The stakes are considerable. According to the International Agency for Research on Cancer, roughly 20 million new cancer cases and 9.7 million cancer deaths were recorded globally in 2022, and the burden is projected to grow by 77 percent in new cases by 2050, with mortality nearly doubling. Cancer remains a leading cause of death in China, and dying patients and their families endure profound physical, psychological, social, and spiritual distress. In a global expert assessment of end-of-life care quality across 81 countries and regions, China ranked 53rd, a finding that the study team describes as an urgent call to strengthen how terminally ill patients are cared for in their final days.

Nurses, who have the most frequent contact with dying cancer patients, sit at the center of this challenge. Prior research has shown that they often lack knowledge of end-of-life care, and that gaps in knowledge are reflected in their attitudes and behaviors. Previous training efforts have had mixed results: a Swedish randomized trial improved communication skills but focused narrowly on end-of-life communication, while a Turkish course increased nurses’ acceptance of death but also heightened their fear of it. The Chinese team’s earlier CARES-based course improved attitudes and behaviors but lacked grief support and practice guidelines, and its pre-post design could not exclude environmental biases.

To close these gaps, the researchers built their program on two foundations. First, they developed a supportive care strategy list for end-of-life cancer patients, grounded in supportive care theory and clinical guidelines. Second, they used the Delphi method — a structured consensus process among experts — to construct a training curriculum covering dying phase identification, symptom management, psycho-emotional care, family engagement, and bereavement support. The design draws explicitly on the knowledge-attitude-practice (KAP) model, a widely used framework in health education that holds that knowledge provides the foundation for attitudes, attitudes drive behavioral change, and improved practice ultimately achieves better health outcomes.

The intervention itself was substantial: 18 classes of 45 to 60 minutes each, delivered weekly over seven weeks in February and March 2024. Content was organized into six modules, ranging from an overview of end-of-life supportive care and recognition of the terminal phase, through end-of-life communication, patient-centered symptom and comfort care, family-centered care, and finally bereavement support for families after death. Instruction deliberately avoided passive lecturing alone, incorporating case analyses, role-playing, scenario simulations, video-based learning, and hands-on operational demonstrations. Four instructors — clinical oncology nurses with more than a decade of experience and faculty of the Chinese Nursing Association’s Hospice and Palliative Care Nursing Specialist Training Program — delivered the course, and assessment included situational simulations and reflective summaries.

The study enrolled 28 matched pairs of nurses from 28 clinical departments at Peking University Cancer Hospital, with one nurse per department volunteering for training and a demographically matched colleague serving as a wait-list control. Matching covered age, gender, education level, nursing rank, and years of oncology nursing experience, with experience differences capped at three years. One control participant withdrew after resigning, leaving 27 complete pairs. Baseline questionnaires were collected in late February 2024, and follow-up assessments occurred roughly eight months after training, from late November to early December 2024. The team measured knowledge with a purpose-built 50-item End-of-Life Care Knowledge Questionnaire spanning seven domains, attitudes with the Chinese-validated Frommelt Attitude Toward Care of the Dying Scale, and behaviors with a 31-item practice questionnaire developed by the same group.

The results on knowledge were striking. The training group’s total knowledge score rose from 103.19 before the intervention to 131.41 at follow-up, a statistically significant gain, while the non-training group’s score moved only from 106.22 to 111.48, a change that did not reach significance. In inter-group comparisons after the intervention, the trained nurses outperformed their matched colleagues in the total score and in six of the seven knowledge domains — everything except emotional and spiritual support. Within the training group, every domain improved, including overview of the dying, pain management, comfort management, airway management, restlessness and delirium management, emotional and spiritual support, and nurses’ self-care. The control group showed no significant change in any domain except pain management.

Attitudes shifted as well. Both groups began with relatively high attitude scores — 120.89 for the training group and 117.44 for the controls on the Frommelt scale — but the trained nurses rose significantly to 128.11 at follow-up, while the control group’s change was not statistically significant. The researchers attribute this to the curriculum’s emphasis on the importance and urgency of terminal-phase care, its use of real clinical cases and authentic feedback from patients and families, and its ability to alleviate nurses’ apprehensions while fostering professional engagement. Notably, roughly half of the participating nurses had received either no prior end-of-life care training or only brief sessions under 60 minutes, underscoring how much structured education was needed.

Behaviors told a more nuanced story. Within the training group, all five behavioral domains — pain and comfort management, airway management, restlessness and delirium management, emotional and spiritual support, and self-care — improved significantly, with the total behavior score climbing from 69.48 to 82.91. Yet the inter-group comparison after the intervention showed no statistically significant difference between the two groups. The researchers offer two explanations. First, raw scores did shift, with the control group starting slightly higher and the training group ending slightly higher, and the data imputation strategy used for nurses without dying-patient care experience may have underestimated the intervention’s effect. Second, and more intriguingly, the two groups worked in the same departments: the trained nurses served as role models, and their clinical practices provided observational learning opportunities and encouragement for their untrained colleagues, consistent with Bandura’s social learning theory. This spillover effect, while scientifically complicating the comparison, is arguably a practical benefit — the training’s influence radiated beyond the classroom.

The authors are candid about the study’s limitations. It was a single-center, quasi-experimental trial with a small sample, not a randomized controlled trial; the shared-department design introduced confounding through information sharing; convenience sampling may limit generalizability; the curriculum was tested only at a specialized oncology hospital; the eight-month follow-up differs from the six-month benchmarks common in educational intervention studies; and all outcome measures were self-reported, exposing the results to self-report, social desirability, recall, and observation biases. The analysis also did not correct for multiple testing across subscales, and the female-predominant sample precluded sex or gender subgroup analysis. Even so, the consistency of knowledge and attitude gains, sustained at eight months, offers a compelling case. The team recommends that the program be incorporated into continuing education for oncology nurses and paired with sustained quality improvement initiatives, so that evidence-based supportive care strategies become embedded in routine clinical practice — and so that dying cancer patients, and the families who love them, receive care that is competent, compassionate, and dignified.

Subject of Research: Effect of a structured end-of-life care education program on oncology nurses' knowledge, attitudes, and care behaviors

Article Title: Effect of the end-of-life care education program on improving oncology nurses’ knowledge, attitudes, and behaviors: A quasi-experimental study

Article References: Yu, W., Hou, X., Guo, R., Wang, Y., Ma, X., Pang, D., & Lu, Y. (2026). Effect of the end-of-life care education program on improving oncology nurses’ knowledge, attitudes, and behaviors: A quasi-experimental study. iScience, 29(11), Article 117836. https://doi.org/10.1016/j.isci.2026.117836

Image Credits: AI Generated

DOI: 10.1016/j.isci.2026.117836

Keywords: end-of-life care, palliative care, oncology nursing, nursing education, quasi-experimental study, knowledge-attitude-practice model, bereavement support, symptom management, cancer care, China, iScience, continuing education