Voices from the Frontline: Nurses’ Insights on End-of-Life Care through the Palliative Care Value-Added Course – A Qualitative Study

Subtheme: Emphasis on emotional and psychological support

A significant transformation in nursing care practice emerged from participants’ accounts, revealing a shift from task-based care to holistic, patient-centred support. Many nurses highlighted how the ELNEC palliative care training fostered deeper empathy and psychological sensitivity.

A central theme across participants’ accounts was the emphasis on emotional and psychological support. Participant 2, who shared, ‘It taught us not just nursing procedures, but how to understand patients. Now I try to understand their needs and provide psychological support.’ It emphasised the importance of understanding patients beyond clinical procedures. These statements illustrate a profound shift from merely addressing physical symptoms to recognising and responding to the emotional dimensions of patient care. Participant 5 recounted, ‘Before studying palliative care, I thought we needed to use life-supporting equipment to maintain patients’ lives. But now I understand we also need to focus on their needs and try to fulfil their wishes – that will give them quality care.’ This reflection shows an expanded understanding of what it means to deliver truly compassionate, quality care. Participant 2 admitted, ‘I joined palliative care thinking I’d get an extra certificate, but later I realised it was more than that. That course still stays with me – the values were totally different.’ This expression reveals how the experience profoundly shifted personal motivations and professional philosophies.

Subtheme: Family-centred and empathetic communication with psychosocial support

Participants consistently highlighted the importance of showing empathy and emotional presence not only to patients but also to their families. Their training helped them recognise grief responses and offer effective psychosocial support during emotionally challenging moments.

Participant 1 shared, ‘When he got a seizure and she [the mother] was totally upset, I told her it’s part of the condition and stayed with her to comfort her’. The ability to recognise grief and respond empathetically was consistently attributed to the values and concepts learned in their palliative care education.

The application of palliative communication beyond the clinical setting, as described by participant P2, who shared how she applied the same principles to support her own mother during the death of a family member, stating, ‘We can use this training anywhere – in hospitals or at home.’ Participant 1 mentioned learning from senior nurses: ‘I used to watch my senior nurses, how they are presenting things to the family members’. Such experiential learning was key to building confidence and communication competence.

Finally, participants highlighted a strong commitment to a holistic and family-centred approach to care, acknowledging the role of family as central to the patient’s well-being. As Participant 5 succinctly put it, ‘Palliative care education doesn’t only focus on the patient but also on the patient’s family’.

Participants emphasised the importance of guiding families through anticipatory grief and bereavement using sensitive communication and emotional presence. Palliative care education equipped them with the skills to provide not only clinical updates but also psychosocial comfort.

Sensitive disclosure and trust were emphasised as vital when interacting with family members. Participant 1 reflected, ‘…good communication… patients’ disease conditions… improving quality of life effectively… without causing them any kind of discomfort…’. Participants also stressed the importance of empathy and understanding. Participant 2 shared, ‘It always helps us to understand others’ emotions… we should have that ability…’. Providing psychosocial support was another critical aspect described. Participant 3 explained, ‘…they initially had depression… once we had good conversations with them, they realised the facts… good relationship with the patients’. Participants also pointed to the importance of evidence-informed care in guiding their interactions. The participants consistently approached their work through a holistic practice lens. A person-centred approach was seen as essential for offering genuine support. Participant 6 expressed, ‘… by valuing the individual, we can provide quality care… understanding what the patient’s needs are.’ Valuing each patient and family’s unique experience allowed participants to offer care that was meaningful and respectful of individual circumstances.

Subtheme: Differentiation between trained and non-trained nurses

Participants observed distinct differences in communication approaches between nurses with and without palliative care training. Trained nurses reported more frequent, meaningful and emotionally aware interactions with patients and families. According to Participant 1, ‘I used to talk a lot with my patients. Every day I ask them about their health. I think in that way, they are getting some comfort.’ This daily, personal interaction reflects a level of emotional attentiveness and relationship-building that goes beyond routine clinical conversations, offering patients a sense of comfort and human connection.

Participants also noted a sense of professional differentiation and recognition stemming from their specialised training. Participant 2 recalled, ‘They only asked about palliative care. They selected only two of us; others were not selected.’

A holistic and family-inclusive perspective was another important differentiator. Participant 3 emphasised, ‘Palliative care nurses assess their needs… psychological or physical. focus on both patient and family’. Similarly, Participant 5 noted, ‘we definitely focus on the spiritual and emotional aspects of the patient’, underscoring how communication extends beyond physical health to address spiritual and emotional well-being dimensions often overlooked by those without palliative care training.

The depth of knowledge and experiential learning gained through palliative care education also contributed to more meaningful patient interactions. Participant 4 explained, ‘We had exposure… seminars, case discussions. We got much more knowledge about palliative care, suggesting that this continuous learning enriched their communication techniques.

Subtheme: Integrating palliative knowledge into daily practice for comprehensive care

Participants described pain and symptom management as a central component of their practice, enriched significantly by their palliative care training. They moved beyond clinical interventions to integrate emotional, spiritual and psychological support in their care plans.

A key theme was effective symptom and pain management. Participant 1 emphasised the realities patients face, stating, ‘...patients are facing many kinds of pain and suffering. So this palliative care education helped me a lot to treat them well’. While Participant 5 noted the value of integrating different approaches, sharing, ‘Combining both pharmacological and non-pharmacological methods definitely helped me.’.

Beyond physical treatment, participants stressed the importance of emotional and psychological support in managing pain. Participant 2 remarked, ‘The only thing we can provide is emotional support’, recognising that, especially in cases where curative treatment is not possible, emotional presence becomes a critical form of care. Participant 4 described, ‘I could manage the patient’s pain through psychological support and all’, illustrating how addressing psychological distress often eased physical suffering.

Participant 3 explained, ‘We are just focusing on their needs. spiritual needs or the economic needs sometimes...’. This broader perspective allowed nurses to identify and respond to suffering in all its forms, not just physical pain. Participants also highlighted how palliative care education enriched their ability to support patients’ overall well-being, focusing on quality of life rather than solely on disease treatment. Training helped integrate patient-centred practices into routine care and strengthened the emotional connection between nurse and patient.

Clinical exposure further enhances nurses’ ability to apply palliative care concepts in real-world settings, reinforcing theoretical knowledge through practice. Palliative principles, once learned, become seamlessly integrated into daily care routines, guiding nurses to prioritise the holistic needs of each patient. Patient-centred communication emphasised by P1- ‘...good communication. patients’ disease conditions… improving quality of life effectively… without causing them any kind of discomfort…’ Emotional support pointed by P3- ‘...they initially had depression… once we had good conversations with them, they realised the facts… good relationship with the patients’. Practical application by P4- ‘... great opportunity to take care of such patients… apply my knowledge to direct patient care’. Integration into routine care by P5-‘...day-to-day life, we are applying every aspect that we studied in palliative care’.

Respect for individuality by P6- ‘...by valuing the individual, we can provide quality care… understanding what the patient’s needs’. Quality-of-life enhancement stressed by P7- ‘...better care to patient for faster recovery or to get nice days in their suffering times’.

Subtheme: Balancing emotions with empathic awareness

Participants described emotional regulation as a learned skill, developed through palliative care experiences that demanded both compassion and composure. These encounters helped them balance empathy with professional boundaries.

Emotional regulation emerged as a critical strategy for supporting patients and families. Participant 1 admitted, ‘I am a very emotional person... I need to be bold... If I want to support her, I need to be bold enough... I told her, ‘Be with him, be a supportive mother like you were.’ This statement highlights the internal struggle many nurses face, balancing their natural emotions with the need to project strength and stability for those in their care.

Participant 2 shared, ‘Personally, I am very emotional... It was totally tough... after some time, I got adjusted... It’s about the time we have there.’ Their reflection illustrates that emotional adjustment is a gradual process shaped by experience and sustained exposure to the realities of serious illness.

Through their experiences, many participants developed professional emotional intelligence, enabling them to balance caring deeply without being overwhelmed. Participant 3 said, ‘Initially we do have emotions… but... I have learned how to accept the fact... how to cope with the current situation...’

Participants also showed an acute awareness of mortality in their work and how acknowledging it with empathy helped them manage their emotions. Participant 4 explained, ‘Definitely it’s emotional, but I try to be empathetic about it,’ recognising that maintaining empathy rather than succumbing to overwhelming grief allowed them to offer better support to patients and families.

A thoughtful distinction between sympathy and empathy was noted. Participant 5 reflected, ‘Actually, we are in a therapeutic relationship... I feel sympathetic many times... I try to maintain that empathy.’ This deliberate shift toward empathy ensures that nurses maintain professional boundaries while still offering genuine emotional support.

The idea of an empathic presence was strongly emphasised. Participant 6 shared, ‘I could show them empathy by realising their pain. we understand each other’.

Subtheme: Integrating palliative care into core curriculum

Participants unanimously stressed the necessity of palliative care education for nursing students, emphasising its relevance across a variety of clinical and non-clinical settings. The course was seen as vital in shaping compassionate and competent care for patients with terminal and chronic illnesses.

Many described palliative care education as an educational necessity for nursing students and other healthcare providers. Participant 1 stated clearly, ‘A palliative care add-on course is really necessary... not only for cancer patients but also other end-stage patients. very important for a nursing student’.

Participants emphasised the importance of maintaining a patient-centred model in palliative care practice. Participant 3 explained, ‘In palliative care, we have a special team... depends on the patient’s requirements... patient-centred care is very important’.

Several participants also highlighted that palliative care education is valuable beyond the hospital setting. Participant 4 shared, ‘If anyone has the opportunity... it is very beneficial... we may have people in our family... we can give them quality care’. Emotional and spiritual dimensions of care were seen as equally important. Participant 5 admitted, ‘Initially, I felt this course was difficult. now I understand it is necessary... helps nurses approach emotional and spiritual aspects’. Participants emphasised the vital role of nurses as primary caregivers for patients at the end of life. Participant 6 observed, ‘It is necessary because there is no one else for the patients. nurses should be well educated about this’. Finally, participants advocated for cross-disciplinary importance, encouraging that palliative care education should extend beyond nursing to include all medical professionals. Participant 7 strongly expressed, ‘It is very necessary for nurses – not only for nurses but for all medical professionals... I strongly recommend.’

Subtheme: Empowering student nurses through enhanced palliative care training

Several participants offered a strong endorsement, emphasising the course’s impact on the quality of care that they provide. Participant 1 shared, ‘Of course... helped me a lot in identifying patients’ problems... helped improve my quality of care... surely recommend this course...’. Similarly, Participant 3 echoed this sentiment, stating, ‘Of course. helped me a lot while treating patients with life-threatening conditions... improved my quality of care. surely recommend...’. A few participants offered a conditional endorsement, recognising that while the course is valuable, engagement must come from genuine interest. Participant 2 remarked, ‘Yes, I will – if people are interested... we cannot force them... share our experience...’ This insight suggests that while palliative care education is transformative, it is most effective when students are motivated and open to its principles. Participant 5 showed active advocacy by saying, ‘Yes, of course. I am suggesting this add-on course to all my juniors.’ A strong theme of universal value was also present. Participant 6 emphasised, ‘Yes, sure... if nurses are educated... it will benefit the patients... every nurse should be aware...’. This highlights a broader vision where palliative care principles are seen as essential knowledge for all nurses, not just those working in specialised units. Finally, enthusiastic endorsement was passionately conveyed by Participant 7, who said, ‘Yes, I will definitely suggest it... It will be very beneficial... thankful for having had this experience.’ Their gratitude underscores the deep personal and professional growth that can result from structured palliative care education.

Subtheme: Developing emotional intelligence, holistic insight and ethical end-of-life care

One of the most frequently mentioned outcomes was the development of emotional intelligence. Participant 1 reflected, ...‘Sometimes it is really important to understand people’s emotions. Sometimes we will be very happy, but the other person may not...’. Similarly, Participant 6 emphasised the role of holistic assessment, stating, ‘...understand the needs of the patients – spiritually, emotionally, physically... provide quality care...’ Participants also pointed to the transferability of skills learned through the course. Participant 4 shared, ‘... we can have people from our family, relatives, or friends.... If we get to see people in this kind of end stage, we can give quality care...’. This reflection reveals that palliative care training has applications beyond professional practice, allowing nurses to support loved ones and communities with dignity and compassion. Finally, the ability to provide a dignified death was seen as a core benefit. Participant 7 succinctly stated, ‘...we can learn how to give a peaceful death. That is the main benefit of palliative care.’ This powerful expression underscores the profound ethical and humanitarian role that trained palliative care nurses play in ensuring a patient’s final experience, which is as comfortable, meaningful and dignified as possible.

Subtheme: Balancing academic demands with the need for experiential learning

Several participants conveyed overall satisfaction, with no significant criticisms. However, a few participants noted challenges related to academic and practical aspects. Participant 2 shared, ‘Exams were a little tough... and you can add more visits, maybe. Even students can take initiative…find out homes where we can visit.’ This suggests that while the theoretical knowledge was valuable, students felt that greater exposure to real-world palliative care environments would enhance learning.

Academic pressure was another minor challenge. Participant 5 pointed out, ‘Actually, our nursing curriculum is too tight, so during exam time I felt some difficulties studying these contents’. Balancing the additional coursework of palliative care education with an already demanding nursing curriculum was seen as a stressor for some.

Participants also identified the need for more experiential learning. Participant 6 suggested, ‘If there were more practical sections, it would have been good.’ This feedback indicates a desire for richer hands-on experiences, enabling students to apply theoretical knowledge directly in clinical settings.

Subtheme: Expanding clinical exposure and course duration for deeper learning

Participants provided several thoughtful suggestions to enhance the value-added palliative care education course, with a strong emphasis on integrating more clinical exposure, practical learning and extended program duration. Participant 1 advocated for more hands-on experience, saying, ‘Include more clinical experience... adequate theory classes... but clinical practice should be there... opportunity to visit patients who are suffering with cancer or other kinds of problems’. Some participants felt that the course duration was too short and suggested extending it to allow for more comprehensive learning. Participant 2 commented, ‘It was a short period of time. really liked the memory we had at palliative care home centres... can add more of that visit’. Similarly, Participant 4 suggested, ‘They could have extended the period of time... 6 months of course... better if extended’. In line with this, there were calls for greater home-based care exposure. Participant 3 proposed, ‘We can increase palliative home visits... we can go do home visits and provide some direct care’. Many participants also highlighted the need for a practical emphasis in the course. Participant 5 remarked, ‘More based on the practical aspects. including more practical will improve quality’. This suggestion aligns with the feedback from Participant 6, who shared, ‘More theory and only some visits... if practical sessions in cancer centres... spent one full day... know more about these things’. They both stressed that practical, hands-on experiences in clinical settings would greatly enrich the learning process. Finally, expanded learning hours were recommended by Participant 7, who suggested, ‘Increasing the hours of sessions... conducting visits to palliative care centres and homes... help them know more’. This call for extended time in both educational sessions and field visits reflects a desire to deepen the level of understanding and compassion that comes with working in palliative care.