: (1) Universities provide foundational knowledge about EOLC, but it still needs improvement; (2) Clinical practice consolidates knowledge, skills and confidence needed to provide EOLC; and (3) Cultural attitudes of patients’ families toward disease and death as barriers to learning and knowledge translation about EOLC
13.	Cao et al. (2023) 52	China	A cross-sectional, questionnaire-based survey. To investigate PC knowledge among UNSs and analyse their influencing factors	- Demographic form - PCQN	- 1074 UNSs and 94 postgraduate nursing students from Chongqing Medical University	Overall, participants had poor knowledge of PC, especially in dimensions of pain management, psychosocial and spiritual care. Personal background, level of education and clinical practice experience were predictors of students’ knowledge about PC
14.	Centeno et al. (2016) 63	Spain	Descriptive qualitative study. To explore UMSs reactions to an optional PC course using their reflective written comments	Evaluative comments written by students	316 UMSs	Students reported that the PC course impacted them positively and recommended the course for all undergraduate students as a core component of medical curricula
15.	Centeno et al. (2016) 73	Spain	Mixed-methods pilot study. To describe the curriculum and evaluation results of a unique course centred on PC decision-making and to introduce and nurture UMSs attitudes and behaviours such as empathy, patient-centred care and holistic care	A post-course reflective exercise; a standardised evaluation form, and a focus group	20 second to sixth-year UMSs	Students’ understanding of and attitudes towards PC improved, and misconceptions were dispelled following the course. There was improved recognition of the multifaceted nature of decision-making, the need to individualise care plans and reconceptualisation of relationships with patients and families and professional role
16.	Chang et al. (2022) 80	Hong Kong	Mixed-methods with pre- and post-questionnaires and focus groups after the simulation-based experience. To explore the effects of PC simulation-based experience on UNSs PC and caring communication	PCQN, FATCOD, the CES	29 senior-year UNSs	Quantitative findings from the pre- and post-questionnaires revealed significant improvements in the students’ knowledge, attitudes and efficacy in PC after the simulation. Results from the focus groups also indicated improvement in students’ understanding of PC and communication
17.	Çıtıl et al. (2018) 44	Turkey	A cross-sectional descriptive study. To determine the awareness of UMSs on PC for terminal cancer patients	A face-to-face questionnaire developed by the researchers	363 UMSs were recruited. 210 completed the questionnaire	More than half of the participants (64%) of the students felt unprepared to communicate with patients and their families, had very limited or insufficient knowledge about PC 76% of the participants emphasised the need for PC, and 45% expressed a need to pursue PC training at a postgraduate level
18.	Cleary (2020) 29	United States	A quantitative cross-sectional survey. To measure and compare knowledge about EOLC using the PC quiz for nurses among two cohorts of graduating nurses in a baccalaureate nursing programme	PCQN	93 convenience sample of two cohorts of UNSs	Total mean scores were low in the cohort that completed (44.5%) and did not complete the EOLC course (46.5%). Participants held misconceptions about presentation and symptom management in the dying patient and integration of palliative with acute care. PC knowledge was higher among the cohort that completed the dedicated EOLC course
19.	Dimoula et al. (2019) 18	Greece and United Kingdom	A three-cohort, cross-sectional survey. To investigate UNSs knowledge about PC and attitudes towards death and EOLC and explore demographic and academic factors as potential moderators of student knowledge and attitudes	Demographic form, PCQN and FATCOD	529 UNSs	Mean total PCQN scores revealed students had low and insufficient levels of PC knowledge, including in the pain/symptom management and psychosocial/spiritual care dimensions. Mean total FATCOD scores indicated positive, liberal and supportive attitudes towards EOLC but limited positive attitudes towards care of an imminently dying, older age was the most significant moderator of knowledge and attitudes
20.	Dobrowolska et al. (2019) 7	Poland	Cross-sectional study. To explore (a) the primary difficulties participants anticipate they will encounter whilst working with dying patients, (b) their interest in developing competencies in caring for dying patients and (c) their interest in working in palliative/hospice settings or with dying patients in the future	Online and hard-copy format questionnaire	112 UNSs and 101 final-year UMSs	At least half of the participants, especially UMSs, anticipated anxiety and professional difficulties in caring for dying, and preferred avoiding work in palliative/hospice settings but expressed interest in PC knowledge improvement
21.	Escribano et al. (2021) 78	Spain	A quasi-experimental study with pre- and post-intervention measures. To evaluate the effectiveness of a simulation programme using standardised patients in complex scenarios linked to chronic and EOL situations in terms of the variables of attitude, self-efficacy and communication skills among UNSs	- Attitude Toward Communication Scale - Self-Efficacy of Communication Skills and - Health Professionals Communication Skills Scale, before and after simulation training with standardised patients	161 UNSs	Baseline findings showed female participants obtained significant better attitudinal scores towards communication and in informative communication dimensions. Participants’ self-efficacy and communication skills significantly improved after completing the intervention
22.	Eyigor (2013) 3	Turkey	Descriptive questionnaire-based survey. To evaluate UMSs knowledge on PC and their views on PC in clinical practice	Validated palliative care knowledge questionnaire	175 fifth-year UMSs	Majority had insufficient knowledge of PC in domains – use of opioids, communicating with PC patients, pain management and reported the training they received was inadequate and lacked positive role models
23.	Ferri et al. (2021) 48	Italy, Spain, United Kingdom	An international multicentre cross-sectional study. To explore UNSs attitudes towards care of dying patients and to analyse the variables that can influence them	- Frommelt Attitudes Toward Care of the Dying Scale form B (FATCOD-B) - Demographic form	569 UNSs	Median total FATCOD-B scores revealed students had intermediate levels of attitudes towards care for dying patients and these differed significantly among the three student groups
24.	Fristedt et al. (2021) 49	Sweden	A descriptive and comparative, quantitative study. To examine registered nurses and UNSs attitudes to performing EOLC	FATCOD	- 287 registered nurses in 14 different specialist programmes - 124 UNSs	Registered nurses with clinical experience had a more positive attitude towards EOLC compared with UNSs (p < 0.032). FATCOD scores in the two groups differed statistically significantly in 17 out of 30 FATCOD variables
25.	Gerlach et al. (2021) 79	Germany	Pre-post mixed-methods cohort study. To analyse the evaluation of interdisciplinary subject 13 PC (Q13), attitudes and knowledge, self-confidence regarding PC and its related topics in students after Q13 and again in the same students after they had completed the practical year (PY)	17-item questionnaire integrating qualitative free-text analysis	176 final-year (fifth and sixth year) UMSs	Teaching was perceived as more helpful than the PY (p < 0.001). Students rated themselves as less competent after the PY in all areas surveyed, including pain management (p < 0.0386). Self-confidence when communicating with patients about disease incurability decreased significantly after the PY (p < 0.0117).
26.	Hagelin et al. (2016) 5	Sweden	Descriptive cross-sectional study. To describe Swedish first-year UNSs attitudes towards care of dying patients	FATCOD	368 UNSs selected from six universities	67% of the students reported overall positive attitude towards caring for dying patients. Age, earlier care experience, education and place of birth influenced students’ attitudes
27.	Harazneh et al. (2015) 25	Palestine	Descriptive cross-sectional study. To assess the PC knowledge using PCQN of Bachelor of Science UNSs in Arab American University/Jenin, Palestine.	PCQN	198 UNSs in third and fourth year	Students had inadequate information about PC with a PCQN total percentage score of 41% (SD = 13.89).
28.	Haroen et al. (2023) 81	Indonesia	A quasi-experimental study with a pre- and post-palliative survey. To assess the PCN knowledge and attitude of UNSs towards EOLC after completing the multi-methods PC nurses’ courses	- PCQN and - FATCOD	164 UNSs	Students’ knowledge of pain and symptom management (p < 0.001) and positive attitude towards EOLC increased significantly (p < 0.001), from 75.6% to 91.5% after the course
29.	Hökkä et al. (2022) 66	Finland	A descriptive qualitative study. UNSs perceptions of the development needs in PC education and factors influencing learning in undergraduate nursing studies	An online open-ended questionnaire	A national survey of 766 final-year UNSs	Participants felt unprepared to provide high-quality PC even though they recognised PC as important
30.	Jafari et al. (2015) 75	Iran	Quasi-experimental study with one-group pre-test/post-test design. To examine UNSs attitude towards caring for dying patients and effects of education on their attitude	FATCOD before and after an educational intervention	30 UNSs	Only 20% of the students reported previous experience of working with dying patients in their clinical courses and held moderately negative to neutral attitudes towards caring for dying patients. FATCOD means scores showed students’ attitude improved significantly from 3.5 ± 0.43 before the intervention to 4.7 ± 0.33 (p < 0.001) after the intervention
31.	Jiang et al. (2019) 9	China	Descriptive cross-sectional survey. To investigate UNSs knowledge about and attitudes towards PC and analyse their influencing factors	Revised PCQN	1200 UNSs, stratified sampling	Students’ mean score on the revised PCQN was 16.10 ± 5.04. Only 19.8% expressed desire to work in PC in the future. Knowledge and school, grade, gender, birthplace and religious beliefs (p < 0.01) significantly influenced students’ knowledge of PC while talking about death and history of caring for dying family members significantly influenced students’ attitudes (p < 0.05)
32.	Karkada et al. (2011) 87	India	Cross-sectional correlative survey. To examine nursing students’ level of knowledge and attitude towards PC and associated factors	Researcher-developed structured questionnaire comprising 20 multiple choice questions	83 third-year diploma nursing students, cluster sampling	Only 43% of the students were aware of the PC, 80%. had poor knowledge (6.4 ± 1.64) on PC while 93% had favourable attitudes (56.7 ± 8.5) towards PC. Students’ age influenced their knowledge (χ2 = 18.52, p < 0.01)
33.	Khraisat et al. (2017) 43	Saudi Arabia	Descriptive cross-sectional survey. To assess Saudi UNSs knowledge about PC	PCQN	154 UNSs	Students had multiple misconceptions about PC and their knowledge was inadequate with total PCQN mean score at 7.30 (SD = 0.56; range: 0–13)
34.	Korzeniewska-Eksterowicz et al. (2013) 74	Poland	Cross-sectional with pre-post course evaluation. To evaluate the impact of PPC education on UNSs and UMSs knowledge and attitudes	Anonymised questionnaire developed by authors	320 final-year UMSs and 55 UNSs	Both nursing and medical students’ knowledge about and attitudes towards PC significantly improved upon completion of the course
35.	Kudubes and Bektas (2020) 91	Turkey	An intervention and control group comparative study. To investigate the effect of web-based PPC education on UNSs knowledge level and practices related to PC	Information form, the Palliative Care Related Knowledge Level Form for Nursing Students and the Self-Reported Palliative Care Practices Scale	265 UNSs	A statistically significant difference between the total and subscale pre-test and post-test scores of the students in the intervention and control groups, indicating the effectiveness of the web-based PPC education as an effective training model
36.	Laporte et al. (2020) 46	Switzerland	Cross-sectional study. To determine UNSs attitudes towards caring for terminally ill patients, as well as the associations between these attitudes and year of study, exposure to terminally ill people, self-perceived nursing skills and subjective impact of instruction	FATCOD-B	178 UNSs (63 preparatory grade, 67 first years, 48 third year)	Mean FATCOD-B score was 117.7 (SD: 9.8, median: 118.0). Being aged 24–26 years (95% CI: 2.00–11.95, p = 0.006) and year of study (95% CI: 1.69–5.25, p < 0.001) were significant factors for positive attitudes towards caring for terminally patients
37.	Leung and Wong (2021) 50	China	Cross-sectional study. To investigate the confidence and its association with knowledge, attitude and exposure on providing PC among UMSs	- Demographic form - 20-item Palliative Care Knowledge Test 5-item researcher-developed questionnaire (exposure in providing PC); 10-item researcher-developed questionnaire (confidence to provide PC); 10-item researcher-developed questionnaire (attitude towards PC)	303 UMSs	59.4% lacked confidence (95% CI: 53.8–65.0) to provide PC. Knowledge (p < 0.010) and attitude (p < 0.003) were significantly positively associated with confidence to provide PC, while exposure to death of family/friends (p < 0.024) was negatively associated
38.	Moehl et al. (2020) 77	United States	Pre-and post-intervention evaluation. To test the impact of an e-learning module about pain in communicative people with dementia on third-year UMSs who had or had not completed an experiential geriatrics course	16-item paper and pencil exam	161 third-year UMSs from two universities	Knowledge gain was significantly greater among students who viewed the dementia module and participated in the geriatrics course. The modules did not improve attitudes in any group, but students’ confidence improved in all groups
39.	Moody et al. (2018) 90	United States	Prospective cohort study. To test the effectiveness of a PPC-PBL module on third-year UMSs and paediatric faculty’s declarative knowledge, attitudes towards, perceived exposure and self-assessed competency in PPC	Knowledge exam and survey instrument	26 faculty and 190 third-year UMSs	Declarative knowledge (p < 0.002), perceived exposure (p < 0.001) and self-assessed competency (p < 0.001) of the students improved significantly in all three PPC learning dimensions after the PPC-PBL. Students (and faculty) rated PC education as ‘important or very important’ both at baseline and follow-up
40.	Morrison et al. (2012) 89	United States	Wait-list control crossover design in a longitudinal required course. To assess the impact of a required PC educational intervention on UMSs PC pain knowledge and EOL attitudes	Questionnaires developed from previously validated instruments	157 third-year UMSs	Statistically significant increases in knowledge and improvements in attitudes (p < 0.001) across the study time points and interaction effect between time and groups (p < 0.006). Attitudinal improvements were observed after the workshop while knowledge increases were observed after patient experience, online pain module and reflective essay
41.	Pandey et al. (2015) 92	Nepal	Descriptive analytical study. To examine the perception of the UMSs to PC in a teaching hospital	Self-structured pretested questionnaire	270 UMSs	Found inadequate knowledge and perception of PC among the students. Only 152 (56%) had heard the word ‘palliative care’, 84 (31%) responded PC can be provided early in the life-threatening illness trajectory, 80 (30%) knew it doesn’t intend to postpone and hasten death, 49 (18%) never knew PC was not included in their curriculum, while 227 (82%) expressed interest to learn about PC
42.	Pastrana et al. (2021) 64	Germany	Descriptive qualitative study. To capture the experiences of a select group of UMSs’ following a community-based PC course	Semi-structured focus group discussions (2)	15 female UMSs in their second to fifth year	Students whose encounters with patients and their families went beyond a review of their medical records had a better grasp of the holistic nature of PC than those who did not.
43.	Pieters et al. (2019) 45	Netherlands	Cross-sectional study. To gather UMSs views on the importance of, their confidence in, and knowledge of PC	A modified structured questionnaire based on Weber et al. 55	222 final-year UMSs at four Dutch medical faculties	Students had limited knowledge of PC; only 48% of the students correctly answered more than half of the questions. 59.6% expressed a lack of confidence to provide PC, in particular handling the spiritual dimension (77%). Students felt several topics were inadequately covered in the curriculum. Students considered PC education relevant, particularly training in patient-centred care and communication
44.	Polat and Karatas (2018) 6	Turkey	Descriptive cross-sectional with quantitative design. To determine UNSs knowledge of PC	19-item questionnaire prepared by the researchers	658 UNSs	Only 5.3% of participants correctly answered all items, while 26.3% and 5.3% gave correct answers regarding PC theoretical framework symptom management respectively
45.	Pope (2013) 41	United States	Cross-sectional survey to assess the PC knowledge of junior and senior level UNSs and to compare the PC knowledge between them	PCQN	72 nursing students from a junior and senior level UNSs	All lacked adequate information on PC. Total PCQN was 61%. Juniors’ PCQN scores were significantly lower 11.7 (2.83) (p < 0.05) than seniors 12.93 (1.98). Participants scored highest on understanding PC is an aggressive treatment
46.	Schallenburger et al. (2024) 86	Germany	Cross-sectional evaluation study. To evaluate the impact of the elective course’s content, a comparison of attitudes towards assisted dying requests from PC patients with two other participant groups	31-item structured questionnaire with two parts; global evaluation (18 items) and specific outcome-based assessment of the elective (13 items)	13 UMSs-online elective course on handing the desire to die in PC patients (group 1); 37 UMSs who only took compulsory course in PC (group 2); 258 physicians with critical care training (group 3)	Group 1 students were very satisfied with the blended-learning format (100%) and the course itself (100%) and declared the course deepened their knowledge (81.0%) and training skills (71.2%). Among the participants, the highest willingness to assist with or accompany the various options for assisted dying was observed in group 2 participants followed by group 3 and then group 1
47.	Sharour et al. (2017) 26	Jordan	Descriptive cross-sectional study. To explore UNSs attitudes towards death and caring for dying cancer patients	FATCOD and DAP-R	100 UNSs	Younger students had more negative thoughts, attitudes and emotions towards caring for dying cancer patients. Students with higher academic level showed a more positive attitude and were more willing to care for dying cancer patients
48.	Sujatha and Jayagowri (2017) 53	India	Descriptive cross-sectional. To assess the awareness of PC among undergraduate students of medicine, nursing, pharmacy and physiotherapy	Author-developed questionnaire	200 undergraduates, 50 from each of the colleges nursing, medical, pharmacy and physiotherapy	Students had inadequate basic knowledge about PC. At least 80% of nursing and medical students agreed death should occur without any pain or symptoms. 70% recognised the need for PC
49.	Sukcharoen et al. (2023) 69	Thailand	Qualitative case study research. To investigate UNSs experiences of providing PC in the intensive care unit	In-depth interviews with key informants	Nine purposively sampled Thai UNSs	The experiences of providing PC emerged in two themes: (1) self-perception while providing care for terminally ill patients and (2) providing care for terminally ill patients with respect to the patients’ dignity. Generally, participants had low self-confidence, limited nursing practice skills and fear of dealing with terminally ill patients
50.	Sweeney et al. (2013) 82	Ireland	Mixed-methods pre-post evaluation. To assess the impact of a UMS-selected module in PC	SEPC and TS pre-module and post-module	24 third-year direct entry (5-year course) and second-year graduate entry (4-year course) UMSs, 18 students completed the qualitative part	15.5% (24 of 155) eligible students chose the module. Significant differences were seen in pre-module and post-module. Self-efficacy in PC scores (communication p < 0.0001, patient management p < 0.0002 and teamwork p < 0.03) Students commented the module should be core in the curriculum
51.	Thyson et al. (2022) 85	Germany	An outcome-evaluation study. To objectively evaluate changes in knowledge, skills and attitude among the participants of an elective blended-learning course	29-item structured questionnaire comprising 15-item global evaluation and 14-item outcome-based evaluation of the elective course	62 UMSs	Overall, learning gains (⩾50%) were seen across all areas of competence, and in 50% of all retrospective self-assessment items. The highest learning gain (64%) was seen in the students’ ability to meet a severely ill patient without fear while the lowest learning gain was observed in having to confront and accept their own mortality
52.	Usta et al. (2016) 54	Turkey	Descriptive cross-sectional study. To determine the level of knowledge of UNSs about PC and the notion of death	Researcher-developed questionnaire on knowledge and opinions of PC	357 UNSs	The mean PC knowledge score of students was intermediate, at 70.54 ± 11.01. Factors that affected knowledge were – being female (p < 0.001), age and higher grade (p < 0.001), having received PC training (p < 0.03), history of an encounter with terminally ill patients (p < 0.001)
53.	Valsangkar et al. (2011) 83	India	Interventional repeated measures study. Evaluation of knowledge regarding PC in people living with HIV/AIDS and the impact of a structured intervention on knowledge dimensions	Pre-test assessment and a post-test assessment following a structured intervention	106 medical interns	The mean scores on knowledge showed a consistent increase after the structured intervention across three dimensions of knowledge of PC and its application (t = 9.12, p < 0.001).
54.	Wang and Yuan (2022) 70	China	A descriptive qualitative study. To explore the experiences of UNSs participating in a simulation-centred educational program	Data were collected using semi-structured interviews	52 year 2 and year 3 purposively sampled UNSs	The educational program improved students’ learning experience and competence in hospice care
55.	Wang et al. (2023) 71	China	A descriptive qualitative study. The Death Cafe: Effectiveness of a hospice care educational program for UNSs based on life experience	During the implementation phase, a small-group interactive teaching approach was utilised. Students recalled and shared experiences or events related to death they experienced. During the reflection phase, the students were asked to finish an essay ‘the meaning of life’ answering four questions without standard right answers	71 UNSs	Students’ attitudes towards death changed from negative (fearful) to positive through imagining death when role-playing the different stages of life. The program enhanced students’ view and understanding of life and coping with death
56.	Watts (2014) 61	United Kingdom	A qualitative study. To explore UNSs understandings of PC	In-depth individual interviews	11 final-year adult-UNSs	Participants recognised the broad scope and compassionate care and emotional support dimensions of PC. Understanding was superficial and focused on the imminently dying phase
57.	Weber et al. (2011) 55	Germany	An interinstitutional questionnaire-based cross-sectional study. To evaluate knowledge and attitude of final-year UMSs in Germany towards PC	A three-step questionnaire developed by an interdisciplinary panel of experts in PC	101 final-year UMSs at two German universities (76 from Mainz, 25 from Göttingen)	Overall, only 5%–10% of students declared a high level of confidence in dealing with PC issues except for pain therapy (69% of students in Mainz vs 24% in Göttingen were ‘confident’). Only one-third correctly answered at least half of the questions. A vast majority supported the introduction of a mandatory PC course in the undergraduate curriculum
58.	Wong et al. (2020) 56	Hong Kong	Cross-sectional survey. To explore the knowledge, attitudes and educational needs of pre-clinical medical and nursing students in Hong Kong	Researcher-developed pretested self-administered 44-item questionnaire covering 11 categories related to participants’ knowledge of and attitudes towards PPC	- 58 first to third-year pre-clinical UMSs - 186 first to fourth-year pre-clinical UNSs	Only 38% of participants had heard about PPC, but 74% advocated for its commencement. More medical students than nursing students felt they were mentally unprepared to discuss death and dying while a large proportion of nursing students misunderstood fundamental palliative concepts and pain assessment methods Many reported undergraduate curricula should integrate PPC and it should be delivered at home even though very few had a clue about the existing referral structure
59.	Xu et al. (2019) 57	China	A KAP cross-sectional survey	Standardised biodata form and DAP-R	366 nursing interns in eight teaching hospitals	Statistically significantly higher DAP-R scores were observed in the domains of – death avoidance, approach acceptance and fear of death while statistically significantly lower scores were seen in the domains of –; natural acceptance and escape acceptance religious beliefs, experience of a deceased family relative, death education and family atmosphere of discussing death were positively associated with one or more domains of attitude towards death
60.	Yoong et al. (2024) 68	Singapore	A descriptive qualitative study. To explore UNSs perspectives and learning experiences of participating in a PC and EOLC simulation programme	Eight face-to-face focus group discussions	A purposive sample of 75 third-year UNSs	The students suggested and supported inclusion of advanced practice nurses/clinical experts as facilitators to provide essential insights. They also suggested the use of other simulation modalities such as virtual simulations to enable the participation of all students and provision of a wider range of simulated scenarios
61.	Younis and Hamdan-Mansour (2024) 58	Jordan	Cross-sectional descriptive study. To examine knowledge related to PC and attitudes towards dying people among UMSs in Jordan	PCAK and -FATCOD-B	404 UMSs	UMSs had inadequate knowledge of PC in many domains – pain management (n = 156, 39%), managing other PC symptoms (n = 164, 41%) and in handling difficult conversations/breaking bad news discussion (n = 178, 44%). However, students had favourable attitudes towards caring for dying patients, more especially in communication and relationship with patients. significantly higher (p < 0.001) mean FATCOD-B scores were found in females (M = 109.97) than males (M = 105.47) and those who had exposure to PC (p < 0.001)
62.	Zhang et al. (2022) 59	China	A cross-sectional survey. To explore the factors associated with attitudes towards the older adults among UNSs, to clarify the impact of empathy and EOLC on the attitude of the older adults and to provide a basis for the follow-up of education courses	- A demographic form - 30-item (FATCOD-B) – Chinese version - 20-item C-JSE-HPS - 34-item KAOP	371 UNSs	Students had positive attitude towards older adults even though it was slightly lower than the average level in China. Education (β = −0.125, p < 0.025) and personal experience (β = −0.132, p < 0.008) had a negative correlation on attitudes towards older adults, while EOLC (β = 0.140, p < 0.013) and empathy (β = 0.285, p < 0.001) correlated positively with attitudes towards older adults Religion, EOLC and empathy correlated positively with UNSs attitudes towards older adults
63.	Zhou et al. (2021) 88	China	Descriptive correlational study. To describe UNSs knowledge, attitudes and self-efficacy about PC and to examine the associations between these variables in China	The Chinese versions of the PCQN, the DAP-R, FATCOD and the Palliative Care Self-Efficacy Scale	187 third-year UNSs	Most participants possessed favourable attitudes towards death and caring for the dying but had low level of knowledge and self-efficacy regarding PC and EOLC education (β = −0.125, p < 0.025) and personal experience (β = −0.132, p < 0.008) correlated negatively with attitudes towards older adults, while EOLC (β = 0.140, p < 0.013) and empathy (β = 0.285, p < 0.001) correlated positively with attitudes towards older adults. Religion, EOLC and empathy correlated positively with participants’ attitudes towards older adults
64.	Zhu et al. (2023) 84	China	A pre-post intervention study with a quasi-experimental design. To evaluate the effects of a death education based on narrative pedagogy in a PC course on the attitude towards death, coping with death, and attitude towards caring for the dying among UNSs in China	- DAP-R - CDS and - FATCOD-B	60 UNSs	The mean score of neutral acceptance was highest pre-intervention followed by neutral acceptance, death avoidance, fear of death, approach acceptance and escape acceptance in that order. Post-intervention, the mean score of neutral acceptance and escape acceptance remained highest and lowest respectively, while death avoidance and fear of death decreased. Mean score of neutral acceptance (p < 0.048) and approach acceptance (p < 0.046), CDS (p < 0.003) and positive attitudes towards caring for dying patients (p < 0.009) increased significantly after intervention

BSN, Bachelor of Science in Nursing; CDS, Coping with Death Scale; CES, Caring Efficacy Scale; CI, confidence interval; C-JSE-HPS, Chinese version of the Jefferson scale of empathy–health profession students; CYP, children and young people; DAP-R, Death Attitude Profile-Revised Scale; DAS-E, Death Anxiety-Extended Scale; EOLC, end-of-life care; FATCOD, Frommelt Attitudes Toward Care of the Dying Scale; KAOP, Kogan’s Attitudes toward Older People Scale; KAP, knowledge, attitude and practice; KAS, knowledge and attitudes survey; KASRP, knowledge and attitudes survey regarding pain; p, probability at an acceptable confidence level; PBL, problem-based learning; PC, palliative care; PCAK, palliative care assessment knowledge; PCN, palliative care nursing; PCQN, palliative care quiz for nursing questionnaire, PLWHA, people living with HIV/AIDS, PPC, paediatric palliative care; PY, practical year; Q13, interdisciplinary subject 13 palliative care in Germany; SD, standard deviation; SEPC, Self-Efficacy in Palliative Care Scale; TS, Thanatophobia Scale; UMSs, undergraduate medical students; UNSs, undergraduate nursing students.

Figure 2.

Convergent integrated approach to data synthesis and integration.

Results

Methodological characteristics of the articles included in the review

Disaggregating the articles based on study design: of the 64 research articles 31 employed a descriptive quantitative cross-sectional design.^{3,5,6,7,9,18,24–26,29,39–59} Twelve studies were qualitative,^60–71 two had mixed-methods design,^72,73 eight were quasi experimental with a pre-post intervention design,^{74–78,81,83,84} three employed a quasi-experimental with a pre-post mixed-method design,^79,80,82 two were outcome-evaluations,^85,86 two descriptive correlational,^87,88 two prospective longitudinal,^89,90 one was an intervention control group comparative study ⁹¹ and one descriptive analytical study. ⁹²

Stratifying the articles by geographical region and country where the studies were conducted: 28 were conducted in Europe: Turkey,^3,6,44,54,91 Germany,^{55,64,79,85,86} Sweden,^5,49,76 United Kingdom,^61,67,72 Spain,^63,73,78 Poland,^7,74 Greece, ⁴² Ireland, ⁸² Netherlands, ⁴⁵ Finland, ⁶⁶ Switzerland, ⁴⁶ Italy, Spain and UK, ⁴⁸ and Greece and UK ¹⁹ . Twenty-nine studies were conducted in Asia including: 12 in East Asia: China,^{9,50,52,57,59,65,70,71,84,88} Hongkong^56,80; 10 in West Asia: Palestine,^24,25,51 Jordan,^{26,39,40,47,58} Saudi Arabia, ⁴³ Iran ⁷⁵ ; 4 in South Asia: India,^53,83,87 Nepal ⁹² ; and 3 in Southeast Asia: Singapore, ⁶⁸ Thailand, ⁶⁹ Indonesia. ⁸¹

Five studies were conducted in North America (all in United States).^{29,41,77,89,90} Australia ⁶⁰ and Africa (Cameroon) ⁶² had only one study each. See Figure 3.

Figure 3.

Showing geographical distribution of eligible studies included in the review (n = 64).

Regarding field of study, 40 studies were conducted with UNSs,^{5,6,9,19,29,24–26,39–41,43,46,48,49, 51 ,52,54,57,59–62,65–72,75,76,78,80,81,84,87,88,91} 20 with UMSs^{3,42,44,45–47,50,55,58,63,64,73,77,79,82,83,85,86–89,90,92} and 4 with both groups^7,53,56,74 (See Table 2).

Emergent themes

The review identified three major thematic categories as shown in Figure 4: (1) students’ knowledge of PC and EOLC, (2) Students’ attitude, perception and orientation towards PC and EOLC and (3) predictors of knowledge, attitude and perception towards PC and EOLC.

Figure 4.

Interaction between emergent master themes.

Theme 1: Nursing and medical student’s knowledge of PC and EOLC

A wide body of research from both LICs and HMICs reports inadequate and poor knowledge levels of PC and EOLC among UNSs, for example, in Canada, ²³ Jordan, ³⁹ Palestine,^25,51 Cameroon, ⁶² Turkey, ⁶ Poland, ⁷ United States, ²⁹ China^49,85 as well as among UMSs, for example, in Germany,^55,79 Turkey,^3,44 Greece, ⁴² Poland,^7,74 Netherlands, ⁴⁵ Hong Kong, ⁵⁶ Jordan.^47,58 Other studies report similar findings in UNSs.^{9,18,43,93,94}

In their study to determine Turkish nursing students’ knowledge of PC, Polat and Karatas ⁶ found only, 5%, 26% and 5% correctly answered all questionnaire items, PC theoretical framework and symptom management respectively. These findings are similar to those of Çıtıl et al. ⁴⁴ who found 52% of the 210 Turkish UMSs they studied had never heard about PC, 64% felt anxious to communicate with the patients and their families, and only about 10% of those who were aware of PC felt the known information was adequate. In the United States, Cleary et al. ²⁹ found UNSs knowledge of PC and EOLC were low at 45% and 47% respectively. In India, Karkada et al. ⁸⁷ found 80% of students had poor knowledge on PC practices with only 43% being aware of the term PC, with similar findings among pre-final and final-year Indian medicine and nursing students. ⁵³ Very few studies report intermediate knowledge among UNSs and UMSs.^54,58,68 In the United States, Pope ⁴¹ found 61% of UNSs were knowledgeable about PC, similar to findings reported earlier by Brajtman et al. ²³ who found 61% of Canadian UNSs knew about PC.

Alhamdoun et al. ⁹⁵ identified students had poor knowledge of PC, especially in the symptom management and the definition of PC domains. In Palestine, Harazneh et al. ²⁵ found the overall PC knowledge among third- and fourth-year level UNSs was 41%. With regard to mean knowledge scores on the PCQN questionnaire in UNSs, both narrow and wide variations across countries and regions exist. For example, 10.41 in China, ⁹⁶ 8.20 in Greece, ¹⁸ 9.04 in China, ²⁵ 5.23 in Saudi Arabia. ⁹⁷ The commonalities in findings in these studies underscore a global problem and an urgent need to address training deficiencies to improve PC knowledge among future physicians and nurses. However, on the other hand, the findings should be interpreted with caution, owing to variability in sample characteristics, curricula and course content, methodologies and outcome measurements.

Theme 2: Undergraduate nursing and medical students’ attitudes, perceptions of and orientation towards PC and EOLC

Subtheme 2.1: Undergraduate students’ attitudes and perceptions towards PC

Unfavourable attitudes ranging from low to high negative attitudes towards PC and EOLC, particularly caring for PC and the dying patients was reported by eight studies conducted with UNSs^{24,26,39,49,57,66,69,75} compared with only one study conducted with UMSs. ⁹² A Polish study conducted with both UNSs and UMSs reported similar findings. ⁷ These unfavourable attitudes have varied manifestation with students experiencing perceived or actual emotional or occupational feelings of distress, fear, helplessness, powerlessness, unpreparedness and uncertainty to handle patients with terminal disease.

However, 11 studies reported favourable attitudes ranging from limited to intermediate positive attitudes towards care for the dying among UNSs^{5,18,46,48,51,59,61,68,87,88} and UMSs. ⁵⁸

Hagelin et al. ⁵ found a majority (67%) of Swedish first-year UNSs had an overall positive attitude towards caring for dying patients. Similarly, Karkada et al. ⁸⁷ reported higher positive attitude scores towards EOLC among Indian UNSs. Earlier research postulated that nurses’ attitudes towards death might influence their attitudes towards caring for dying patients.^98,99

Subtheme 2.2: Students’ orientation towards PC and EOLC

There is a common emergent theme about how students navigate multiple difficulties ranging from basic to complex difficulties in performing tasks such as managing emotional reactions around death and dying, communicating with the dying patient and their family, handling challenging EOL conversations and disease incurability, and providing basic nursing and clinical care to the dying patient.^{7,44,45,50,55,56,60,62,66,67,69,79,88} Two studies found UNSs and UMSs were unprepared to cope and provide care for children and young people at EOL,^56,67 even when they recognised EOLC for children and young people as a sad but important part of the job role. ⁵⁶

Elsewhere, in Turkey, two studies conducted with UMSs found participants felt unprepared to provide PC and anxious about communicating with patients and families.^3,44 Pieters et al. ⁴⁵ also found 60% of final-year Dutch UMSs at four medical faculties reported they did not feel confident in providing PC, especially addressing spiritual needs/issues (77%) of patients. This finding is corroborated by Leung and Wong ⁵⁰ in China who found that 60% of UMSs felt they were not confident to provide EOLC. Furthermore, Sweeney et al. ⁸² in their mixed-methods study assessing UMSs’ Self-Efficacy in PC found only 15% of the Irish students assessed selected PC as their first choice.

Theme 3: Predictors of students’ knowledge, perceptions of and orientation towards PC

Subtheme 3.1 Education and training curricula as a predictor of students’ knowledge

The literature identifies numerous associated factors that have a significant bearing on knowledge of PC and EOLC among students. One of the central themes is inadequate, limited and or/ inconsistent training content about PC and EOLC in nursing and medical curricula, widely cited as a predominant predictor of students’ lack of knowledge or inadequate, awareness, skills, confidence and the competences they need to provide high-quality PC. Surprisingly, this phenomenon is prevalent in resource-rich countries as well, for example, Germany,^55,64 Poland, ⁷⁴ Turkey,^3,6,44 Jordan, ³⁹ Australia,^40,60 Greece, ⁴² China,^52,57,88 Netherlands, ⁴⁵ Greece and United Kingdom, ¹⁸ Poland, ⁷ Hong Kong, ⁵⁶ Saudi Arabia, ⁹⁷ Jordan, ⁴⁷ Finland ⁶⁶ and Palestine. ⁵¹

Watts, ⁶¹ in their qualitative study of final-year nursing undergraduates’ understandings of PC found that, whereas participants had reasonably broad knowledge of PC (especially scope, compassionate care and emotional support domains), their understanding was superficial.

Conversely, literature shows education and training orientates nurses and medical doctors to the concepts and principles of PC, resulting in improved knowledge and practical competences (skills) necessary for them to provide PC and EOLC. Jiang et al. ⁹ found nearly all (96%) Chinese UNSs in their study reported additional learning on PC as necessary. Studies conducted with UMSs report similar findings. Argyra et al. ⁴² found that 60% of Greek students who attended a PC course believed the majority of patients with chronic pain do not receive adequate treatment, while another study conducted in the Netherlands reported students felt several topics were inadequately and superficially covered in the curriculum. ⁴⁵

Numerous studies conducted with UNSs and UMSs report increased knowledge and improved positive attitudes, perceptions, practices and orientation towards PC and EOLC following education and training. These studies include an interventional repeated measures evaluation study in India, ⁸³ outcome and pre- and post-intervention evaluation studies in the United Kingdom, Poland, Iran, Sweden, Spain, Hong Kong, United States, Indonesia,^{72,74–78,80,81,85} prospective longitudinal studies in United States,^89,90 a descriptive analytical study in Nepal, ⁹² a qualitative evaluation in Cameroon ⁶² and Spain, ⁷⁰ cross-sectional evaluations in Greece, Ireland and Poland,^7,42,82 and an intervention comparative study in Turkey. ⁹¹

Centeno et al. ⁷³ found that a PC course exposed second to sixth year Spanish UMSs to the concepts and principles of PC, including improved awareness of PC, holistic approaches and self-awareness, positive attitudinal and behavioural change and helped dispel myths and misconceptions, and increased awareness of patient-centred care.

To note, the literature emphasises the importance of problem-based learning (PBL) and simulation-based scenarios in strengthening students’ knowledge and competences to provide PC and EOLC in both UNSs^{68,70,75,78,80,81} and in UMSs.^85,89,90

Education and training as a predictor of students’ perceptions of and orientation towards PC

There is wide evidence in the studies showing that education is an important predictor of positive attitudes towards PC and EOLC among UNSs and UMSs. They include higher and/or better knowledge scores about PC, higher grade or academic level,^18,26,46,52 prior training and experiential learning or exposure to PC or death education and clinical practice.^{5,29,57,58,70,73,75–78,80,81,85,86,89} Reflexive teaching and practice are also cited as important predictors of positive attitudes towards death and dying among UNSs and UMSs. ⁷¹

The role of PC and death education in improving positive attitudes, particularly decreasing death avoidance, fear of death and overall death anxiety, and increasing students’ competencies and self-efficacy, including communication skills in the care of the dying patients, is widely supported by experimental studies with both UNSs^{72,75,76,80,81,84} and UMSs.^82,85,89,90 Two recent descriptive qualitative studies in UNSs corroborate the findings.^70,71 Similar finding are reported in cross-sectional studies.^87,88

Kudubes and Bektas ⁹¹ in their study investigating the effect of web-based PPC education on Turkish UNSs knowledge level and practices related to PC found positive correlations especially knowledge increase, self-reported efficacy and PC practices. In a qualitative study exploring the experiences of attending an undergraduate course in PC, Centeno et al. ⁷³ reported Spanish UMSs viewed PC as combined clinical, humanistic and holistic medicine. Through the course, they rediscovered medicine and developed an understanding of the need to be reflective and more humane and compassionate towards patients with PC needs. These findings are consistent with those of Çıtıl et al. ⁴⁴ who found that 76% of Turkish UMSs emphasised the need for PC education, while 45% wished for PC training at a postgraduate level. A recent qualitative study conducted in the United Kingdom found participants recognised EOLC for children and young people as a sad but important part of the job role. ⁶⁷

Notably, this review found that there is limited evidence on attitudes towards PC and EOLC among UMSs and UNSs in LMICs, with only one study conducted in Africa. In a Cameroonian qualitative study evaluating the impact of a PC course on nursing students’ practice, Bassah et al. ⁶² found the course improved the majority of students’ knowledge and competences, especially in the areas of physical care, communication with patients and family, spiritual and psychosocial care.

Inappropriate perceptions and inadequate orientation towards PC and EOLC are prevalent among students, as well as qualified HCPs. Again, the studies attribute this phenomenon to deficient education and training curricula.^9,27 In Turkey, Eyigor ³ found 65% of their study participants stated they had received insufficient education on PC, especially pain and symptom control, 90% had received no training on communication skills regarding PC patients, while 34% and 54%, respectively reported opioids use in cancer patients and pain management were inadequate.

However, conflicting findings also exist, for example, in their study of third-year Australian nursing students’ attitudes, experiences, knowledge and education concerning EOLC, Adesina et al. ⁶⁰ found that whereas students’ confidence, and competence to provide care to dying patients improved with education, as many as 63% indicated they felt inadequately prepared.

Sociodemographic factors

Age, religion/religious beliefs, level of education, gender differences and prior history of working with PC patients are identified in the literature as some of the significant predictors of knowledge of PC among medical and nursing students. These include being older,^{9,47,54,87,93} history of exposure or training in PC or EOLC education,^{39,51,52,54,70,73,76,80,81,86} having cared for a dying patient or relative or clinical practice experience^{39,42,51,52,54,60,64,65,77,89,90} and higher level of education,^51,65 school,^9,18 being female, ⁵⁴ religious beliefs and personal background or birthplace ⁹ and empathy. ⁵⁹

In their study of 324 Turkish UNSs, Usta et al. ⁵⁴ found the knowledge scores of PC of older and higher-grade students were higher compared to younger and lower grade students. A combination of mental maturity and life experiences and information absorption accumulated in clinical practice could explain this finding. ¹⁸ Similar findings are reported in India ⁸⁷ and Jordan. ⁹³ In a study of perception of PC among UMSs in Nepal, Pandey et al. ⁹² found participants’ knowledge of PC increased from 12.5% at the beginning of their medical education to 94% in final year.

Regarding gender, two studies, in Turkey ⁵⁴ and in China, ⁹ reported higher knowledge of PC among undergraduate female students than males; Ross et al. ¹⁰⁰ reported similar findings among hospice and generalist nurses in the United States. On the contrary in Palestine, Alwawi et al. ⁵¹ found male UNSs had significantly better knowledge of PC than their female colleagues.

Regarding students’ perceptions and orientation towards PC and EOLC, predictive factors included being female,^18,58 older age (being a ‘mature’ student),^26,46 experience of caring for a dying family relative and family atmosphere,^9,57 religion or religious beliefs and empathy, ⁵⁶ previous death work ⁹ and profession. ⁷ Dobrowolska et al. ⁷ found more medical than nursing students predicted more challenges when working with PC patients. Few studies report contrary findings. For example, in China, exposure to death of a family member or friend resulted in reduced confidence to care for the dying among Chinese UMSs, while education and personal experience were found to have a negative correlation with positive attitudes towards EOLC. ⁵⁹

Some studies found no significant association between sociodemographic factors and students’ perceptions and attitudes and orientation towards PC, including gender and previous experience of caring for PC and dying patients among UNSs^24,75 and UMSs. ¹⁰¹

Discussion

This international systematic review aimed to appraise existing research evidence on UNSs and UMSs knowledge, perceptions of and orientation towards PC and EOLC.

The review found insufficient knowledge about PC and EOLC despite training is common to nearly all the studies. Inadequate and inconsistent teaching and training on PC and EOLC, including in communication skills, is cited and/or appears to be the main perpetuating factor for this phenomenon, reported in numerous studies conducted with nursing^{3,40,93,102–104} and medical students,^44,105–107 as well as among qualified graduates.^108–110

Other contributing factors include paucity of expertise and role models to effectively teach and mentor students in PC and EOLC.^105,106,111 In particular, there is a recurrent theme in the literature about the training being predominantly theoretical and didactic with very limited, or virtually no attention and opportunities for simulated and experiential teaching and learning. Handling challenging conversations is a hardship and dilemmas for student participants in most, nearly all of the studies.^19,44,79 Very few studies report students possessed positive attitudes towards caring for palliative and dying patients, particularly in communication and relationship with patients.^58,82 These observations highlight major deficiencies in the design or adequacy and delivery of the curriculum and teaching. To foster appropriate attitude and skills development among trainees, the need for urgent reforms in curricula is imperative. In particular, teaching and training should integrate a blend of both theory- and practice-based approaches. The important role of curricula and training that combines simulated, real-world experiences and interactions with palliative and dying patients in improving and consolidating students’ grasp of PC and EOLC concepts, including developing appropriate knowledge, positive attitudes, self-efficacy, communication skills, patient management, emotional and self-awareness and confidence, and patient centredness has been emphasised by numerous studies.^{39,51,52,64,65,73,78,80,82,89} Watts ⁶¹ qualitative evidence revealed that interactive, reflective pedagogical approaches significantly increased nurse students’ confidence, high-order cognitive skills and critical thinking with sound clinical judgement in clinical practice.

Mastroianni et al. ¹¹² found training which integrates both theoretical and practical learning improves students’ knowledge and also their attitudes towards PC, death, dying and EOLC. In a prospective cohort study assessing the effectiveness of a PPC PBL among third-year American UMSs, Moody et al. ⁹⁰ reported improved knowledge, self-assessed competency and attitudes among the study participants. Findings are consistent with those of other earlier studies which reported PBL methods as effective for teaching PC to students.^113–115 In their study in the United States, Morrison et al. ⁸⁹ found UMSs pain knowledge improved after exposure to patients following an online pain module and reflective essay. A German study found UMSs whose encounters with patients and their caregivers went beyond a review of patients’ medical notes had a better understanding of the holistic approach of PC compared to their colleagues. ⁶⁴ These results corroborate the findings of numerous other studies.^{113,116–122} These studies, with their differing methodologies, add to the triangulation of findings. However, the time between the intervention and assessment of outcomes in these studies was predominantly short, which precludes longitudinal assessment of the impact of interventions (training) on outcomes, particularly knowledge, attitudes and confidence. It is also worth noting that the evidence is predominantly skewed towards high resourced settings.

Handling death work, performing tasks related to death and dying is a major challenge for students in this review. The students have negative views and inappropriate attitude towards caring for the seriously ill and the dying. To them, PC is a hard and emotionally demanding job and so they dislike it. Similar findings on fear and avoidance behaviours have been reported in studies elsewhere in UNSs and UMSs^{98,118,123–127} as well as among practicing health professionals.^7,99,104 The low number of studies reporting positive attitudes among UMSs could be explained by limited research on death and dying in UMSs. This begs the question whether curricula and training pay adequate attention to death education. It can be hypothesised that preference rates could even be lower among UMSs and UNSs in many parts of the world, especially in developing countries where barriers such as limited resources, research, training, prohibitive cultural beliefs and practices and limited recognition of the role of EOLC and PC are predominant. This underscores the urgent need for nursing and medical schools the world over to prioritise and strengthen death education but also introduce introductory and refresher training for those in practice.

Despite contradictory results from few studies which found no significant relationship between exposure to death work and attitude and confidence towards EOLC,^50,60 several studies emphasise that exposure to death work and prior clinical experience improve students’ confidence and positive attitudes towards care for the dying.^59,128–132 These differences in observations could be explained by variations in sociocultural norms, teaching and training, cultures of care, as well as sampling and the methodological designs used. Research suggests appropriate education is a good way to enable students to develop an appropriate understanding of death work including recognition of death as a natural life process.^{7,88,133–135}. Mastroianni et al. ¹¹² argues attitudes towards PC, death and EOLC are psychological and are learned as part of a person’s social and cultural experiences, and as such they can be influenced by education, training and encounters in the clinical settings.

This review has found limited research among key populations such as children and young people^{47,67,74,90,91} and persons living with dementia. ⁷⁷ This presents a critical evidence gap and raises the question whether this stems from deficiencies in the curricula or it is just that research is not prioritising these special populations. Furthermore, the wide disproportionate distribution of the research with as many as 56 of the 64 studies (88.5%) located in high-income and upper middle-income countries with just one study in Africa is a worrying observation. Low- and middle-income countries shoulder the greatest unmet need for PC, hence it is imperative there should be research to inform their evidence base. That is to say, research is needed to inform the design of curricula to adequately prepare and empower future nurses and doctors for their job role, including caring for PC and EOLC patients including special or key populations.

Some of the observations in this review are striking. Dobrowolska et al. ⁷ in their study of predicted difficulties, educational needs and interest in working in EOLC among UNSs and UMSs in Poland found medical students were more interested in curing than in caring. Similar finding was reported by Jeffers and Ferry among nursing students in the United States. ⁹⁹ The urge and preference to cure could explain a knowledge gap and a lack of understanding of the important holistic, person-centred nature of PC and EOLC. The review has also identified that a students’ interest in PC might be influenced by their profession, for example, Dobrowolska et al. ⁷ found UNSs demonstrated significantly lower interest in receiving training in PC than their medical colleagues.

Limitations and strengths of this review

This review has a few limitations. First, only four databases were searched for articles published and the articles are all in English. It is hypothesised that some eligible articles published in other databases and languages could have been missed. Nonetheless, the review searched credible and broad databases so it is likely very few articles published elsewhere were missed. Second, owing to heterogeneity in the data due to diverse study designs, methodologies and outcome measures used in the studies, meta-analysis was not feasible, which could potentially limit deeper analysis and understanding of the findings.

However, this review has noteworthy strengths. First, the rigorous literature search, appraisal, syntheses and integration with a clear and detailed audit trail and transparent reporting of results enhance the interpretation as well as clarity, auditability and credibility of the review results. Second, this systematic review integrates data from studies with various methodologies, aiding triangulation of the results. Third, the international nature of the review provides a reasonable generalisable picture of available evidence and evidence gaps on the topic, laying a foundation for future research. For example, the disproportionate concentration of research evidence in high resourced parts of the world identified in this review highlights an urgent need for investment and prioritisation of research to build an evidence base in LMICs. Moreover, the latter shoulder the hugest burden of unmet need for PC globally.

Conclusion

This review found that students’ knowledge levels of PC are predominantly low with rates ranging from 5% to 61% across different regions of the world, including in HMICs regions like the United States, Canada, Europe and Asia.

Similarly, nursing and medical students’ perceptions and orientation towards PC are rated with scores ranging from poor to low in most of the studies with participants manifesting low self-efficacy in providing PC and EOLC, that is, unpreparedness, unwillingness and incompetence in areas such as pain and symptom management, and communication skills, particularly in handling challenging conversations with patients and families.

There is a dearth of documented research from Africa on the topic with only one study identified in this review. The little research that exists is concentrated in HICs and MICs. There is need for more research studies with emphasis on LMICs, including studies which use interventional, longitudinal, evaluation and qualitative designs. Qualitative research (grounded theory) should examine how sociocultural variables, such as religion and gender, influence students’ knowledge, attitudes and orientation towards PC and EOLC.

Inadequate, limited and/or inconsistent curricula and training content about PC and EOLC is a common theme in the literature, including in studies undertaken in upper MICs and in HICs. There is need for regular review of curricula to ascertain their adequacy in meeting learners’ training needs.

Furthermore, more emphasis is needed on death education, including handling challenging or conversations to orientate and empower future doctors and nurses to be able to do death work rather than shunning it. There is need for educational institutions and other stakeholders to ensure those who teach PC receive appropriate and adequate training to empower them also. The mode of instruction should be more comprehensive, integrating various pedagogical approaches such as simulation and PBL as well as practical, case studies and field attachments in cancer, palliative and hospice care settings. The latter will allow trainees to gain exposure and experience learning in a real-world environment rather than relying on theoretical teaching and knowledge.