Death literacy in senior nursing students: an experiential learning approach

Carlos Laranjeira^1,2 , Joel Vitorino^1,2 , Isabel Semeão^2,3 , Ana Querido^1,2

¹Center for Innovative Care and Health Technology (ciTechcare), Polytechnic University of Leiria, Portugal; ²School of Health Sciences, Polytechnic University of Leiria, Portugal; ³Hospital Palliative Care Team, Local Health Unit of the Leiria Region, Leiria, Portugal

How to cite: Laranjeira, C.; Vitorino, J.; Semeão, I.; Querido, A. (2026). Death literacy in senior nursing students: an experiential learning approach. In: 12th International Conference on Higher Education Advances (HEAd’26). Valencia, 15-18 June 2026. https://doi.org/10.4995/HEAd26.2026.21776

Abstract

Nursing students must deal with the fact that death is an inevitable event in life, whether it be that of a close friend or family member, or part of clinical training. This study aims to explore how a Compassionate End-of-Life Aid course can foster nursing students’ awareness and knowledge of challenges in caring for a terminally ill person. Forty senior nursing students who participated in the Compassionate End-of-Life Aid course were invited to answer an assessment tool, including both quantitative and qualitative replies. Overall, 83% of participants rated the course feasible and “very good”. Three main themes were found: (1) Secure learning atmosphere; (2) Sharing experiences of witnessing the death of loved ones; (3) Talking openly about death and dying. Death education through immersive experiential practices is essential to empower students to care for terminally ill patients with dignity, overcoming trivialization or fear.

Keywords: Palliative Care; Last aid; Death Literacy; Nursing students; Compassion

1. Introduction

Talking about death is still taboo in many cultures. A lack of information and preparation about the dying process can increase the suffering of those facing a serious illness, as well as that of family members and caregivers, especially during bereavement. Death is part of life, but when discussion of death is avoided or silenced, it can generate fear, loneliness, and helplessness (Dursun et al., 2022).

The Last Aid course was created to transform this lack of awareness and discussion. This international initiative seeks to educate the public about palliative care (PC), the end of life (EoL), and bereavement, offering support, techniques, and information so that people know how to act, support, and connect with empathy in the final moments. Thus, it strengthens social bonds and contributes to collective well-being, creating more compassionate communities. This approach relies on three elements: social consciousness, education, and the establishment of networks. Key factors for its success include robust leadership and a high level of engagement (Vitorino et al., 2024). A potential obstacle to the establishment of compassionate communities is the hesitance of caregivers to solicit and accept assistance from others (Grindrod & Rumbold, 2018).

Key PC competencies encompass the evaluation and management of symptoms of serious illness, effective communication techniques to assist patients and families in comprehending and managing illness throughout its progression, advocacy abilities to guarantee person-centered care consistent with personal objectives and values, and the provision of dignified care for terminal patients along with bereavement support (Glover et al., 2019). The extensive range of these abilities, necessitating physical, psychological, and emotional responsiveness, is a challenge for conventional nursing education. The disparity in PC material within nursing courses, coupled with insufficient faculty preparation to teach this subject, results in a knowledge deficit among nurses regarding PC (Ferrell et al., 2018).

Compassionate community engagement and Last Aid courses are strategies for raising awareness and improving knowledge about death, dying and PC (Bollig & Bauer, 2021). The course was developed in 2008 by the German physician Georg Bollig, a specialist in PC and intensive care medicine. According to Bollig and Bauer (2021), participating in the course increases knowledge about the dying process, reduces fear and stigma related to death, and strengthens social cohesion by encouraging the emergence of compassionate communities where people support each other in difficult times. The courses are often conducted by two certified teachers possessing expertise in PC, such as physicians, nurses, hospice volunteers, clergy, and social workers. Workshops take place in a variety of community sites, including hospitals, churches, schools, and other public spaces. They are also offered as training programs for healthcare professionals, law enforcement officers, or military personnel. The training comprises four 45-minute modules, totaling 3.5 to 4 hours, including breaks (Giehl et al., 2023). It provides participants the opportunity to gain knowledge, reflect on their personal experiences regarding dying and death, and cultivate a palliative attitude (Giehl et al., 2023). The integration of Last Aid courses and compassionate communities may enhance EoL care for individuals passing away at home (Bollig et al., 2019).

Compassionate End-of-Life Aid (CEoLA) courses offer fundamental instruction and serve as a platform for discussing and reflecting on death and dying within society and how we can act as citizens and foremost as professionals. Therefore, it is essential to assess the course curricula and to conduct additional research on participants' experiences. Currently, as a thorough scientific assessment has not yet been performed, there is insufficient scientific evidence regarding the effect on participants and the impact of the courses. Therefore, this study aims to explore how a CEoLA course can foster nursing students’ awareness and knowledge of challenges in caring for a terminally ill person.

2. Methods and Materials

2.1. Study design

A descriptive and exploratory qualitative study was carried out following the COREQ reporting guidelines. The qualitative approach allowed the investigation of subjective views on the phenomenon, including opinions, values, and beliefs, constructed from the lived experience of each individual, i.e., views that arise from personal reflection of past and present experiences when thinking, feeling, relating, and acting regarding EoL care (Renjith et al., 2021). The study adhered to ethical guidelines and was approved by the Ethics Committee of the Polytechnic University of Leiria (CE/IPLEIRIA/54/2023).

2.2. Participants and recruitment

Using a purposive sampling strategy, fourth-year undergraduate nursing students enrolled in the CEoLA were invited to participate in the study. While these students had previously cared for dying patients during clinical practice, they had not yet been taught PC Nursing. All participants received a succinct presentation on the significance of assessing the course to enhance its quality in terms of learning outcomes. They were notified that participation in the study was optional. Forty senior nursing students, aged 20 to 45 (23.57±3.89), voluntarily engaged in the CEoLA course. Upon granting informed consent to participate in the study, they were distributed in four different groups, each composed of 10 individuals.

2.3. Compassionate End-of-Life Aid (CEoLA) course

Kolb’s Experiential Learning Theory (ELT) provides a comprehensive framework in advanced nursing education. ELT asserts that learning is a cyclical process consisting of four stages: “concrete experience, reflective observation, abstract conceptualization, and active exploration” (Cheng et al., 2022, p.1). This approach effectively complements pedagogical strategies including case-based learning, mind mapping, and reflective journaling, which together improve engagement and competency growth in clinical education (Cheng et al., 2025).

To transform experiences into actionable knowledge, the four modules of the CEoLA course (1. Dying as a normal part of life; 2. Experiencing Suffering; 3. Relieving suffering; and 4. Exercising Compassion) were running as a workshop, follow the Kolb’s experiential learning cycle (Cheng et al., 2025). Themes include Death and suffering, EoL care, advanced care planning and decision-making, compassionate care and symptom management, and cultural dimensions of death and bereavement. The workshop took place in a single day comprising four instructional units of 45 minutes each. This experiential immersion training was broken into two segments, each lasting 1.5 hours with a 30-minute intermission. The instructors were nursing faculty members with experience in the field of PC. They were formerly allotted a full day of training. The workshops encompassed both teaching (e.g., strategies to alleviate pain, dyspnea, and nausea, emotional and spiritual suffering, as well as information regarding locally available PC facilities and support) and reflection on death and dying in general. Additionally, sensorial immersive approaches were used to stimulate several senses—visual, auditory, olfactory and tactile—to foster a sensation of presence and enhance memory retention. Sensory cues function as elements of immersion using real-world EoL cases, all of which can influence cognitive engagement and emotional regulation.

2.4. Data Collection

The research was carried out from September to December 2025 (1^st semester). The authors created a web-based questionnaire using the Google Forms platform to evaluate the workshop, consisting of (1) sociodemographic data of the participants; (2) ranking the course as a whole (using a 4-point Likert scale from 1=very good to 4=inadequate); and (3) closed and open questions (e.g. Was the course helpful?; I used to think that..., now I think that...; By the end of the course, I learned that...).

2.5. Data analysis

Descriptive statistics were employed to characterize the participants. The conventional content analysis method proposed by Graneheim and Lundman (2004) was employed for the qualitative data analysis. The following steps were followed: 1. Identification of units of meaning: words, phrases, or paragraphs from the interview text; 2. Condensation: preservation of the core of the units of meaning; 3. Generation of codes: application of labels to the units of meaning; 4. Creation of categories: definition of set(s) of content that share a common trait; and, finally, 5. Formulation of themes: expression of the latent content of the text.

3. Findings and Discussion

Overall, 83% of participants classified the course as feasible and “very good”. Nearly all participants (96%) found the course material easily understandable, 89% indicated that they had acquired numerous new insights, and 91% found the CEoLA course to be beneficial for everyone. The qualitative data were organized into three main themes, as described below.

(1) Secure learning atmosphere

Most students characterized the ambiance as pleasant and inviting. They valued the candid exchanges regarding the personal experiences of both instructors and participants. Some described an atmosphere of trust and transparency:

Creating an intimate space allowed for the sharing of experiences and the airing of emotions (P14, 20 years).

(2) Sharing experiences of witnessing the death of loved ones

Some participants expressed their emotions and reflections regarding the loss of their loved ones and the impact of being present during the dying moments on their grieving process. Some students reported sadness and an inability to do anything:

I remember being completely lost after losing my grandmother, and even today it's hard for me to talk about it (P32, 38 years).

At this point, evidence revealed that nursing students frequently experience sadness, uncertainty, and confusion while delivering care to dying persons, highlighting the imperative for practical exposure in PC (Ferguson et al., 2017; Liu et al., 2011).

Other students expressed gratitude for having helped their loved ones during the EoL trajectory:

If I feel at peace today, it's because I was there when she (my mother) passed away (P21, 21 years).

Having lived through family experiences of loss has given me the tools to be better prepared to care for people in palliative care situations. My perspective on death has changed; now I feel more compassionate (P36, 24 years).

Notably, being present during their final moments affected their grief process. Nursing students may become more empathetic and compassionate toward patients and their families despite having gone through the feelings and difficulties of dying. For that reason, experiential education not only promotes personal growth but also motivates students to learn (Haroen et al., 2023; Vitorino et al., 2025).

(3) Talking openly about death and dying

Several students appreciated the relatively untroubled perspective on death and dying during course discussions. Despite being first-time participants, the majority engaged in candid discussions regarding death and dying inside the group. Several students conveyed their motivation to deliver compassionate care to patients and their families. This aspiration to engage compassionately with the patient frequently coincided with introspection over their own convictions about severe illness and mortality.

Through the immersive techniques used, I learned that dignity in care is not limited to techniques, but is reflected in my attitudes, behaviors, compassion, and dialogue with the patient and family (P5, 22 years).

I used to think that palliative care was limited to EoL healthcare and nothing more, but now I think that palliative care goes far beyond that and should be further developed and worked on with the community to make these processes more natural and dignified for everyone. (P19, 23 years).

I learned to appreciate the small details that make all the difference in the comfort of others. (P40, 29 years).

Overall, this study emphasizes that experiential immersion in PC can enhance abilities in senior nursing students. Awareness of one's own views and values is a crucial ability in delivering health care, particularly in the context of EoL care (Laranjeira et al., 2021; Pereira et al., 2025). Initially, students may experience apprehension regarding their capacity to engage with dying individuals; however, they often discover that these relationships may be constructive and significant (Frost et al., 2025; Mackay & Bluck, 2010).

3.1. Study Limitations

We have to acknowledge some limitations. First, the sample size was limited and not representative of the entire population of nursing students. Second, student participants were restricted to seniors. Consequently, many assessed competences were possibly attributable to the independent maturation of student nurses. In this project, the options of interaction with dying patients and their families were distinctive and surpassed conventional patient-nurse contact. In further iterations of the study, we aim to engage students earlier in their schooling and assess this dimension of competency acquisition. In addition, the study did not assess students’ prior knowledge or experience with PC, thereby limiting its capacity to measure changes in knowledge attributable directly to the course. Pre- and post-intervention assessments are recommended to best evaluate the program’s impact. Ultimately, while students' perspectives were gathered during their engagement in PC education through the Last Aid course, we cannot conclusively ascribe these results to the program without a control group. These are concerns we aim to resolve in further endeavors.

4. Conclusions

Education about death in nursing is therefore fundamental to equip students with the skills to approach the EoL in a humane, ethical, and technical way, reducing anxiety, fear, and feelings of failure. It fosters the development of PC skills, improving the patient's quality of life and family support, as well as promoting the professional's emotional self-care. Offering immersive experiences in delivering comfort to PC patients may assist students in recognizing the essential human significance of care and comfort as vital to their nursing profession. Innovative educational programs aimed at preparing the next generation of nurses, particularly given the increasing prevalence of patients with severe illnesses, aligned with the nursing profession's commitment to PC.

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