End of life care being compromised by lack of nurse training, exclusive survey reveals

Poor discharge planning and lack of funding identified by Nursing Standard and Marie Curie survey as barriers to senior nurses planning end of life care

Poor discharge planning and lack of funding identified by Nursing Standard and Marie Curie survey as barriers to senior nurses planning end of life care   

Nurses can have little time to provide good quality end of life care. Picture: iStock

One quarter of UK nurses have never received end of life care training, an exclusive survey by Nursing Management's sister title, Nursing Standard, and terminal illness charity Marie Curie has revealed.

Findings from the exclusive survey of more than 600 UK nurses and healthcare assistants show a wide range of training experiences, and a strong desire for more education.

Almost 90% of respondents said they were involved in caring for dying patients, but only 75% had received training.

The survey also uncovered how end of life care is being compromised by pressures on the NHS.


of respondents saw more end of life patients in hospital, due to lack of community care, than in 2017  

65% of respondents said they have too little time to provide good care for the dying, a similar proportion to last year’s survey. Staffing levels and time constraints were other main barriers identified, followed by lack of provision in the community, including care homes, people’s homes and hospices.

Leading nurses in end of life care have questioned how nurses could be expected to provide good quality care without sufficient training.

Commons health committee report

The results of the survey, which show that access to continuous professional development (CPD) budgets was a ‘major issue’, come just weeks after the House of Commons health committee published a report on the nursing workforce.

The health committee report, which highlighted the huge pressure nursing staff are under, states: ‘We recommend that the cuts to nurses’ training budgets should be reversed and greater attention be given to ensuring nurses can access CPD.’

Desire for more training 

More than 60% of nurses said they wanted more training in having difficult conversations, dealing with grief and loss, and pain relief.

When it came to the training respondents had received, only 61% had been trained in difficult conversations and only 49% in grief and loss. 70% had received education on pain and symptom management, and 78% on recognising when someone is dying. 68% had had training on do-not-resuscitate decisions as part of advance care planning conversations.

41% wanted more training on recognising when someone is dying, but only 10% were not confident in telling when someone had entered the last months or weeks of life.

Dee Sissons

The figures for who had received training had increased from 2017, when 58% said they received any end of life training. In this year's survey, a higher proportion of respondents worked with patients in the final months, weeks and days of life than last year.

'Nurses are really struggling'

Marie Curie executive director of nursing Dee Sissons says that the lack of training is a big concern.

‘Nurses are really struggling to do their best in difficult circumstances,’ she says.

‘Nurses want to give the best possible care that they can. To do that, they need training and support so they have the right skills for delivering high-quality care in partnership with other people.

'It is not just about initial training; it is also about revisiting these skills and keeping confidence up for things like difficult conversations, particularly for the 10% who said they don’t have regular contact with people at the end of life.’

What nurses told the survey

Emergency department (ED) nurse: ‘Worked in ED for many years. Don’t remember getting any specific training apart from when I was a student nurse.’

Community clinical nurse specialist: ‘Specific training was put on by the community trust that I work for, through links with the local hospice palliative care team. I also completed the Recognising and Prioritising Care of the Deteriorating Adult course. This was a good course and helped me amalgamate my experiences over the years.’

District nurse clinical team leader: ‘Poor discharge planning, lack of handover to community teams and poor prescribing of end of life medication in the acute hospitals.'

Paediatric intensive care nurse: ‘We had an afternoon session as part of our foundation course when we started, it wasn’t much and unfortunately I can’t remember much.’

Oncology nurse in a private hospital: ‘It is an area I am interested in so regularly look out for courses. There are still a lot of staff who are scared of this area and training isn’t easy to come by.’

Clinical nurse specialist in acute trust: ‘Never received any training in my 37-year career.’


Many respondents said they would like the opportunity to undertake more coaching and wished their employers offered more courses.


of nurses have too little time to provide good care for the dying

One palliative care nurse specialist said they had only received mandatory e-training, which was ‘woefully inadequate’.

An emergency department nurse manager who cares for dying patients at least once a week, said they had never received specific training. ‘I have picked up most of these [end of life care] skills over the years with little professional input. Younger nurses and doctors struggle tremendously with end of life discussions and protocols,’ the nurse said.

Keri Thomas

Keri Thomas, national clinical lead for the Gold Standards Framework (GSF) Centre in End of Life Care, which provides training for front-line staff, says it is essential that general nurses are offered sufficient training as they will be carrying out the majority of end of life care.

Predicted rise

At any point, approximately 1% of the general population are in their last year of life, a figure that rises to 30% of those in hospital and an estimated 80% of those in care homes. With the number of deaths predicted to rise by 25% by 2040, and more people living longer with complex needs, it is clear that the majority of cases cannot, and should not, be covered by specialist palliative care services.

Professor Thomas says: ‘One in three hospital inpatients need some kind of improved end of life care, such as earlier recognition, better assessment, advance care planning discussions and proactive planning.’

However, 34% of respondents were not confident about starting conversations to do with end of life care with patients in the last year of life.

‘I would strongly suggest that nurse managers consider the critical role of the nurses in improving the experience and outcomes for patients and those important to them'

Eleanor Sherwen

'There is a terrific hunger in nurses to increase knowledge, awareness and understanding,’ Professor Thomas says.

‘We try to build confidence and competence, as good end of life care requires a proactive approach, good clinical skills, and the more human level of good communication, listening and speaking, which are important nursing skills. Palliative care specialists cannot look after every person in the last year of life in hospital or in the community.

'Generalists will be caring for 90% of hospital patients in the last year of life, but they need to be upskilled and enabled to do this well. We see great progress in our work enabling nurses across all settings using GSF. There is obviously a considerable gap and even more needs to be done in future.’


of nurses have had no end of life care training

However, some nurses did talk about receiving more extensive training, including courses that were five or six days long, and good education and support from their local specialist staff and hospice.

Eleanor Sherwen

A staff nurse on an acute medical ward described how regular sessions from palliative care nurse specialists was part of their preceptorship programme.

One district nurse, who had received training in the past six months, said: ‘I also have regular supervision and access to palliative care leads within the trust and nurse specialists from our local hospice.’

But RCN professional lead for end of life and palliative care Eleanor Sherwen says that the survey results are ‘worrying and disappointing’.

‘I would strongly suggest that nurse managers consider the critical role of the nurses in improving the experience and outcomes for patients and those important to them, and to ensure that education and training in this vital arena is not compromised in anyway.’

Community struggles

94% of nurses have seen dying patients stranded in hospital due to delays in funding and care provision.

54% said the number of acute sector patients waiting to go home or to care homes has increased since last year.

The Nursing Standard and Marie Curie survey highlights how community nurses are struggling to provide the care they aspire to give.

Patients could be discharged from hospital too late, or sometimes too early and without care packages and the necessary equipment, district nurses said.

One district nurse clinical team leader commented: ‘There is poor discharge planning, lack of handover to community teams and poor prescribing of end of life medication in the acute hospitals.'

Providing night community nursing, particularly in rural areas, was highlighted as one difficulty in the survey. One community staff nurse said patients have to wait an ‘unacceptably long time’ at night.


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