Teaching palliative care skills

November 1, 2020

As our population ages, the need for palliative care will increase. Greater clarity around undergraduate palliative and end-of-life care curriculum content is needed to prepare the future health workforce.

Advances in the management of chronic diseases, combined with an ageing population, have resulted in a rising prevalence of people with life-limiting conditions and multi-morbidities, with a corresponding increase in demand for palliative care. This trend reflects global challenges in health care and an urgent need for workforce development to meet the future needs of the population and ensure access to high-quality primary palliative care across all health-care settings.

Future projections for palliative care show the number of deaths in New Zealand is expected to rise steadily over the next 50 years, increasing by 83 per cent – from 30,300 in 2016 to 55,500 by 2068. This is reflected in a 92 per cent increase in the numbers of people needing palliative care, up from 24,400 in 2016 to 46,700 by 2068. This increase is due to the ageing population and will be felt in all health-care settings.1 This is supported by a study at Auckland City Hospital in 2013, which showed 20 per cent of inpatients met the criteria for palliative care. The majority were over 70 and two thirds died within six months of admission.2

Education fundamental

The National Health Needs Assessment for Palliative Care estimates 80 per cent of these people will be cared for by primary (non-specialist) palliative care providers, and describes education as fundamental to ensuring the health workforce is prepared to care for these patients and their family/whānau.3 Nurses are at the frontline of patient care and will therefore feel the full force of this increase, including new graduates who have the least amount of training and experience.

Palliative and end-of-life care is recognised as an important component of undergraduate education among health-care professions.

International research reports that many nurses do not feel well prepared to provide palliative and end-of-life care and find it stressful and emotionally distressing, which may be reflected in the care they provide.4, 5 Personal attitudes and beliefs may also influence nurses’ willingness to care for people at the end of life,6 although education is effective in addressing these issues.7, 8 Little is known about how registered nurses (RNs) in New Zealand learn to care for patients who are dying. Our research attempts to shed light on this issue.

Internationally, palliative and end-of-life care (PEOLC) is recognised as an important component of undergraduate education among health-care professions.9, 10 However, it has been underrepresented in undergraduate curricula until relatively recently.7, 11 In fact, a recent article in The Lancet highlights this issue, stating the health-care workforce would have been better prepared for the COVID-19 pandemic if the long-standing recommendation to include palliative care in pre-registration training had been heeded.12

Fortunately, this is beginning to change, as many countries now include PEOLC in their undergraduate teaching. This has been driven by recommendations from governments and professional bodies in response to forecasts of overwhelming need. However, PEOLC still remains optional in most areas. National online programmes are available for nurses in Australia (Palliative Care for Undergraduates www.pcc4U.org) and the United States (End-of-Life-Nursing Education Consortium www.aacnnursing.org). In Europe, 43 per cent of countries include palliative care in undergraduate nursing curricula, including France, Austria and Poland where PEOLC teaching is mandatory.13

In New Zealand, the Ministry of Health (MoH) identified the need for workforce development in the Palliative Care Strategy.14 This recommended the Nursing Council provide guidelines for the minimum palliative care content at undergraduate level. However, a 2008 survey of New Zealand undergraduate nursing programmes (in which six schools – 37.5 per cent – responded) found no identifiable modules in palliative care, but rather an integrated approach to teaching. This made it difficult to determine what was covered, and reflected a lack of visibility, and inconsistency between programmes.15

More recently, the MoH Palliative Care Action Plan prioritised the need to improve access to primary palliative care by “supporting work to modify undergraduate education and training to provide the minimum knowledge and skills related to primary palliative care”.16 This statement provides a clear mandate for the council to introduce competencies to guide curriculum development. Without such competencies, teaching about PEOLC will remain optional and risk being squeezed out in favour of other topics, leaving graduates unprepared and without the necessary skills to care for these people and their family/whānau.

Survey of nursing schools

It is against this background that a national online survey of nursing schools was undertaken in 2019 as the first phase of a doctoral research project. This was approved by the University of Otago Human Ethics Committee. The aim of the survey was to obtain information about how PEOLC is taught and assessed in undergraduate nursing programmes in New Zealand. The results will be used to identify strengths, barriers and opportunities for PEOLC curriculum development.

Preliminary results indicate that PEOLC is taught in all programmes that responded (76 per cent, n=13). Teaching was mostly in an integrated manner, but with wide variability in curriculum time, methods and content, and an overall lack of assessment in PEOLC. Pressure on curriculum time and lack of clinical placements were identified as barriers to development.

Much depends on the availability of a “palliative care champion” to advocate for, and coordinate teaching in each school. This may reflect the absence of any specific requirements from the Nursing Council to include PEOLC in undergraduate curriculum content for RNs, although it may be inferred, depending on interpretation.17

Interestingly, however, the council does include questions that relate broadly to PEOLC concepts in State final examinations.18 Overall, there is a need for greater clarity around the minimum PEOLC content required for undergraduate nursing education to secure the necessary support for curriculum development and prepare graduates to meet the palliative care needs of the population in the future.

Next phases of the research

The next two phases of this research explore graduates’ exposure to PEOLC-related activities in clinical practice, as well as their self-efficacy and attitudes towards providing this care. This included the factors that influenced their development of self-efficacy in PEOLC during their undergraduate training. The full results from the survey of nursing schools, and the subsequent phases of this research will be reported at a later date.

Lis Heath, RN, MN, is a lecturer in palliative care at the Department of Medicine, Otago Medical School, University of Otago.
Richard Egan is a lecturer in health promotion in the Department of Preventive and Social Medicine at the University of Otago.
Jean Ross, RN, BN, MA, PhD, is associate professor at the School of Nursing, Otago Polytechnic.
Ella Iosua is a senior research fellow in the Centre for Biostatistics, University of Otago.
Robert Walker is a professor in the Department of Medicine, University of Otago.
Rod MacLeod is a Hospice New Zealand clinical adviser.


  1. Ministry of Health. (2016). The Need for Palliative Care in New Zealand Technical Report (PDF, 5.17 MB). Wellington: Ministry of Health and Heather McLeod & Associates Ltd.
  2. Gott, M., Frey, R., Raphael, D., O’Callaghan, A., Robinson, J., & Boyd, M. (2013). Palliative care need and management in the acute hospital setting: a census of one New Zealand hospital. BMC Palliative Care, 12(1), 15. doi:10.1186/1472-684x-12-15
  3. Palliative Care Council of New Zealand. (2013). National Health Needs Assessment for Palliative Care. Phase 2 Report: Palliative Care Capacity and Capability in New Zealand (PDF, 3.46 MB). (ISBN 978-0-478-40255-1 (online)). Cancer Control New Zealand.
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  6. Peters, L., Cant, R., Payne, S., O’Connor, M., McDermott, F., Hood, K., Morphet, J., & Shimoinaba, K. (2013). How Death Anxiety Impacts Nurses’ Caring for Patients at the End of Life: A Review of Literature. The Open Nursing Journal, 7, 14-21. doi:10.2174/1874434601307010014
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  8. McClatchey, I. S., & King, S. (2015). The impact of death education on fear of death and death anxiety among human services students. OMEGA-Journal of death and dying, 71(4), 343-361. https://doi.org/10.1177/0030222815572606
  9. Palliative Care Competence Framework Steering Group. (2014). Palliative Care Competence Framework (pdf 3.1MB). Dublin: Health Service Executive. 
  10. World Health Assembly. (2014). Strengthening of palliative care as a component of comprehensive care throughout the life course.
  11. Latta, L., & MacLeod, R. (2018). Palliative Care Education: An Overview. In R. D. MacLeod & L. Van den Block (Eds.), Textbook of Palliative Care (pp. 1-21). Cham: Springer International Publishing.
  12. Radbruch, L., Knaul, F. M., de Lima, L., de Joncheere, C., & Bhadelia, A. (2020). The key role of palliative care in response to the COVID-10 tsunami of suffering. The Lancet, 395(May 9). https://doi.org/10.1016/s0140-6736(20)30964-8
  13. Arias-Casais, N., G. E., Rhee, J. Y., Lima, L., de Pons, J. J., Clark, D., Hasselaar, J., Ling, J., Mosoiu, D., & Centeno, C. (2019). EAPC Atlas of Palliative Care in Europe 2019 (V. E. Press Ed.).
  14. Ministry of Health. (2001). The New Zealand Palliative Care Strategy. Wellington: Ministry of Health.
  15. Kent, B., North, N., Janssen, A., Waterworth, S., Dyson, L., Farrell, N., & Bates, A. (2008). A Report on Palliative Care and Cancer Nurses’ Educational Needs. Auckland: Auckland Uniservices Limited.
  16. Ministry of Health. (2017). Palliative Care Action Plan. Wellington: Ministry of Health.
  17. Nursing Council of New Zealand. (2020). Handbook for pre-registration nursing programmes. Wellington: Author.
  18. Personal communication with Nursing Council, June 16, 2020.