caring for dying persons and their families has always been a major responsibility of nurses . nurses working today can expect to care for dying persons and their families in hospitals , private residences , nursing homes , prisons , and most other places of employment . this care can be very difficult to provide , in part because death is such a significant event but also because it is not always evident when a dying process is occurring . in the 1960s , the enlightened approaches of elizabeth kubler - ross , cicely saunders , and jeanne quint benoliel began to impact end - of - life care , helping to shift it from primarily cure - oriented and life - prolongation efforts to palliative or comfort - oriented care and quality - of - life - remaining efforts [ 26 ] . in canada , balfour mount is widely considered the father of palliative care through his efforts , which include founding montreal 's royal victoria hospital palliative care service in 1974/75 . today , palliative care is widely recognized as an essential healthcare service , and it has become a nursing and medical specialty in many countries [ 79 ] . since 2004 , the canadian nurses association has had a certification program for nurses who choose to specialize in hospice / palliative care . this credential , signifying an expert level of palliative care knowledge and skills , is not a prerequisite however for every nurse who provides end - of - life care . as deaths occur in many different settings and across all age groups [ 1 , 11 ] , every nurse must be prepared to care for dying people and their families . palliative or end - of - life care education is thus an important component of introductory nursing programs . the palliative or end - of - life care education provided to nursing students in canada and other countries has been infrequently studied , with trend and other vital information for planning and evaluation purposes thus not available . more than a decade has passed since the last published research study in 1997 by downe - wamboldt and tamlyn   provided readily accessible information on the death education offered in introductory nursing programs to nursing students across canada . a research investigation was subsequently designed to assess , describe , and compare palliative or end - of - life care education across canadian undergraduate nursing programs , so as to be able to critically examine canadian student nurse death education trends . many research articles aimed at improving the care of terminally ill and dying persons have been published since the palliative care movement began over 30 years ago . however , only two published research studies on the death education of canadian student nurses were located [ 12 , 14 ] . the more current one by downe - wamboldt and tamlyn   provided information on nursing and medical programs across canada and the united kingdom . three additional studies focused on death education for nursing students in the united kingdom [ 1517 ] , and two studies focused on death education for student nurses in the united states [ 18 , 19 ] .   the most current investigation of canadian education , by downe - wamboldt and tamlyn , involved a mail questionnaire sent to 29 nursing schools , with completed surveys received from 27 . all 27 had death education content , with 93% having this content integrated throughout the curriculum and 7% having a required course instead . the average total time allotted for death education per program was 24.5 classroom hours and 36.25 clinical practice hours . lectures were the most common instructional method ( 70% of schools ) , followed by case studies , small - group discussions , and viewing audiovisual materials ( 59% each ) . less common teaching strategies were self - directed activities ( 44% of schools ) , role - playing ( 30% ) , clinical experience ( 19% ) , and journal writing ( 4% ) . the most common educational topic was the needs of the family ( 88% of schools ) , followed by communication ( 82% ) , loss / grief ( 82% ) , and bereavement ( 82% ) . additional common topics were spirituality ( 78% of schools ) , the role of healthcare professionals ( 78% ) , pain / symptom control ( 78% ) , dying of cancer ( 74% ) , ethical issues ( 70% ) , death anxiety ( 63% ) , cultural diversity ( 63% ) , the hospice movement ( 63% ) , dying of aids ( 59% ) , legal issues ( 56% ) , and body image ( 52% ) . students were most often given tests ( 74% of schools ) to examine their knowledge , although more than half of the schools also required students to write papers , demonstrate effective clinical practice , and/or write case studies of their experiences . discussions ( 82% of schools ) comprised the most common method for evaluating the student 's affective domain , followed by clinical practice observation ( 63% ) , attitude measurement ( 26% ) , and death anxiety measurement ( 22% ) . the first investigation of death education in canadian nursing schools , by caty and downe - wamboldt , also employed a mail questionnaire sent to 29 nursing schools . their study revealed 21 of the 28 responding schools ( 75.1% ) provided death education , with 19 ( 90.4% ) integrating it throughout the curriculum and 2 ( 9.5% ) having a required course . of the 7 schools that reported no mandatory death education , 4 indicated that none was provided and 3 indicated they had an elective course for students . these two studies show that death education had become a standard component of introductory canadian nursing programs by the mid-1990s , as compared to the 1980s when only 3/4 schools included it . since the 1990s , educational changes could be expected , such as new or more topics , differences in weighting of death education against other topics , evaluation methods , and teaching / learning methods . change is also expected because context - based or problem - based learning ( pbl ) is now common across canadian nursing programs [ 2022 ] . one study has even examined the pbl approach as a method for providing death education to post - rn students . the common concern with pbl of uneven learning across students was not found to be evident , as all student subjects reported fruitful discussions of personal experiences and published information . interdisciplinary courses and other teaching / learning innovations have also been tested for their effects , with some benefits determined [ 2427 ] . these studies collectively indicate that awareness exists among nurse educators that death education should be included in introductory nursing programs . in keeping with the two previous canadian studies , a mail survey was used to gather data from nursing schools / faculties across canada . questions similar to those in previous surveys were included in the survey , with the draft questionnaire piloted at a local school and some questions revised . after research ethics approval was obtained from the university of alberta 's health research ethics board , all 35 schools / faculties offering introductory nurse education were surveyed in mid-2004 about the death education provided in the 2003/04 academic year . the canadian association of schools of nursing website was used to formulate this list and gain a contact name for each site , with the envelope addressed to each dean or director . all schools / faculties were situated in universities , with these offering four - year programs and with many of these universities having similar satellite programs offered in smaller universities or colleges . after a reminder letter and repeat survey were sent to nonresponders , a total of 29 completed questionnaires were received ( 82.9% response rate ) . descriptive / comparative data analyses appropriate for the data variables were then conducted using the spss computer software package . these findings were later compared to those gained in 2010 from a representative at each of the same schools / faculties ; teachers were asked by email communications to determine if there had been any major changes in death education since the 2003/04 year . all representatives reported ( again by email ) that their schools were continuing to primarily provide death education in various pbl scenarios and/or courses and through opportunities gained in a wide range of clinical venues . for the 2003/04 year , 28/29 ( 96.6% ) school representatives reported that death education was a standard or mandatory curriculum component , with the one school ( 3.4% ) not having it as such reporting that a course was in development ( this course was subsequently initiated the next year ) . integrating death education content throughout the program was the approach used by 16 schools ( 57.1% ) , while 12 ( 42.9% ) schools addressed this content in a required course that all students had to take . eight of the schools , that had content integrated throughout the curriculum , also had an elective palliative or end - of - life care course available to students . the 28 schools with death education present employed 5.9 teaching / learning strategies on average ( 5.5 median ) . lectures were commonly reported ( 82.1% of schools ) , followed by small group discussions ( 78.6% ) and case studies ( 67.9% ) . eight ( 28.6% ) had a palliative clinical practicum , although this was a required experience at only one school . among these eight schools , palliative clinical practice hours ranged from 25 to 340 ( 179.2 mean , 151.0 median ) in total . one respondent reported having an elective only practicum as there were  too many students and not enough palliative care nurses / clients . four of the 28 respondents indicated that they could not tabulate instructional hours as the content was integrated throughout their pbl program , while 9 ( 32.1% ) other respondents provided a target number of hours ranging from 4 to 215 ( 47.6 mean , 39 median ) . these instructional hours were spread over all four years ( 39.3% ) , placed entirely in the first year ( 35.7% ) , or divided across years two and three ( 25% ) . the most frequently cited educational topics were attitudes to death and dying ( 92.9% of schools ) , communication with family and friends of the dying person ( 92.9% ) , and personal exploration in relation to death and dying ( 92.9% ) . communication with dying patients , cultural diversity , loss / grief / bereavement , and pain and symptom management were also common topics ( 89.3% each ) , followed by the role of the nurse ( 85.7% ) , spiritual issues ( 82.1% ) , death anxiety ( 60.7% ) , legal issues ( 53.6% ) , and body image ( 50.0% ) . the average number of topics covered per school / faculty was 11.4 , with 12 the median number . seven respondents ( 25% ) indicated that they did not employ any cognitive testing of students , while 21 ( 75% ) reported evaluating cognitive knowledge through tests and/or written papers . case study testing was also reported as occurring in 57.1% of schools / faculties , and clinical practice evaluation was reported as occurring in 66.7% of schools . most ( 95.2% ) of the 21 schools also evaluated the affective domain , with 95.2% using discussion - based evaluation to ensure that students were emotionally prepared to provide end - of - life care . clinical practice evaluation was also commonly used to evaluate the student 's affective domain ( 61.9% ) , in addition to attitude testing ( 28.6% ) and death anxiety measurement ( 14.3% ) . most respondents ( 93.1% ) indicated that they personally felt death education  should be provided  to all undergraduate nursing students , with the remaining 6.9% indicating that death education  should be allotted significant attention  or  must be provided . lack of time in the curriculum was the most frequently cited challenge ( 53.6% ) , followed by a lack of clinical placement or practice options ( 28.6% ) and a lack of knowledgeable teachers ( 21.4% ) . one respondent indicated that his school / faculty had twice the number of students wanting to take a death education course as space allowed . another raised the issue that if a student chose not to take the elective course and then did not care for dying patients in any practicum , that student could entirely avoid learning about death , dying , and end - of - life care . another respondent reported highly variable student exposure to dying persons and stated the concern that not all students have multiple experiences to develop attitudes , knowledge , and skills before graduation . this survey found that palliative or end - of - life care education was a component in all but one of the surveyed introductory nursing programs in the 2003/04 year and with that school / faculty implementing a required course the next year . although one limitation of this study is that surveys were not returned by 6 school representatives ( 17.1% ) , this study and the previous mid-1990s survey by downe - wamboldt and tamlyn   both indicate that canadian nursing schools typically offer death education to their nursing students . these findings are in keeping with the long - standing view among nurses that death education is essential for student nurses to prepare them for their future work [ 13 , 28 ] . one interesting difference identified across the mid-1990s and 2003/04 study findings is that death education was reported more often in the past as being integrated throughout the curriculum , despite canadian schools / faculties having since shifted to pbl as their primary teaching / learning approach [ 2022 ] . it is possible that death education began to be more deliberately planned across pbl scenarios and courses , as compared to the past when lectures were the primary teaching / learning method . in the 1990s , death education would have been more dependent on a teacher recognizing its significance and having selected knowledge or skills to teach . in contrast , pbl scenarios do not require classroom tutors to have palliative care knowledge or expertise , although clinical teachers should all have at least baseline end - of - life care knowledge and skills . in the united states , the issue of nursing teacher preparedness has been addressed by a train - the - trainer approach endorsed through the end - of - life nursing education consortium . canadian teacher training needs were recently illustrated as a concern through brajtman , fothergill - bourbonnaia , fiset , and alain 's 2009 single - site study which found only modest knowledge levels about the care of dying persons among 53 nurse educators . recently , the canadian hospice palliative care association along with a number of canadian nursing groups and health canada have collectively initiated a process to increase the amount of death education in nursing programs and also ensure its certainty there . another finding of interest , which was evident regardless of the shift to pbl as a primary instructional method , was that teaching / learning strategies were similar across the two surveys . lectures comprised the most common teaching / learning approach by 70% and 82.1% of schools / faculties , respectively . tests and written papers were the two most common methods for testing cognitive knowledge that were identified in both studies , followed by clinical practice and case study evaluations . similarly , discussions and clinical practice observation were two consistent methods used most often to evaluate the student 's affective domain . this is an issue for further research and perhaps attention and change , as these teaching / learning and evaluation methods may not be the most relevant or successful . graduating students need to be capable and feel well prepared to care for dying persons and their families . for instance , future students could be asked to : ( a ) write and present a scholarly paper on a chosen death / dying topic ( as these activities require in - depth work and critical thinking ) , ( b ) interview family members or friends about a recent death / dying experience and then compare their findings with classmates ( so they reflect on differences or similarities across people and situations ) , and/or ( c ) assist a palliative / end - of - life care research study or research proposal development process ( as active learning is more effective than passive learning ) . one difference between the two studies was an increase over time in instructional hours ( 24.5 and 47.5 on average , respectively ) and also clinical hours ( 36.25 and 179.2 hours on average , respectively ) . the increased time allotted to death education could explain the greater number of topics covered by each school / faculty in the 2003/04 year as compared to the mid-1990s . these changes suggest that educators are encouraging a more in - depth understanding of the needs of dying persons and their families . these changes could also reveal action on the enduring concern that nurses do not always feel adequately prepared to provide end - of - life care . although all nurse educators who responded to the 2004 survey indicated that death education should be included in introductory nursing programs , some volunteered the information that issues existed which could reduce the likelihood of every student becoming prepared to provide end - of - life care upon graduation . as indicated , these issues were essentially twofold : ( a ) there is a competition for time or space in very full curriculums , and ( b ) limited student exposure to dying persons . this space or time competition and lack of exposure to dying persons are not likely to end soon , as many important topics need to be covered in nursing curriculums , and most patients or clients are not dying . although death education is obviously valued as it was included in all but one school / faculty ( and by the next year it had been included in that school / faculty 's curriculum ) , it is likely that death education will need to be more emphasized in the future . population growth and population aging are beginning to double the number of persons who can be expected to die each year in canada . currently , around 250,000 persons die annually in canada , with 61% of deaths taking place in hospital and most of the remaining deaths occurring in nursing homes and private residences  places where nurses commonly work . although classroom preparation is clearly important for cognitive and perhaps affective foundations , clinical exposure and other real - life experiences are often essential for helping student nurses gain the knowledge , skills , and attitudes they require to provide effective end - of - life care and to be comfortable in providing that care . creativity may be needed to expand clinical practice opportunities beyond the current heavy reliance on the two traditional training settings of hospital units and nursing homes . additional learning opportunities , for instance , could be gained from experience with or exposure to loss / bereavement support groups , funeral home tours , code team follow - throughs , and/or shadowing organ harvesting or transplantation nurses . all nurses need to be prepared to care for dying persons and their families , with introductory nursing education programs critical for this preparation . since the mid-1990s , nurse educators in canada appear to have continued to recognize death education as essential in introductory nursing programs . the 2004 survey findings reported here indicate that nursing student death education has been growing in significance in canada , as more hours of classroom and clinical work are being devoted to it . however , there appear to be a number of challenges remaining to ensure that all student nurses have gained at least a basic level of theoretical and clinical preparedness upon graduation . given the projected increase in the number of dying persons in canada , it will be important to continue monitoring nursing student death education . advocating for more certain death education so that all students in nursing schools / faculties gain a solid foundation for practice may be needed . in addition , research to determine the immediate and long - term outcomes of this education is recommended . research and advocacy in other countries are also needed , as nurses worldwide must all be prepared to provide end - of - life care .
an investigation was done to assess for and describe the end - of - life education provided in canadian nursing programs to prepare students for practice . 
 all 35 university nursing schools / faculties were surveyed in 2004 ; 29 ( 82.9% ) responded . at that time , all but one routinely provided this education , with that school developing a course ( implemented the next year ) . as compared to past surveys , this survey revealed more class time , practicum hours , and topics covered , with this content and experiences deliberately planned and placed in curriculums . 
 a check in 2010 revealed that all of these schools were providing death education similar to that described in 2004 . 
 these findings indicate that nurse educators recognize the need for all nurses to be prepared to care for dying persons and their families . 
 regardless , more needs to be done to ensure novice nurses feel capable of providing end - of - life care . 
 death education developments will be needed as deaths increase with population aging .