Nurse Education Today 131 (2023) 105981

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Research article

The Death Café: Effectiveness of a hospice care educational program for

nursing undergraduates based on LIFE experience—A qualitative study
Jingjun Wang 1, Chen Qiu 1, Lin Zhou, Xuehua Huang, Xiaolin Li *
West China School of Medicine/West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Nursing students' knowledge of hospice care is limited to textbooks due to the inadequate education
Hospice care and training system in China and student's willingness to participate in hospice care.
Nursing students Objectives: To deepen nursing students' understandings toward life and death, to improve their knowledge about
Nurse education
hospice care, and to promote their willingness for hospice care practice.
Content analysis
Design: This study used a qualitative descriptive study design.
Settings: The study was conducted at a medical university in Sichuan province, China.
Participants: 71 nursing sophomores participated in this study.
Methods: The Death Café teaching program was implemented which requires students to recall their memories
about death and to imagine how they felt about dying, as if they were having a conversation in a death-themed
café. During the implementation phase, a small-group interactive teaching approach was utilized. During the
reflection phase, the students were asked to finish an essay answering four questions without standard right
answers. The essays that students finished were used for evaluating the effectiveness of the Death Café program.
The answers of the first two questions were presented as a word cloud. Graneheim and Lundman's qualitative
content analysis method was used to analyze answers of the third and fourth questions.
Results: Word cloud analysis indicated that at the beginning of the program participants showed more negative
emotions (i.e., fearful). Students' attitudes toward death changed from negative to positive through imagining
death when role-playing the different stages of life. The program enhanced students' understanding of life and
taught the students effective ways to cope with death. Students clarified the objectives and necessary preparation
for providing hospice care and gained new understandings for improving their hospice skills.
Conclusions: The Death Café program can address students' negative emotions and perceptions of death. Students
gained personal benefits and professional benefits of coping with life and death from the program.

1. Introduction of nursing students to engage in hospice care (Zhang et al., 2022). Since
undergraduate nursing students are the major source of hospice care in
Hospice care was first proposed by Dr. Saunders in the 1960s, which the future, it is essential to develop education and training programs for
evolved into a subdiscipline of modern healthcare (Lu et al., 2018). nursing undergraduates.
Hospice care is defined by the World Health Organization (WHO) as the
provision of active and comprehensive care for people who are termi­ 2. Background
nally ill and not responding to curative treatment. Implementing effec­
tive hospice care could improve quality of life and psychological status According to the Seventh National Census Report published in 2022,
of people who are dying and their relatives (Deng et al., 2015). there are a total of 13.5 % of older people aged 65 and above in China, an
Hospice care has been developing rapidly in China in recent years, increase of 4.87 % compared to 2010 (National Bureau of Statistics of
yet many issues exist (Ling et al., 2020). Systematic hospice care edu­ China, 2022). Demand for hospice care in China is constantly rising
cation for nursing students is inadequate, resulting in a low willingness (Chen et al., 2022). Approximately 7.5 million deaths occur in China per

* Corresponding author at: No. 37, Guoxue lane, Wuhou District, Chengdu, China.
E-mail address: [email protected] (X. Li).
1
Jingjun Wang and Chen Qiu are considered co-first authors of this study.

https://doi.org/10.1016/j.nedt.2023.105981
Received 14 March 2023; Received in revised form 29 August 2023; Accepted 1 October 2023
Available online 5 October 2023
0260-6917/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
J. Wang et al. Nurse Education Today 131 (2023) 105981

year, with approximately 80 % (6.0 million) of people requiring hospice understanding toward hospice care, and to clarify the directions for
care (Xie et al., 2020). providing effective hospice care. It also aimed to inspire students to
To date, China has made great progress in promoting the develop­ recognize the meaning of life and to live in the present.
ment of hospice care, however, the resources for hospice care are still
inadequate. The quality of death index posted by the Economist Intel­ 3. Methods
ligence Unit indicates that China is in the bottom 10 among 80 countries,
which reflects the inadequacy and low quality of hospice care (Zhu et al., 3.1. Study design
2021). A total of 2342 healthcare institutions in China were equipped
with hospice care departments in 2019 (Chen et al., 2022). However, the This study adopted a qualitative descriptive study design based on
proportion of hospice care coverage is only 1 % (World Health Orga­ qualitative content analysis. Word clouds and Graneheim and Lund­
nization, 2008). The development of hospice care in China is also limited man's qualitative content analysis method was utilized in the study to
by inadequate educational systems (Lu et al., 2018). interpret nursing students' experience in the Death Café program (Gra­
In 2008, hospice care in the United States was defined as a sub- neheim and Lundman, 2004).
specialty affiliated with several specialties, and equipped with its own
specialized theoretical and practical systems in 2008 (Lamba et al.,
3.2. Participants and data collection
2016). Practitioners have to complete clinical practice within a certain
amount of time as well as pass related exams to obtain qualifications in
At study commencement, a total of 82 students participated in the
hospice care (Quest et al., 2009). However, current hospice care courses
Death Café program. To ensure the rigor of this study, strict inclusion
in China are mostly offered as an elective course or just added as a single
criteria were adopted: (1) students who were 18 years older; (2) students
chapter in textbooks (Zhang and Tang, 2017).
without cognitive impairment, psychological disorders, and severe so­
Hospice care is not well understood by health professionals or the
matic diseases; (3) students who volunteered to participate in this study;
public in China (Li et al., 2022). A qualitative study reported that many
(4) students with good engagement and a satisfactory ability of
nursing students have only heard about hospice care once or twice, and
communication and expression during participating in the program.
they have rarely experienced professional hospice care education (Li
Data from 11 students who did not meet the inclusion criteria were
et al., 2022). Nurses spend more time with people who are dying and
removed. A total of 71 students participated in this study. The process of
their relatives compared to other health professional staff and their
sample selection is shown in Fig. 1 (Fig. 1).
perceptions toward hospice care are reflective of service quality (Kwon
All participants were informed that they were free to withdraw at
et al., 2021). Nursing students are the main source of future hospice care
any time without any ramifications. Informed consent forms were signed
practice, it is essential to deepen students understandings toward hos­
by all participants. The students were guaranteed that their anonymity
pice care and to be aware of the professional qualities and specific in­
and confidentiality would be protected. The Ethics Committee of West
terventions required for practicing hospice care (Li et al., 2022).
China Hospital Sichuan University approved the present study: No:2023
Compared to senior nursing students, nursing sophomores are not well
(83).
educated in theoretical and practical components of hospice care
(Wallace et al., 2009). During the four years of undergraduate educa­
tion, sophomore nursing students have accumulated basic nursing 3.3. Procedures
knowledge, and have ample time for subsequent hospice education.
Therefore, this program was developed as a teaching program based on 3.3.1. Implementation phases
the cognitive level of sophomore nursing students.
The Death Café program aimed to deepen nursing students' (1) Grouping the students: there were 82 students who initially
participated in the Death Café program. (Data were drawn from

Fig. 1. Sampling process.

2
J. Wang et al. Nurse Education Today 131 (2023) 105981

71 students who met the inclusion criteria). The students were content analysis in question (4): capacities required by hospice care, and
divided into 8 groups of 9–11 participants. Each group was led by concrete interventions of hospice care (Table 1).
an instructor. A group of students were further divided into 3–4
subgroups of 2–3 participants for each activity. 4.1. Emotional responses toward to the program
(2) The instructors' guide and demonstration: before the program
was conducted, each instructor introduced the background and The corpus consisted of 71 texts, a total of 98 emotional words were
contents of the Death Café program. mentioned. The words with the highest appearance were fearful (N =
(3) Lifeline drawing: all participants were asked to draw a lifeline on 25) and sad (N = 21). A few positive emotions also emerged such as
the ground, marking the time points of 30 years old, 60 years old, peaceful (N = 1) and relieved (N = 2). More details are shown by the
80 years old, and the terminal stage. word clouds in Fig. 2.
(4) Experience sharing: one student from each subgroup was selected
to go along the lifeline, while the other members of the subgroup
4.2. Attitudes toward death at specific timepoints
accompanied and listened. At the start point, the student recalled
and shared experiences or events related to death that they
As the students imagined they became older, the proportion of stu­
experienced. Moving forward along the lifeline at different age
dents who held positive attitudes increased while the proportion of
points, participants were asked to share the feelings about death
students who held negative attitudes reduced (Fig. 3).
at the specific moments. The roles of sharing and listening
exchanged followed the same process.
4.3. Understandings toward life and death
3.3.2. Participants' feedback and reflection phase
After completing the activity, students were asked to finish an essay Students' understanding of the meaning of life was deepened by
named “the meaning of life”, and answer the questions below: participating in the Death Café program. In addition, students also
learned strategies for coping with death effectively from this program.
(1) Have you ever had a moment when your life was threatened, or All details are demonstrated in Table 1.
experienced the death of a significant loved one? Please sum­
marize the emotional responses at these moments in three words. 4.3.1. Views of the meanings of life
(2) How do you feel about death when you walked into the 30, 60, Some students felt that the meaning of life focused on themselves, for
80 years old, and the terminal stage? If possible, please select examples, the meaning of life focused on life experience, pursuit of
words from negative, positive, or neutral perspectives, to describe pleasure, or self-actualization, while others felt that the meaning of life
the feeling about life ending at the specific moments respectively. focused on connections with others or society, for examples, the
(3) Could you please share your understandings toward life and meaning of life placed an emphasis on the maintenance of a central
death? relationship or social-contribution.
(4) After this program, what can you do for hospice care? Students believed at a certain point in life it will surely bring
meaning to your life: An experience, we feel it with our hearts, we cried, we
3.4. Data analysis laughed, the weight of life is growing (participant 10). Others stated that the
meaning of life places an emphasis on self- actualization. Maslow's hi­
The emotional responses that students reflected in questions (1) and erarchy needs theory stated that self-actualization is the highest level of
question (2) were presented as word clouds to emphasize the frequency need of an individual. Some indicated that life is meaningful as long as
of each keyword that students mentioned. Feedback from students on
the third and fourth questions were analyzed by Graneheim and Lund­ Table 1
man's qualitative content analysis method through defining meaning Personal and occupational benefits from the Death Café program.
units, condensed meaning units, codes, subcategories, categories, and Questions Categories Coding
themes. Each meaning unit was condensed and assigned a code, then
Question Views of the meanings of Life experience
sorted into subcategories. Categories were formed by grouping all the 3 life Self-contribution
subcategories. Finally, themes were developed. Data were analyzed Relationship maintenance
using NVivo 12.0 software. Pursuit of pleasure
Self-actualization
Coping measures with Cherishing the present
3.5. Trustworthiness death Preparing in advance
Contributing oneself
To achieve research credibility, an adequate number of participants Question Capacities required by Empathy ability
with death-related experiences were included according to the inclusion 4 hospice care Observation ability
Stress management
criteria. For dependability, all researchers engaged in data analysis were
Professional knowledge
senior nurses in hospice and psychological care. Students' feedback Positive concepts of life and death
submitted at the reflection phase were required to be completed within Professional ethics
48 h after the program to reduce time bias. Transferability was achieved Concrete interventions of Providing appropriate environment
through a broad sample size and precise description of the participants hospice care Assessing the patient's psychological
status
experiences. Accompanying and supporting the
terminal patients
4. Results Listening to the patients
Adjusting patients' emotions
Implementing death educations
71 sophomore nursing students participated in this study. The word
Educating and taking care of relatives of
cloud analysis in questions (1) and (2) demonstrated a change in stu­ the terminal patients
dents' attitudes toward death from 30 years old to the terminal stage. Implementing spiritual care
The results of qualitative content analysis in question (3) contained two Offering physical care
categories: views of the meaning of life and coping measures to death. Promoting the development of hospice
care
Similarly, two categories were contained in the results of qualitative

3
J. Wang et al. Nurse Education Today 131 (2023) 105981

Fig. 2. Emotional response.

Fig. 3. Transformation of attitudes at specific moments.

they can spend life happily: I think living happily is the meaning of life cope with the death. Since death is inevitable, it is better to cherish the
(participant 60). moment and use the limited time to accomplish more things without
Opinions of the meaning of life focused on connections with others or regrets: I will use this limited time to accompany my relatives and take
the society. Some students argued that the meaning of life is relationship advantage of the youth. (participant 1).
maintenance: The meaning of life is spending good moments with loved ones Regarding preparing death in advance, participant 22 argued: We
within a limited time (participant 1). Meanwhile, participant 4 said: can spend a decade or two after retirement to adjust our mindset. So that we
Contributing to society as much as possible can make life more meaningful. can leave gracefully at the end of our lives. It is feasible to prepare to die in
This group of students argued that life is meaningful as long as one advance. When the moment really comes, face it with a calm mind.
contributes to others or society. In addition, some students indicated that as long as you can make a
contribution to others or to this society, even if you unfortunately pass
4.3.2. Coping measures to death away one day, the impact you have made on others will still be there: I
Some students considered that they would cherish the present to registered as a Chinese human organ donor in the hope that my body can

4
J. Wang et al. Nurse Education Today 131 (2023) 105981

shine a light for people who are trying to survive in the cracks (participant 4). 5. Discussions

This study introduced a short-term educational program, which

4.4. What can you do for hospice care aimed to enhance the understandings toward hospice care among
nursing sophomores through focusing more on the students' experience
Students indicated that their understanding of the critical capacities and allowing them to consider how to provide effective hospice care
required for hospice care deepened. They stated that they also gained from a person's perspective, rather than teaching hospice skills directly
new insight into the nursing interventions needed for implementing to the students. A mini-classes curriculum method was utilized. This
hospice care. All details are demonstrated in Table 1. study allowed students to provide feedback through an open-ended
question format. The results of this study indicated that the percep­
4.4.1. Capacities required by hospice care tions to death and life among the students demonstrated a significant
Some students indicated that nurses need to empathize with their improvement. Most importantly, the understandings of hospice care
patients and offer the hospice care that people require rather than among the students were deepened on multiple levels.
provide care indifferently: I believe that the patients in the terminal stage
are the same as I was at that time, so I need to empathize with them 5.1. Emotional responses of the students
(participant 14).
Observation ability is necessary for hospice care. Nurses should pay According to the results of word cloud analysis, the proportion of
close attention to the patients' physical and psychological status. Par­ students who held a negative attitude toward death decreased from 30
ticipants 12 argued: I feel that I should observe closely to prevent unexpected to the terminal stage. Constantly, the proportion of positive attitude is
tragedies. enhanced.
Various negative psychological responses of nurses might emerge Since the participants were all sophomores, they may be relatively
when implementing hospice care. Students indicated that nurses should inexperienced in dealing with death. When their life was threatened by a
be equipped with effective stress management ability to withstand risk of death, they might intuitively demonstrate negative emotions.
multiple stresses: I think as health care professionals we should improve our Similar results have been obtained in previous studies, for example,
quality to bearing pressure (participant 12). Sharma et al. (1996) suggested that compared to senior students, junior
Nurses may encounter a number of ethical issues in providing hos­ nursing students were more fearful when they confront death.
pice care to patients. Students indicated that a positive concept of life As the program progressed, participants “experienced” more life
and death and professional ethics are demanded: Staff should establish a events from their own imagination and other's sharing and students'
correct concept of life and death to guide patients on how to face death attitudes also changed. The results were supported by a previous study
(participant 39). Participant 49 indicated: Nurses need to embrace noble which found that nursing students' attitude toward death significantly
professional ethics. changed from negative to positive after appropriate guidance. This il­
Students also indicated that nursing staff need to improve their lustrates the importance of guiding nursing students to face death events
professional ability, master the expertise of related diseases: As a student, (Berndtsson et al., 2019).
I should learn more professional knowledge about hospice care (participant
67). 5.2. Personal benefit gained from the program

4.4.2. Concrete interventions of hospice care A sense of meaning in life is the degree to which an individual is
Students argued that appropriate environments are required: Ensure aware of the meaning and purpose of his or her life. It is a subjective
that the ward is clean, and create a relaxing environment (participant 59). evaluation of whether his or her life is meaningful (Yu et al., 2022).
Nurses should pay attention to the patient's physical and mental Content analysis indicated that participants obtained new understand­
state, in which the nurse is required to assess the patient's psychological ing of the meaning of life. Enhancing nursing students' sense of meaning
condition, listen to the patients, accompany and support the patients, of life is crucial to their professional development. The World Health
and adjust the patient's emotions. A student indicated: Observe the pa­ Organization suggested that the meaning of life is an essential predictor
tient's psychological state and prevent accidents during this period as well of the cultivation of the professional calling among students (Cheng
(participant 40), while another student argued: Understand their negative et al., 2021). Previous authors suggested that nursing students' percep­
emotions at the moment, and don't accuse the patient of their inappropriate tions of hospice care are affected by the perceived meaning of life (Yu
comments, just listen to them (Participant 45). et al., 2022).
The students believe that death education should be an essential part Death coping capacity refers to the positive adaptive behaviors that
of hospice care. Participant 20 said: We should also guide patients to face individuals adopt when they are exposed to stressful death situations
death correctly and help them to recognize that death is a fact that must be (Nmimeyer, 1994). Coping with death includes three types: coping with
experienced, but in a different order. Most relatives of the dying patients all human beings' death (for instance, all people around the world die),
will go through a tough process. Students argued that nurses are sup­ coping with other's death (for instance, someone I knew died), and
posed to assist families: When patients are dying, their family members will coping with one's own death (for instance, when I knew that I was going
suffer from psychological burdens, care for them is required (participant 49). to die). For nurses, coping with death involves coping with the death of
In addition, some patients may have unique religious beliefs, in patients and coping with the nurses' own death (Yan, 2021). Previous
which case the nurse should respect the patient's religious beliefs. A studies mainly focused on how nursing students cope with patients'
students said: Nurse should respect the patient's religious beliefs, meet their death, but ignored the perception of their own and relatives' death issue
requests appropriately (participant 2). Physical care for dying patients (Yan, 2021). However, previous studies have shown that nurses' atti­
were also mentioned: The patient's pain and discomfort should be alleviated tudes about their own mortality significantly affect the quality of care
(participant 28). they provide (Gurdogan et al., 2019). Excessive anxiety about one's own
Apart from routine physical and psychological care, some of the death leads to avoidant nurse-patient interaction, which prevents nurses
students mentioned that it is essential to promote the development of from empathizing with patients and their families (Buzgova and Jan­
hospice care in China. The students identified that enhancing the pub­ ikova, 2019). Reducing nursing students' own death anxiety contributes
lic's and health staff's awareness of hospice care is necessary: We are to positive attitudes toward hospice care (Buzgova and Janikova, 2019).
granted to make effort for promoting the development of hospice care in This also confirms the importance and necessity of including the Death
China. Café program in undergraduate nurse education. In this study,

5
J. Wang et al. Nurse Education Today 131 (2023) 105981

participants shifted from being fearful and helpless about death before Ethical approval
participating in the program to acquiring effective death coping capa­
bilities when the Death Café program ended. The participants' opinions The Ethics Committee of West China Hospital Sichuan University
of hospice care also renewed. approved the present study: No:2023(83).

Fundings
5.3. Occupational benefit gained from the Death Café program
This work was supported by the West China Nursing Discipline
For nursing students, identifying the competencies needed for hos­ Development Special Fund Project, Sichuan University (Grant No:
pice care in the future and targeting self-improvement of hospice care HXHL21012).
skills are essential to becoming a professional nurse (Cerit, 2019). After
the program, students become more conscious of personal competencies CRediT authorship contribution statement
which is needed to provide effective hospice care. For example, empathy
ability, professional knowledge, stress management and professional Jingjun Wang: Formal analysis, Conceptualization, Investigation,
ethics were mentioned, which the importance has been validated by Writing original draft.
previous studies (Chen et al., 2022). The findings provide new directions Chen Qiu: Methodology, Formal analysis, Writing original draft,
for nursing students to improve themselves in a follow up study, for Writing - Review & Editing.
instance, in the clinical skills training programs for hospice care. Lin Zhou: Visualization, conceptualization.
Students stated that an appropriate treatment environment should be Xuehua Huang: Methodology, Investigation.
provided for people who are dying. Providing an appropriate physical Xiaolin Li: Formal analysis, Conceptualization, Investigation,
environment, for example, ensuring proper hygiene, proper tempera­ Supervision.
ture, helps to improve quality of life of the people who are dying (Zadeh Jingjun Wang and Chen Qiu contributed equally to this study.
and Eshelman, 2019). People who are dying often suffer from severe
pain, respiratory distress, etc. Management and care of physical symp­
toms is also essential (Perone et al., 2018). Students indicated that Declaration of competing interest
hospice care is comprehensive for the people who are dying and their
families, including somatic care and psychological interventions. Psy­ None.
chological care and assessing a person's psychological status and the
other psychological supports were mentioned by the students. A quali­ Acknowledgements
tative study of terminally ill people noted that they often suffer from
loneliness, depression and feelings of abandonment, and that they The authors wish to thank the study participants for their contribu­
perceive themselves as a burden to their families and feel lack of dignity tion to the research, as well as current and past investigators and staff.
(Perone et al., 2018). It is essential to provide effective psychological
support. Appendix A. Supplementary data
Notably, some students suggested that nursing students are also ex­
pected to contribute to the development of hospice care in China. Supplementary data to this article can be found online at https://doi.
Compared with certain developed countries, hospice care in China is in org/10.1016/j.nedt.2023.105981.
the initial stage (Lin et al., 2022). Since death is a relatively taboo topic
in China, the public's awareness of hospice care is relatively lower than References
countries such as England and the United States (Ni et al., 2019).
Accepting hospice care is always viewed as an abandonment of treat­ Berndtsson, I.E.K., Karlsson, M.G., Rejno, A.C.U., 2019. Nursing students’ attitudes
ment in the context of Chinese culture compared to painful treatments, toward care of dying patients: a pre- and post-palliative course study. Heliyon 5 (10),
e02578. https://doi.org/10.1016/j.heliyon.2019.e02578.
resulting in a lower acceptance of hospice care (Lin et al., 2022). Buzgova, R., Janikova, E., 2019. Czech adaption of the collett-lester fear of death scale in
Enhancing public awareness of hospice care and promoting its devel­ a sample of nursing students. Omega-J. Death Dying 80 (1), 20–34. https://doi.org/
opment is necessary. 10.1177/0030222817725183.
Cerit, B., 2019. Influence of training on first-year nursing department students’ attitudes
on death and caring for dying patients: a single-group pretest-posttest experimental
study. Omega-J. Death Dying 78 (4), 335–347. https://doi.org/10.1177/
5.4. Limitation 0030222817748838.
Chen, L., Li, X.H., Pan, X., Pan, Q.N., Huang, H.Q., Tao, P.Y., Li, G.Y., Ma, J.H., Huang, J.
C., 2022. Nurses’ knowledge, attitudes, and willingness to practice hospice care: an
This study has several limitations. A qualitative evaluation approach analysis of influencing factors. PLoS One 17 (2), e0259647. https://doi.org/
was used to assess student benefits in the present study. For subsequent 10.1371/journal.pone.0259647.
studies, quantitative evaluation methods could also be involved. Sec­ Cheng, L., Chen, Q., Zhang, F., 2021. Mediating effects of meaning in life on the
relationship between general self-efficacy and nursing professional commitment in
ondly, the current program was developed for sophomores majoring in nursing students a structural equation modeling approach. Medicine 100 (29),
nursing. We also plan to develop an educational and training program of e26754. https://doi.org/10.1097/md.0000000000026754.
hospice care for broader participants. In future studies, broader nursing Deng, D., Lin, W., Law, F., 2015. The study on evaluation and improvement of quality of
life in patients with advanced cancer by China’s hospice program. Am. J. Hosp.
students and clinical nurses could be included. Palliat. Med. 32 (4), 365–371. https://doi.org/10.1177/1049909114523331.
Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research:
concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today
6. Conclusions 24 (2), 105–112. https://doi.org/10.1016/j.nedt.2003.10.001.
Gurdogan, E.P., Kinici, E., Aksoy, B., 2019. The relationship between death anxiety and
The Death Café program can improve students' negative emotions attitudes toward the care of dying patient in nursing students. Psychol. Health Med.
24 (7), 843–852. https://doi.org/10.1080/13548506.2019.1576914.
and perceptions about death, deepen their perception of the meaning of
Kwon, S.H., Park, M.H., Kim, H.S., 2021. Education, role, and prospects of advanced
life, and strengthen their coping ability with death. In addition, this practice nurses in hospice and palliative care in South Korea. J. Hosp. Palliat. Care
program provides students with a clearer understanding of the services 24 (1), 1–12. https://doi.org/10.14475/jhpc.2021.24.1.1.
needed by people who are terminally ill through an imaginative Lamba, S., DeSandre, P.L., Quest, T.E., 2016. Opportunities and challenges facing the
intergrated physician workforce of emergency medicine and hospice and palliative
approach and provides a new direction for students to enhance their medicine. J. Emerg. Med. 51 (6), 658–667. https://doi.org/10.1016/j.
profession later on. jemermed.2016.06.056.

6
J. Wang et al. Nurse Education Today 131 (2023) 105981

Li, S., Zhang, Z., Zhang, X., 2022. A qualitative study exploring nursing students' knowledge and perceptions. J. Prof. Nurs. 25 (1), 50–56. https://doi.org/10.1016/j.
perspectives on and attitudes towards hospice care in China. Nurse Educ. Today profnurs.2008.08.003.
105384. https://doi.org/10.1016/j.nedt.2022.105384. World Health Organization, 2008. Palliative care definition. Retrieved from.
Lin, H., Ko, E., Wu, B., Ni, P., 2022. Hospice care preferences and its associated factors http://www.who.int/cancer/palliative/en/index.html,2008-08-30 (Accessed 02. 08.
among community-dwelling residents in China. Int. J. Environ. Res. Public Health 19 2023).
(15), 9197. https://doi.org/10.3390/ijerph19159197. Xie, Y., Xu, Y., Yang, S., Yan, J., Jin, X.Q., Liu, C., 2020. Investigation of the awareness of
Ling, M., Wang, X., Ma, Y., Long, Y., 2020. A review of the current state of hospice care in and demand for hospice care and attitudes towards life-sustaining treatment at the
China. Curr. Oncol. Rep. 22 (10), 99. https://doi.org/10.1007/s11912-020-00959-y. end of life among community residents in Hangzhou. BMC Palliat. Care 19 (1), 128.
Lu, Y., Gu, Y., Yu, W., 2018. Hospice and palliative care in China: development and https://doi.org/10.1186/s12904-020-00628-8.
challenges. Asia Pac. J. Oncol. Nurs. 5 (1), 26–32. https://doi.org/10.4103/apjon. Yan, W., 2021. Effectiveness of lecture-simulation-combined palliative care course to
apjon_72_17. improve nursing students' knowledge, attitude and coping. Int. J. Inf. Educ. Technol.
National Bureau of Statistis of China, 2022. Statistical Bulletin of the People's Republic of 11 (4), 171–177. https://doi.org/10.18178/ijiet.2021.11.4.1507.
China on National Economic and Social Development in 2020. Retrieved from. http: Yu, H., Sun, C., Xie, L., Wang, L., Song, J., Zhu, Y., Xiao, R., Lowe, S., Bentley, R.,
//www.stats.gov.cn/tjsj/pcsj/rkpc/7rp/indexch.htm. Zhou, D., 2022. Using a mediating model of death attitude and meaning in life to
Ni, K., Gong, Y., Li, F., Cao, X., Zhang, H., Chu, H., Li, T., Mairipaiti, A., Zhao, Y., Li, N., understand nursing students attitude about hospice care. Nurse Educ. Today 116,
2019. Knowledge and attitudes regarding hospice care among outpatients and family 105448. https://doi.org/10.1016/j.nedt.2022.105448.
members in two hospitals in China. Medicine 98 (16), e15230. https://doi.org/ Zadeh, R.S., Eshelman, P., 2019. Palliative design meets palliative medicine: a strategic
10.1097/md.0000000000015230. approach to the design, construction, and operation of healthcare facilities to
Nmimeyer, R.A., 1994. Death Anxiety Handbook: Research, Instrumentation, and improve quality of life and reduce suffering for patients, families, and caregivers.
Application. Taylor & Francis, Philadelphia. Herd-Health Environ. Res. Des. J. 12 (3), 179–186. https://doi.org/10.1177/
Perone, S.A., Nikolic, R., Lazic, R., Dropic, E., Vogel, T., Lab, B., Lachat, S., Hudelson, P., 1937586718820663.
Matis, C., Chappuis, F., 2018. Addressing the needs of terminally-ill patients in Zhang, X.F., Tang, S.Y., 2017. Advances in hospice education and training research.
Bosnia-Herzegovina: patients’ perceptions and expectations. BMC Palliat. Care 17, J. Chinese Gerontol. 37 (09), 2333–2336.
123. https://doi.org/10.1186/s12904-018-0377-2. Zhang, X., Zhang, X., Li, Y., Chen, T., Siow, L., Ye, X., Wang, Y., Wang, Y., Ming, W.,
Quest, T.E., Marco, C.A., Derse, A.R., 2009. Hospice and palliative medicine: new Wu, J., 2022. What are the acceptances and associated influences of hospice care in
subspecialty, new opportunities. Ann. Emerg. Med. 54 (1), 94–102. https://doi.org/ Mainland China? A national cross-sectional study. Front. Public Health 10, 985218.
10.1016/j.annemergmed.2008.11.019. https://doi.org/10.3389/fpubh.2022.985218.
Sharma, S., Monsen, R.B., Gary, B., 1996. Comparison of attitudes toward death and Zhu, S., Zhu, H., Zhang, X., Liu, K., Chen, Z., Yang, X., Sun, C., Xie, W., Xu, Q., Li, W.,
dying among nursing majors and other college students. Omega-J. Death Dying 34 Pang, D., Cui, Y., Wang, H., 2021. Care needs of dying patients and their family
(3), 219–232. https://doi.org/10.2190/wnx7-nfya-mfe9-y064. caregivers in hospice and palliative care in mainland China: a meta-synthesis of
Wallace, M., Grossman, S., Campbell, S., Robert, T., Lange, J., Shea, J., 2009. qualitative and quantitative studies. BMJ Open 11 (11), e051717. https://doi.org/
Intergration of end-of-life care content in undergraduate nursing curricula: student 10.1136/bmjopen-2021-051717.