Nurses Lacking Education in Palliative Care Experience Moral Distress


New findings show that while nurses need to provide more palliative care to patients, they are not prepared to do so, leading to high levels of moral distress.

In a recent study titled, “Palliative Care and Moral Distress: An Institutional Survey of Critical Care Nurses,” researchers found that respondents experienced more moral distress while in the clinic and if they had less perceived use with palliative care.

Fewer than 40% of respondents reported being highly component in any type of palliative care, and 38% of those respondents reported not having any palliative care education in the past 2 years.1

Researchers concluded that due to this lack of training, when nurses perceive their ability to provide palliative care is inadequate and are asked to provide this care, they are more prone to feeling moral distress. This moral distress not only impacts their work, but can also affect their home lives creating psychosocial damage detrimental to a nurses’ wellbeing, and while this study is focused on critical care nurses, these issues within palliative care extend to the oncology nurse.

“While this is a critical care group, the findings are extremely relevant to the oncology population and oncology nurses across settings,” said Betty Ferrell, PhD, MA, FAAN, FPCN, director of the Division of Nursing Research and Education at City of Hope, in an interview with Oncology Nursing News® addressing the use of education to help palliative care practices.

“There have been similar studies like this, including in the oncology nursing space, and generally all of those studies have had very similar findings that nurses are not prepared to care for very sick or dying patients,” Ferrell explained, highlighting that moral distress for nurses in these situations comes from the gap of knowing the care that is right to deliver and the care that the nurse is prepared to deliver.

This is where further education needs to step in to fill the gap, like the End-of-Life Nursing Education Consortium (ELNEC), a program that Ferrell was the principal investigator on, and co-author of the study Kenneth R. White, PhD, RN, ACNP, ACHPN, has recommended for any nurses engaged with palliative care.

White, professor of nursing and medicine and Associate Dean of Strategic Partnerships and Innovation, School of Nursing, University of Virginia, and a palliative care nurse practitioner, University of Virginia Medical Center, Charlottesville, Virginia, had the chance to speak with Oncology Nursing News® and discuss the findings of the study and how education and collaboration is essential for health systems to help address the moral distress nurses are experiencing.

Oncology Nursing News®​​​​​​​: Can you briefly describe the objectives of this study?

White: We sought to find out more about what critical care nurses viewed as their self-assessed level of palliative care knowledge and competency. A second objective was also assessing at the time of the study, the respondent’s self-perceived moral distress.

How did this study come about, and where was the need for this study first identified?

Alex Wolf was obtaining his DNP degree from UVA and focused his education on palliative care. He is a critical care nurse by experience and sought to learn more about critical care nurses’ perceptions of palliative care. He had observed in his own practice that critically ill patients were not always given the option for palliative care when facing complex chronic illness. Two of the faculty co-authors (White and Epstein) had developed a survey instrument, “Palliative Care Competencies of Registered Nurses,” which was used to gather information for the results.

Aside from having health system leaders prioritize palliative care training, are there any resources for nurses to use to help increase their understanding of palliative care?

Yes! The ELNEC is a national program that is focused on increasing knowledge in the palliative care domains. ELNEC is designed for specific patient populations and has “train-the-trainer” programs for replication and rapid spread. There are many other resources available such as the Clinical Practice Guidelines for Quality Palliative Care, 4th Edition. (The AACN also provides its own list of palliative care and end-of-life clinical resources).

For respondents and other nurses experiencing moral distress from being unable to provide proper palliative care, how would you advise them to help treat their own moral distress?

It is important to find someone to talk to when a person experiences moral distress in their practice. It may be a colleague, a nurse manager, or a member of the ethics consult service. At UVA, nurses have championed a palliative care group in order to learn more about palliative care and to have a voice with other professional colleagues in improving access to palliative care.

While the study focused on nurses in the intensive care unit, how do you think these findings may apply to palliative care training in the oncology nurse setting?

The survey that was used in this study was adapted for critical care nurses from a study that was originally designed for oncology nurses. The results of two national studies that surveyed oncology have been published and a follow up 10 years later.

The findings with the critical care nurses are similar to the findings with oncology nurses. The most often cited knowledge gap is how to talk with patients and families about death and dying.

What do you hope happens for the future of palliative care?

Although it is important for nurses to have more knowledge about palliative care and to be able to recognize signs of moral distress, it is also important that nurses and physician colleagues collaborate and practice inter-professionally. It has been shown that when nurses have more knowledge about palliative care, the moral distress may increase when their patients are not receiving the best care possible, which may include palliative approaches. Palliative care is a discipline that must be learned and practiced inter-professionally.


  • Wolf AT, White KR, Epstein EG, Enfield KB. Palliative care and moral distress: an institutional survey of critical care nurses. Critical Care Nurse. 2019;39(5):38-50.

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