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Hökkäetal. BMC Palliative Care (2022) 21:40
https://doi.org/10.1186/s12904-022-00915-6
RESEARCH
Finnish nursing students’ perceptions
ofthedevelopment needs inpalliative care
education andfactors inuencing learning
inundergraduate nursing studies – aqualitative
study
Minna Hökkä1,2*, Juho T. Lehto3,4, Helvi Kyngäs1 and Tarja Pölkki1,5
Abstract
Background: Nurses have an essential role in providing high-quality palliative care to patients and their families.
Hence, they require adequate palliative care education. However, there is only limited insight into how final-year
nursing students perceive palliative care education in undergraduate nursing programs. This study aimed to describe
nursing students’ perspectives of the development needs of palliative care education. An additional two aims
emerged based on the collected data, namely, to describe the preferred education for palliative care and the factors
which promote or hinder palliative care learning during undergraduate nursing studies.
Methods: The research was guided by a descriptive qualitative approach and applied inductive content analysis. The
frequencies (f) of identified codes (reduced expressions) were counted to show the noteworthiness of each cat-
egory in relation to the entirety. The participants were final-year nursing students (n = 766) who had participated in a
national survey.
Results: The inductive content analysis identified three unifying categories. The first was ‘Development needs and
views of palliative care education’ (f = 524), which consisted of the main categories ‘the need to develop palliative care
education’ (f = 414) and ‘meaning of palliative care and its education’ (f = 110). Secondly ‘Preferred types of palliative
care education’ (f = 1379), including the main categories ‘teaching contents in palliative care education’ (f = 905),
‘teaching methods for palliative care learning’ (f = 393), and ‘placement of palliative care studies’ (f = 81). Thirdly ‘The
facilitators and barriers to palliative care learning’ (f = 401), consisting of the main categories ‘factors facilitating pallia-
tive care learning’ (f = 66) and ‘barriers to palliative care learning’ (f = 335).
Conclusions: This study provides detailed information about nursing student’s perspectives of palliative care educa-
tion and its development needs. Hence, the results are relevant to decision-makers who want to develop under-
graduate nursing curricula. This study highlights that palliative care education should be developed by ensuring that
all students have equal access to palliative care education provided by highly competent teachers. Possibilities for
clinical placements or visits to palliative care units during the education should also be improved. The participating
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Open Access
*Correspondence: minna.hokka@kamk.fi
1 Faculty of Medicine, Research Unit of Nursing Science and Health
Management, University of Oulu, PO BOX 5000, 90014 Oulu, Finland
Full list of author information is available at the end of the article
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Hökkäetal. BMC Palliative Care (2022) 21:40
Background
e need to develop palliative care education was
highlighted by the Council of Europe (CoE) during
an assembly in 2018. Access to palliative care should
be a human right and, therefore, the provision of pal-
liative care should be integrated into the health care
system [1]. Furthermore, education is one of the core
components in the World Health Organization’s public
health strategy to successfully integrate palliative care
into health care [2, 3] and has also been reported to
facilitate the development of palliative care [4]. Several
contemporary phenomena, i.e., an aging world popula-
tion, the increase in noncommunicable diseases, and
the emergence of novel viruses, recently highlighted by
the COVID-19 pandemic, demonstrate that there is an
immense demand for palliative care, which is expected
to double by 2060 [5].
Nurses, as the largest occupational group in health
care, have an essential role in ensuring high-quality
care [6]. Nurses are also the primary providers of pallia-
tive care for patients and their families in many differ-
ent contexts [6–8]. Hence, they should have sufficient
palliative care education and competencies to provide
high-quality palliative care [5, 9, 10].
To ensure that all nurses possess the required pallia-
tive care competencies, undergraduate nursing educa-
tion should cover palliative care [11, 12]. Nevertheless,
previous research has reported that undergraduate
nursing students lack competence to provide palliative
care [13, 14] and feel unprepared for palliative care and
encountering death [15–17].
e need to develop palliative care education has previ-
ously been highlighted [18]. For example, the European
Association for Palliative Care task force group published
a report focusing specifically on the development of palli-
ative care in nursing education [19]. Although this report
is known in the European countries, there is still large
variety in palliative care education both across and within
countries. Notably, over half of European countries (56%)
reported in a recent survey that palliative care was not a
mandatory subject in undergraduate nursing education
[20]. In Finland, universities of applied sciences (UASs)
largely vary in terms of how palliative care is covered in
undergraduate nursing programs. As a result, the recent
statement of the Ministry of Social Affairs and Health
includes recommendations for how Finnish nursing edu-
cation should be developed [21].
Previous evidence has shown that palliative care edu-
cation increases nursing students’ knowledge of pallia-
tive care and positively influences their attitudes towards
end-of-life care [18, 22–24]. Furthermore, palliative care
education promotes students’ personal growth and self-
awareness [25]. e need to integrate palliative care into
undergraduate education has been emphasized before,
with attempts at including this part of care into nursing
curricula intensifying during the last 10 years [18]. Nev-
ertheless, there is still an evident need to develop the
extent to which palliative care is integrated into under-
graduate nursing education [11, 18, 20, 21].
Most of the qualitative research on the topic of pal-
liative care in nursing education published in the last
10 years has focused on students’ experiences of differ-
ent teaching interventions, e.g., simulations or elective
courses [26, 27], and students’ perspectives or attitudes
towards end-of-life care or care for the dying patients
[28, 29]. To our knowledge, there is only limited quali-
tative evidence of final year nursing students’ per-
spectives of the development needs in palliative care
education in undergraduate nursing programs and how
this area of care could be better integrated into the nurs-
ing curriculum.
Methods
is study aimed to describe nursing students’ perspec-
tives of the development needs of palliative care edu-
cation. An additional two aims emerged based on the
collected data, namely, to describe the preferred educa-
tion for palliative care and the factors which promote
or hinder palliative care learning during undergradu-
ate nursing studies. e research applied a descriptive
qualitative approach with an inductive content analysis
method [30]. e intention of the study was to present a
comprehensive summary of the phenomenon of interest
without claiming any methodological roots [31].
Settings
e study was performed across all of the Finnish UASs
(n = 21) providing an undergraduate nursing program.
In Finland, all registered nurses are required by law to
have completed a Bachelor’s degree nursing program
from a UAS [32]. After graduation the registered nurses
need to apply for licensing to work as a nurse in Fin-
land. e Bachelor’s degree program lasts approximately
three-and-a-half years and comprises 210 European
students felt unprepared to provide high-quality palliative care even though they responded that palliative care is an
important topic in their nursing studies.
Keywords: Palliative care, Education, Nursing, Student
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Hökkäetal. BMC Palliative Care (2022) 21:40
Credit Transfer and Accumulation System (ECTS) cred-
its and fulfills the criteria of the European Union Direc-
tive 2013/55/EU [33]. e education includes 90 ECTS
of clinical training. e education is free-of-charge and
is funded by the Ministry of Culture and Education. e
nursing teacher’s educational requirements are also regu-
lated by law, e.g., they must hold a Master’s degree and
have at least 3 years of working experience in the nursing
field [34].
e UASs have autonomy in developing the under-
graduate nursing curriculum. However, criteria set by
the European Union [33] and a national consensus-based
report of nursing competencies published in 2015 [35],
and renewed in 2020 [36], serve as a framework for cur-
riculum development. e renewed report of compe-
tencies includes palliative care, which was not so clearly
addressed in the previous version. Registered nurses
can deepen their competencies according to their own
interests during their undergraduate nursing studies by
choosing courses in the limits of the curriculum. Still,
when graduating they all are registered nurses without
specialization.
Participant characteristics anddata collection
e data were collected as part of a larger national cross-
sectional survey that targeted undergraduate nursing stu-
dents. e inclusion criteria for participation were that
the student is in the final year of studies and is enrolled
in nursing degree program in a Finnish UAS provided
in either of the official languages in Finland (Finnish or
Swedish). Detailed participant characteristics are shown
in Table1.
Data collection ran from September 2018 to March
2019. e participants consisted of a convenience sam-
ple of final year nursing students studying in a UAS at
the time of data collection. Convenience sampling is a
commonly used sampling method when recruiting par-
ticipants from a particular setting. e sampling method
aims to provide a group of participants with experience
of the study phenomenon. In this study, the setting was
UASs and the participants were final year nursing stu-
dents, who had sufficient experience with nursing educa-
tion to evaluate the development needs of palliative care
education [31].
Each UAS named a contact person who would perform
the data collection. In 19 of the UASs, the contact per-
son (first author in two UAS) distributed the paper ques-
tionnaire to final-year nursing students during a teaching
session in a classroom, with the students answering the
questionnaire during this session. In two UASs, students
responded to the questionnaire online through a link
sent via email to the student group by the contact per-
son, with one follow-up message sent later to remind the
students to complete the questionnaire. An information
letter containing the study purpose, researchers’ contact
information, including a description of their occupation,
academic position, and interest in developing palliative
care education, was attached to the survey. e students
responded to the questionnaire completely anonymously,
with no personal data being collected and no prior rela-
tionship was established between the researchers and any
of the students.
e contact persons estimated that there were 1868
final-year students studying at the time when the ques-
tionnaire was provided to the student groups. A total of
1331 students gave an eligible response to the survey, of
which 766 (57,6%) answered the open-ended, qualitative
question included in this sub-study. e survey included
six background questions, questions of students view of
the palliative care contents provided in nursing studies
and their self-assessed competence about palliative care,
and an open-ended question: “Tell your thoughts on how
palliative care education should be developed”. e data
of this sub-study consisted of students written answers
to this open-ended question. e length of the students
written answers varied from one sentence to half of a
Microsoft Word A4 page. e questions were developed
by the authors. e clarity of the questionnaire was pre-
tested by one student group (n= 15), no amendments
were required based on the pretest. Information covering
the characteristics and relevant experience of the authors
can be found in Table2.
Data analysis
e qualitative analysis was performed by an inductive
content analysis method, in which categories emerge
from the data and no theoretical framework is used as
a starting point [30, 37]. e students’ responses (only
Table 1 Characteristics of the responding students
Number of respondents 766
Age in years, median (range) 25 (20–58)
Gender, n (%)
Female 678 (88.5)
Male 80 (10.4)
Did not define 8 (1.1)
Previous health or social care education, n (%)
None 432 (56.4)
Practical nurse 307 (40.1)
Other education 27 (3.5)
Previous work experience in social or health care, n (%)
None 273 (35.5)
Work experience 491 (64.3)
Unanswered 2 (0.2)
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Hökkäetal. BMC Palliative Care (2022) 21:40
Table 2 Researcher characteristics
Author (gender) Credentials, Occupation at the time of the study Education on qualitative research Experience in qualitative research
(MH) (female) RN (Master’s degree), MNSc, PhD-candidate
Head of School at a University of Applied Science Has completed formal qualitative research study modules at
Master’s and PhD levels. Has conducted qualitative research studies. Has taught qualita-
tive research methods. Has supervised Bachelor’s and Master’s
theses which have used qualitative research methods.
(JL) (male) MD, PhD, Professor in a University and Chief Physi-
cian in a University Hospital Has studied the principles and application of qualitative
research methods through informal learning activities. Has conducted qualitative research studies. Has experience in
developing measurement tools and questionnaires.
(HK) (female) RN, PhD, Professor in a University Has completed formal qualitative research methods educa-
tion at Master’s and PhD levels. Has conducted qualitative research studies. Has taught qualita-
tive research methods at Master’s and PhD levels. Has super-
vised Master’s and PhD theses which use qualitative research
methods. Has authored a textbook and conducted research
about content analysis as a research method. Has experience
in developing measurement tools and questionnaires.
(TP) (female) RN, PhD, Professor in a University Has completed formal qualitative research methods educa-
tion at Master’s and PhD levels. Has conducted qualitative research studies. Has supervised
Master’s and PhD theses which use qualitative research
methods. Has experience in building measurement tools and
questionnaires.
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Hökkäetal. BMC Palliative Care (2022) 21:40
manifest content) were analyzed to describe the phe-
nomenon of interest. Words, sentences, or phrases which
constructed a meaning were used as the unit of analysis
[30]. No software was used in the analysis process.
In the first phase of analysis, the data were tran-
scribed verbatim from the questionnaires to a Microsoft
Word template, after which the researchers carefully
read through the resulting data several times to become
familiar with the content. During this phase of the analy-
sis, the researchers noticed that the students’ responses
reflected the development needs of palliative care educa-
tion; moreover, they also provided their preferences for
how the education should be delivered, along with factors
that promoted or hindered their learning. In qualitative
research it is possible that the aim and research ques-
tion can change during the analysis process, i.e., the data
direct the process [30]. erefore, the aims of the pre-
sent study were expanded to cover students’ preferences
for how palliative care education should be provided and
which factors promote or hinder their learning.
In the second phase of the analysis, the original data
were reduced to codes, which were relevant to the study
aims. In the third phase of the analysis, the reduced codes
were grouped together based on similarities in content.
e fourth phase of the analysis was data abstraction, i.e.,
sub-categories, categories, main categories and unifying
categories were formed based on the grouped codes. e
identified categories were inductively derived from the
data, while the abstraction was performed in a way that
it applied to all data [30, 37]. An example of the coding
process is provided in Table3.
e coding process was performed by one of the
authors (blinded), after which all other members of the
research group went through the results. Once con-
sensus was achieved, the first author performed the
categorization and abstraction of the data, which was
again critically assessed by all members of the research
group. e frequencies (f) of codes (reduced expressions)
were counted to show the noteworthiness of each cate-
gory in relation to the entirety. e collected data yielded
a total of 2304 codes. Data saturation, which is the point
at which no further data collection is necessary, was
achieved during the analysis process [38]. e research
adhered to COREQ guidelines (Additionalfile1) for the
reporting of qualitative research [39].
Ethical consideration
e standards of the Declaration of Helsinki were fol-
lowed during each step of the study [40]. Each partici-
pating UAS (n = 21) granted a written study permission
for the data collection. Before starting data collection,
the Ethical Committee of North Ostrobothnia’s Hospital
District was consulted regarding the need for a separate
ethical statement. It was not needed since, according to
Finnish law, a statement is not required when the study
does not intervene with participants’ integrity [41]. e
participants were informed about the voluntary nature of
participation in the study and received written informa-
tion about the study aims. Each student responded that
they had read the information letter and agreed to partic-
ipate in the study by answering ‘yes’ to a question of this
issue. If the question was left unanswered or the answer
was ‘no’, the response was rejected. e researchers’ con-
tact information was included in the information letter in
case of questions or concerns of the students related to
the study. Since data collection was anonymous, no per-
sonnel register was formed in the study and anonymity
was protected so that the student cannot be identified
through the examples of authentic data presented in the
study [42].
Table 3 Example of the coding procedure, how the subcategory ‘Importance of genuine encountering’ was inductively produced
f, number of codes included in the subcategory
Example of the original data Example of the resulting code (reduced expressions) Subcategory
in which the
code was
categorized
w46 being heard is really important in terms of a successful, genuine
encounter. w46 being heard is important for genuine encounters
w61 A genuine encounter is important. w61 Genuine encounters are important.
w57 Usually it is enough that we are genuinely present for the other
person. w57 It is enough to be genuinely present. Importance
of genuine
encounters
(f = 5)
w57 Usually it is enough that we are genuinely our own selves for
another. w57 Importance of genuinely being yourself for others.
1129 More emphasis should be placed on …that time should be pro-
vided for genuine encounters with the patient. 1129 (more emphasis) to arrange time for genuine
encounters with patients
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Hökkäetal. BMC Palliative Care (2022) 21:40
Results
ree unifying categories were identified, namely, 1)
development needs and views of palliative care education
(f = 524), 2) the preferred types of palliative care educa-
tion (f = 1379), and 3) factors that promote or hinder
palliative care learning (f = 401) (Fig. 1). Each subcat-
egory presented below will include one quotation as an
example.
Development needs andviews ofpalliative care education
is unifying category included two main categories:
‘e need to develop palliative care education’ (f = 414);
and ‘Meaning of palliative care and its education’ (f = 110)
(Table4).
e main category ‘e need to develop palliative care
education’ (f = 414) included three categories and 14 sub-
categories. In this main category, most codes fell under
the category ‘More palliative care education in general’
(f = 270), which included six subcategories. e subcat-
egories which included the most codes were ‘More pal-
liative care education’ (f = 175) and ‘More resources to
palliative care education’ (f = 36). e students also felt
that equal access to palliative care education, i.e., ‘Obliga-
tory course available to all students’ (f = 16), was an
important area of development. Some examples of the
original data are:
“Definitely more education about this topic into the
nursing degree!” 414.
“More time resources should be given to palliative
care teaching.” 1136.
“A separate obligatory own course to all (students)
about palliative nursing.” 312
e main category ‘Meaning of palliative care and
its education’ (f = 110) consisted of three categories
and 13 subcategories. e category that included the
most codes was ‘Importance of palliative care educa-
tion’ (f = 55), which included four subcategories, while
the subcategory with the most codes was ‘palliative
care is an important topic’ (f = 40). Additional subcat-
egories that included numerous codes were: ‘palliative
care education should be an essential part of nursing
education’ (f = 5); and ‘palliative care should be one of
the most important topics in education’ (f = 5). e stu-
dents expressed the following:
“In my opinion palliative care is a very important
topic for nurses.” 739
“Palliative nursing is an essential part of educa-
tion, and it is important to gain knowledge about
it.” 874
“is subject should be one of the most important
to learn about, so that you can feel safe and know
what to do when you are in the situation.” w13
Fig. 1 Students perspectives of palliative care education and its development needs
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Hökkäetal. BMC Palliative Care (2022) 21:40
Preferred types ofpalliative care education
is unifying category included three main categories,
namely, ‘Teaching contents in palliative care educa-
tion (f=905), ‘Teaching methods for learning palliative
care’ (f = 393), and ‘Placement of palliative care studies
(f = 81), see Table5.
e main category ‘Teaching contents in palliative
care education’ (f = 905) included 18 categories and
78 subcategories. e category with most codes was
‘Encounters in palliative care’ (f = 162), which consisted
of five subcategories, with the subcategories ‘guid-
ance to encounter the closest ones’ (f = 72) and ‘guid-
ance to encounter the patients’ (f = 59) including the
most codes. e students also highlighted the need for
more ‘theory and practice of palliative care encounters’
(f = 16). e students shared the following:
“Education of how we as nurses can encounter…
the closest ones.” 1135
“More education of encounters with dying
patients.” 561
“It would be good to get more theory and advice
concerning humane encounters.” 101
e main category ‘Teaching methods for learning
palliative care’ (f = 393) consisted of six categories and
25 subcategories. e category that included the most
codes was ‘Patient cases and collaboration with work-
ing field in teaching’ (f = 146), and it included five sub-
categories. e three subcategories with the most codes
demonstrated which aspects of teaching the students
preferred, namely, teachers ‘using concrete examples
from practice’ (f = 56), lectures provided by experts in
the field (f = 31), and ‘visits to hospice or palliative care
wards’ (f = 26). As examples, the students stated the
following:
“To orientate with palliative care, concrete exam-
ples from the working environment should be used
so that it could be concretely understood.” 308
“An experienced end-of-life / palliative care pro-
fessional could come and talk about the topic.” 684
Table 4 Unifying category: Development needs and views of palliative care education
f, number of codes (reduced expressions) included in the categories
Main category Category Subcategory
The need to
develop palliative
care education
(f = 414)
More palliative care education in general (f = 270) More palliative care education (f = 175)
More resources to palliative care education (f = 36)
Palliative care education should be more extensive (f = 28)
Obligatory course available to all students (f = 16)
Clear need to develop the education (f = 11)
Palliative care education should be provided to all students (f = 4)
More comprehensive and coherent education (f = 109) Palliative care education as an own course (f = 67)
Palliative care should include deep learning (f = 15)
Comprehensive education of all aspects of palliative care (f = 15)
More possibilities to complete elective studies (f = 7)
Diverse teaching of palliative care (f = 5)
Integrate palliative care clinical practice into the studies (f = 35) Palliative care integrated into clinical practice (f = 20)
Clinical practice in palliative care settings (f = 8)
Possibility to care for palliative care patients (f = 7)
Meaning of
palliative care
and its education
(f = 110)
Importance of palliative care education (f = 55) Palliative care is an important topic (f = 40)
Palliative care education should be an essential part of nursing
education (f = 5)
Palliative care should be one of the most important topics in
education (f = 5)
Palliative care is a broad topic (f = 5)
The meaning of palliative care (f = 33) Palliative care will be required regardless of the workplace (f = 12)
Palliative care affects different patient groups (f = 6)
Just one chance to succeed (f = 5)
Palliative care is a multidimensional issue (f = 4)
Palliative care deserves attention (f = 3)
Palliative care is a valuable type of care (f = 3)
The importance of palliative care in the nursing profession
(f = 22)
Palliative care is a pivotal part of nursing (f = 11)
Every nurse should have basic competences in palliative care
(f = 9)
Palliative care competences build professional growth (f = 2)
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Table 5 Unifying category: Preferred types of palliative care education
Main category Category Subcategory
Teaching contents in palliative care education
(f = 905) Encounters in palliative care (f = 162) Guidance to encounter the closest ones (f = 72)
Guidance to encounter the patients (f = 59)
Theory and practice of palliative care encounters
(f = 16)
Importance of leisurely and empathic presence
(f = 10)
Importance of genuine encounters (f = 5)
Support in palliative care (f = 123) Knowledge of supporting the closest ones (f = 42)
More about psychosocial support (f = 34)
Knowledge of support for patients (f = 23)
Knowledge of the instrumental support for the
patient and family (f = 7)
Knowledge of patient counselling (f = 7)
Maintaining hope (f = 7)
More about supporting the closest ones to partici-
pate in care (f = 3)
Holistic pain management (f = 94) More education of pain management (f = 35)
Education of non-pharmacological pain treatment
(f = 19)
Thorough knowledge of pharmacological pain
management (f = 13)
Knowledge of using patient-controlled analgesia
device (f = 9)
Guidelines to pain management (f = 8)
Knowledge of pain assessment in palliative care
(f = 6)
Knowledge of the holistic nature of pain (f = 4)
Communication and interaction in palliative
care (f = 73)
More about interacting with patient and the clos-
est ones (f = 25)
How to discuss when there are no right words
(f = 9)
How to discuss bad news (f = 9)
How to discuss with the patient (f = 8)
How to discuss meaningful issues (f = 7)
How to discuss with the closest ones (f = 6)
How to communicate about death with the
patient and closest ones (f = 5)
Practical guidance for interactions (f = 4)
Cultural issues in palliative care (f = 61) Knowledge about multiculturality in palliative care
(f = 34)
Knowledge about multicultural nursing in pallia-
tive care (f = 9)
Knowledge about cultural differences towards
death and dying (f = 8)
Knowledge of the customs of other cultures (f = 7)
Knowledge of encounters with people from other
cultures (f = 3)
The basics of palliative care (f = 56) Clarify the main concepts of palliative and end-of-
life care (f = 17)
Education about the philosophy of palliative care
(f = 15)
Main contents of palliative care provision (f = 12)
Identifying the need for palliative care (f = 6)
Education of basic nursing care as a part of pallia-
tive nursing (f = 6)
Special principles of pharmacology in palliative
care (f = 54)
More knowledge about pharmacology in pallia-
tive care (f = 40)
Knowledge of the special features of pharmacol-
ogy in palliative care (f = 8)
Knowledge of the effects and administration of
medicine (f = 6)
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Table 5 (continued)
Main category Category Subcategory
Advanced care planning, decision-making in
palliative care (f = 48)
Clarify the concepts of withholding therapies
(f = 19)
More about setting goals of care (f = 15)
End-of-life decision- making (f = 12)
‘Do not resuscitate’ directives (f = 2)
Education of end-of-life care (f = 31) Knowledge about caring for the dying patient and
their closest ones (f = 19)
Caring for the patient and their closest one after
death (f = 8)
Knowledge about palliative sedation (f = 2)
Knowledge about the symptoms of impending
death (f = 2)
Ethical and legal issues in palliative care (f = 31) Knowledge of ethical questions (f = 24)
Knowledge of values (f = 4)
Education of legal issues (f = 2)
Knowledge of ethics in euthanasia (f = 1)
Somatic symptom management in palliative
care (f = 30)
Care for somatic symptoms (f = 10)
Assessment in symptom care (f = 6)
Knowledge of somatic symptoms (f = 5)
Caring for nausea (f = 5)
Caring for wounds (f = 2)
Caring for shortness of breath (f = 2)
Existential issues in palliative care (f = 26) Knowledge about spiritual support (f = 10)
Knowledge of the meaning of life and existential
questions (f = 10)
Knowledge about different religious views
towards death and dying (f = 6)
Self-awareness in palliative care (f = 25) Facing own feelings of death (f = 8)
Reflection of own feelings regarding care (f = 7)
Guidance for coping at work (f = 6)
Guidance on how to cope with difficult situations
(f = 4)
Palliative care to different patient groups (f = 23) Children’s palliative care (f = 10)
Adolescent’s palliative care (f = 7)
Palliative care in different diseases (f = 4)
Adult’s and elderly people’s palliative care (f = 2)
Psychological symptom management in pallia-
tive care (f = 21)
Knowledge of psychological symptoms (f = 13)
Care for psychological symptoms (f = 8)
Non-pharmacological care in palliative care
(f = 20)
Overall knowledge about non-pharmacological
care (f = 14)
Different non-pharmacological methods (f = 6)
Palliative care in different settings (f = 17) The care pathway and actors in palliative care
(f = 7)
Providing palliative care at the patient’s home
(f = 5)
Providing palliative care in non-specialized units
(f = 5)
Multidisciplinary teamwork (f = 10) Knowledge of multidisciplinary collaboration
(f = 7)
Knowledge of multidisciplinary care (f = 3)
Teaching methods for learning palliative care
(f = 393) Patient cases and collaboration with working
field in teaching (f = 146)
Using concrete examples from practice (f = 56)
Lectures provided by experts in the field (f = 31)
Visits to hospice or palliative care wards (f = 26)
Using patient cases in education (f = 19)
Lectures from expert nurses in the field (f = 14)
Multidimensional teaching methods (f = 88) Face-to-face education (f = 63)
More reflection tasks about the issue (f = 7)
Online videos about palliative care (f = 6)
Using e-learning to create flexibility (f = 5)
Evidence-based education (f = 5)
Taking into account different learning styles (f = 2)
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Hökkäetal. BMC Palliative Care (2022) 21:40
“… by visiting hospice and palliative care units dur-
ing the education.” 198
e main category ‘Placement of palliative care stud-
ies’ (f = 81) consisted of three categories and 11 subcat-
egories. e category which included the most codes was
‘Integrated and unifying palliative care education in the
curriculum’ (f = 35), which included five subcategories.
e subcategories with the most codes highlighted vari-
ous aspects of palliative care learning, namely, ‘repeated
teaching at different phases of education’(f = 12), ‘educa-
tion as an own entirety’ (f = 8), and ‘palliative care edu-
cation should be a natural part of all education’ (f = 6),
which highlighted how palliative care could be integrated
into undergraduate nursing studies.
“e topic could be repeated during the nursing
studies.” 282.
“It should also be one own teaching entity, where
discussion about the topic will be made.” 337
“It could be a small part of every teaching session,
making it “naturally” applicable to working life.” 618
Factors thatpromote orhinder palliative care learning
is unifying category included two main categories:
‘Factors that facilitate palliative care learning’ (f = 66); and
‘Barriers to palliative care learning’ (f = 335) ( Table6).
e main category ‘Factors facilitating palliative care
learning’ included three categories and nine subcat-
egories. e category with the most codes was ‘Previous
clinical experience about palliative care’ (f = 31); under
this category the subcategory ‘palliative care clinical
practice’ (f = 15) included the most codes. e students
Table 5 (continued)
Main category Category Subcategory
Experiences and exposure-based teaching
(f = 49) Experts by experience telling their story (f = 28)
Sharing care experiences with the classes (f = 10)
Teachers sharing their own experiences of pallia-
tive care (f = 7)
Students sharing their own experiences of pallia-
tive care (f = 4)
Learning from discussions about palliative care
(f = 46)
Teacher facilitated discussion about palliative care
issues (f = 31)
Teacher facilitated group discussions (f = 12)
Teacher facilitated discussions of care encounters
and feelings (f = 3)
Skills labs and simulation pedagogy in palliative
care education (f = 40)
Simulation sessions (f = 19)
Skills practice through workshops (f = 12)
Skills training sessions at school (f = 9)
Multidisciplinary teaching and learning (f = 24) Lectures provided by physicians (f = 8)
Learning together with students from other
disciplines (f = 7)
Lectures provided by chaplains (f = 6)
Teaching provided by a multidisciplinary palliative
care team (f = 3)
Placement of palliative care studies (f = 81) Integrated and unifying palliative care education
in the curriculum (f = 35)
Repeated teaching at different phases of educa-
tion (f = 12)
Education as an own entirety (f = 8)
Palliative care education as a natural part of all
education (f = 6)
Palliative care integrated in different courses (f = 6)
Teaching after clinical practice (f = 3)
Preparatory teaching from the first semesters
(f = 29)
Education launched during the first semesters
(f = 16)
Education before the first patient contacts (f = 8)
Education from the beginning of the studies
(f = 5)
In-depth learning during the final semesters
(f = 17)
Palliative care education integrated into advanced
studies (f = 7)
Palliative care education integrated into the last
semesters of studies (f = 7)
Cases and simulations integrated into advanced
studies (f = 3)
f, number of codes (reduced expressions) included in the categories
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Hökkäetal. BMC Palliative Care (2022) 21:40
also expressed that ‘work experience from clinical set-
tings’ (f = 14) and the possibility to achieve ‘mentoring in
clinical practice (f = 2) were conducive to palliative care
learning. e students expressed:
“I have completed my clinical practice in a hospice,
and it was an eye-opening learning experience.” w41
“Palliative care and end-of-life care have become
familiar to me when working as a nurse during my
studies.” w32
“Good instructors in working life and clinical prac-
tice taught me a lot.” 1113
e main category ‘Barriers to palliative care learning’
included seven categories and 31 subcategories. e
category that included the most codes was ‘Insufficient
amount of education’ (f = 119), which included four
subcategories. e following subcategories included the
most codes: ‘too little education of palliative care’ (f = 92);
‘too superficial education’ (f = 14) and ‘ no education of
palliative care’ (n = 7) Some original expressions under:
Table 6 Unifying category: Factors that promote or hinder palliative care learning
f, number of codes (reduced expressions) included in the categories
Main category Category Subcategory
Factors that
facilitate pallia-
tive care learning
(f = 66)
Previous clinical experience about palliative care (f = 31) Palliative care clinical practice (f = 15)
Work experience from clinical settings (f = 14)
Mentoring in clinical practice (f = 2)
Obtained formal education (f = 25) Elective studies regarding palliative care (f = 10)
Education obtained while studying for a former health care degree
(f = 10)
The expertise of the teacher (f = 5)
Intrinsic motivation to learn about palliative care (f = 10) Personal interest in palliative care (f = 5)
Thesis completed on the subject of palliative care (f = 4)
Personal experience of palliative care (f = 1)
Barriers to pallia-
tive care learning
(f = 335)
Insufficient amount of education (f = 119) Too little education of palliative care (f = 92)
Too superficial education (f = 14)
No education of palliative care (f = 7)
Too concise course of palliative care (f = 6)
Insecurity about own performance in palliative care (f = 56) Too little competence to provide palliative care (f = 21)
Hard to encounter the dying patients and the closest ones (f = 8)
Everyone don’t have enough interaction skills to face the dying person
(f = 7)
Unpreparedness how to perform in difficult situations (f = 6)
Palliative care can be frightening (f = 5)
The topic is difficult (f = 5)
Difficult to face death (f = 4)
Discrepancy between teaching methods (f = 43) Too much online learning (f = 18)
Too much self-learning (f = 17)
Too much group work (f = 6)
Classes are too long for such a serious topic (f = 2)
Insufficient structure of education (f = 37) Fragmented entities do not form an overall picture (f = 16)
Death is hidden from the nursing curriculum (f = 10)
The teaching was carried out too fast (f = 8)
No education obtained because of school change (f = 3)
Shortcomings of competences and clinical learning (f = 35) Deficiency in provision of palliative care in the working field (f = 11)
Lack of palliative care competences among nursing staff (f = 10)
Have not faced or cared for palliative care patients (f = 7)
The work environment is responsible for too much of the learning
(f = 4)
It is difficult to face patients due to lack of prior knowledge (f = 3)
Impractical content of the education (f = 27) Education does not develop the competences needed in work life
(f = 7)
Outdated educational contents (f = 6)
The educational content concentrates too much on the dying phase
(f = 5)
Deficiencies in the contents (f = 5)
Insufficient teaching on the care of different diseases and symptoms
(f = 4)
Teacher’s insufficient competences on the subject (f = 18) Teachers lack sufficient competences (f = 10)
Teaching is deficient (f = 8)
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Hökkäetal. BMC Palliative Care (2022) 21:40
“ere is too little palliative care education during
the studies.” 48
“e teaching of palliative nursing was too superfi-
cial.”302
“ … I did not receive any education of palliative
care” 68
Discussion
e participating students expressed their perspectives
of both the current state of palliative care education and
the development needs for this aspect of nursing educa-
tion. e students often shared that undergraduate nurs-
ing studies should generally include more palliative care
education. ese perspectives can reflect to the varia-
tion of the palliative care education in the Finnish UASs
[21]. It is noteworthy that the students regarded palliative
care education as an important and essential topic which
should be integrated into the nursing curriculum. As pal-
liative care should be incorporated in the early stages of
caring for a person with a chronic illness based on the
need not on the diagnosis, prognosis or settings of care,
it is most likely that nurses encounter palliative care
patients during their career [5]. erefore, it is important
that all students would be prepared for the care when
graduating. e students highlighted the importance of
practical aspects of palliative care, i.e., knowledge of how
to manage encounters with patients, which can be gained
by meeting real patients and being taught by experts
from the field such as specialist nurses and physicians.
In general, the education delivered by experts from the
field should be better utilized, since this probably differs
between the UASs in Finland.
e students also expressed their views of which types
of palliative care education they preferred. Notably, the
students described various aspects of palliative care
that they hoped should be integrated into nursing edu-
cation. is may reflect the wide range of competences
nurses need to provide high-quality palliative care. e
palliative care aspects mentioned by students agree with
earlier descriptions of palliative care competences [19,
43–47]. In addition to the content of palliative care edu-
cation, the students specified which teaching methods
they preferred. Earlier literature has confirmed that vari-
ous methods are effective at enhancing students’ pallia-
tive care learning [22, 23, 48], with this study providing a
unique, detailed view of which aspects of palliative care
and which teaching methods they prefer.
e undergraduate nursing students also shared their
views of which factors promote and hinder their pallia-
tive care learning. ey expressed that clinical practice in
palliative care settings and mentoring by experienced
nurses facilitate the learning process. A supportive
mentor-student relationship, including guidance and
role-modelling, has been identified to facilitate students’
clinical learning [49], while other research has stated
that staff support is crucial to good learning experi-
ences [17, 50]. First-hand experience in caring for dying
persons was found to be associated with positive atti-
tudes towards end-of-life care [51]. For students to gain
positive learning experiences about palliative care, they
should be afforded more opportunities to attend clinical
practice placements and receive instruction and support
from experts in the field. is is essential, since students
also expressed that staff members with insufficient pallia-
tive care competences can hinder learning.
Another subject which was reported to be both a facili-
tator and barrier to learning was the teacher’s compe-
tence, i.e., a competent teacher facilitated the learning
process while incompetent teachers served as a barrier to
learning. Student expressed that a competent teacher has
due-to-date knowledge of palliative care and experience
of the subject to share concrete examples to the students.
Competent teachers are also wished to have an open and
supporting attitude to the students’ feelings and concerns
of the subject. e importance of a competent educator
has been highlighted in a European guide for the devel-
opment of palliative nurse education [19]. Furthermore,
previous studies have also stated that teachers need addi-
tional palliative care education [52] and that the lack of
competent teachers can significantly hinder high-quality
education [53]. Hence, educational institutions should
assess and ensure the competence of teaching staff, as
this is related to the quality of undergraduate nursing
education.
e students also identified feelings of unpreparedness
and fear of the topic as barriers to learning. Unprepar-
edness, feelings of vulnerability and fear have also been
reported in earlier research [24, 54, 55]. e expression of
uncertainty and feelings of unpreparedness can often be
explained by insufficient experience and the lack of edu-
cation [17, 56–58]. e barriers to learning reported by
the undergraduate nursing students participating in this
study revealed certain areas of palliative care education
which must be improved in nursing curricula.
Some future implications for research were identified
during the study. is study concerned final-year stu-
dents, who may have limited understanding of all needs
of the education to prepare them to the future work with
palliative care patients. erefore, as a future implica-
tion for research it would be important to focus also on
graduated nurses. is study gave a comprehensive sum-
mary of the phenomenon, hence, to get a more in-depth
view of the phenomenon face-to face or focus-group
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 13 of 15
Hökkäetal. BMC Palliative Care (2022) 21:40
interviews would further bridge the gaps in the knowl-
edge of the palliative nursing education. In addition,
relatively little is known about teachers’ competence and
requirements to provide quality palliative care education.
Even though this was identified as a facilitating or hin-
dering factor in learning palliative care by the students,
more focus on this should be put in future research.
is study gave a comprehensive summary of nursing
students views of palliative care education development
needs. e research also provides information on what
factors should be changed or strengthen to improve stu-
dents learning. e results can be utilized when devel-
oping the undergraduate nursing curriculum. is study
gives information of the preferred placement of the edu-
cation, namely thorough the nursing education. In addi-
tion, it provides an overview of students’ perceptions of
the preferred teaching contents and methods. It calls to
increase the amount of palliative care education and for
more research of the phenomenon, as well.
Strengths andlimitations
Several aspects strengthened the trustworthiness of this
study. e chosen method was suitable for the purpose of
this study. Moreover, data saturation was achieved dur-
ing the analysis [38]. e credibility was strengthened
by reporting in detail the sampling, data collection and
analysis process. e clarity of the open-ended question
was pretested, and the sample included final-year nursing
students from all UASs across Finland. erefore, it can
be assumed that the study population had experiences of
the achieved palliative care education in nursing studies.
Furthermore, dependability was strengthened by pre-
senting an example of the analysis process (Table3) and
tables and figures of categories identified through con-
tent analysis (Tables4, 5 and 6, Fig.1). It should also be
noted that the researchers constantly discussed the anal-
ysis and findings throughout the study. Confirmability
was strengthened by focusing on the manifest content so
that the results would represent the views of the students
[37]. e participants represented students from all UASs
and the data was rich which made it possible to make a
comprehensive summary of the phenomenon, which
strengthen the transferability of the results. In addition,
the sampling and inclusion criteria are described care-
fully in the manuscript. e authenticity of the results
was strengthened by providing authentic citations from
the collected data [30, 59].
e research also included certain limitations which
could weaken the trustworthiness of the study. For
instance, the questionnaire was answered anonymously,
and answering the open-ended question was completely
voluntary. Hence, it is impossible to know the reason(s)
why certain students refused to answer this question.
Furthermore, there was no possibility to ask any further
questions from the students or return the findings to the
students for comments or corrections [30]. In addition,
because the students were not yet graduated, they may
not possess all the understanding of what their future
competence needs would be when caring for patients in
palliative care, which can lead to a limited vision of the
education needs. It should also be noted that several sub-
categories consisted of a small number of codes; however,
they are important because they show different aspects of
the studied phenomenon.
Conclusions
is study provides evidence that palliative care educa-
tion in undergraduate nursing curricula still needs to be
developed in terms of the amount, content, methods and
integration into the programs. e students’ responses
revealed feelings of unpreparedness to provide palliative
care even though the nursing students highlighted the
importance of palliative care as a topic in their education.
Students should have enhanced access to clinical place-
ments or visits to palliative care units to facilitate their
learning of palliative care. Furthermore, a teacher’s com-
petence is also linked to the students’ learning processes.
is study gives detailed information about nursing stu-
dents’ perspectives on palliative care education. Based on
the results of this study, we suggest that final-year nurs-
ing students should gain valuable insight into different
aspects of palliative care through their nursing education,
and this can be ensured by using effective teaching meth-
ods. erefore, the presented results are of great value to
professionals and decision-makers who are planning to
integrate palliative care into the undergraduate nursing
curriculum.
Abbreviation
UAS: University of Applied Sciences.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12904- 022- 00915-6.
Additional le1. COREQ- checklist.
Acknowledgements
The authors wish to thank all the nursing students who participated in this
study.
Authors’ contributions
M.H., J.T.L., H.K and T.P. designed the study methodology. M.H. and J.T.L.
collected the data. M.H., J.T.L., H.K and T.P. analyzed the data and drafted and
revised the manuscript. Furthermore, all the authors read and approved the
final manuscript.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 14 of 15
Hökkäetal. BMC Palliative Care (2022) 21:40
Funding
The data collection was funded by EduPal- project, which was funded by the
Ministry of Education and Culture (Decision 29.3.2018 OKM/258/523/2017) in
Finland. The writing of the manuscript and the open access fee was granted
by Durchman foundation as a personal research grant for the first author.
The funders had no role in the design of this study, in the collection, analysis
and interpretation of data, or in writing the manuscript. The content of this
article reflects only the authors views and the funders are not liable for of the
information contained in the study.
Availability of data and materials
The original data of the current study are not publicly available due to the
terms of the achieved research permits from the UASs and to ensure the study
participants that the data will be retained confidential. Within the limits of
confidentiality, more detailed, but anonymous, data is available from the cor-
responding author on request.
Declarations
Ethics approval and consent to participate
The standards of the Declaration of Helsinki were followed during each step of
the study [40]. The Ethical Committee of North Ostrobothnia’s Hospital District
was consulted before data collection, they stated that formal approval was not
needed for this study. It was not needed since, according to the Finnish law, a
statement is not required when the study does not intervene with partici-
pants’ integrity [41]. Participation in the study was voluntary and an informed
consent was obtained from all participants, each student responded that they
had read the information letter of the research and agreed to participate in
the study by answering to a question of this issue. All research material was
coded with numbers, not with the personal details of the students to reassure
the confidentiality for the participants.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Faculty of Medicine, Research Unit of Nursing Science and Health Manage-
ment, University of Oulu, PO BOX 5000, 90014 Oulu, Finland. 2 Kajaani Uni-
versity of Applied Sciences, Kajaani, Finland. 3 Faculty of Medicine and Health
Technology, Tampere University, Tampere, Finland. 4 Palliative Care Centre
and Department of Oncology, Tampere University Hospital, Tampere, Finland.
5 Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland.
Received: 14 July 2021 Accepted: 15 February 2022
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