Iranian Journal of Nursing and Midwifery Research

REVIEW ARTICLE
Year
: 2019  |  Volume : 24  |  Issue : 4  |  Page : 243--250

Educating the existential view to nurses in cancer care: A review


Negin Masoudi Alavi1, Fatemeh Hosseini2,  
1 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
2 Trauma Nursing Research Center; Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran

Correspondence Address:
Fatemeh Hosseini
Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan
Iran

Abstract

Background: The aim of this study was to review the interventional studies about educating existential concepts to the nurses working in cancer care. Materials and Methods: In this systematic narrative review, the papers published in English and Farsi databases of PubMed, Elsevier, web of since, Scopus, ProQuest, ERIC, Google Scholar and Ovid, MagIran and SID, from 1990 to 2018 were reviewed. Methodological quality of the studies was independently assessed by, using checklists developed by Greenhalgh, and Cochrane Center. No statistical pooling of the outcomes was performed, due to heterogeneity of the outcomes. Results: After wide search, the 17 studies entered to this narrative study. The results showed that educating the existential concept to the nurses dealing with cancer patients can improve their self-competency in providing efficient care to these patients and their ability in decision making. It also enhances their quality of life and decreases the death anxiety and emotional exhaustion. Conclusions: There were limited and low quality interventional studies about the effects of educating existential concepts to the nurses dealing with cancer patients. These studies showed that knowing this philosophy can help nurses to address caring needs of cancer patients more efficiently. The specific method or content of education cannot be recommended because of the large differences in the methodologies between the studies.



How to cite this article:
Alavi NM, Hosseini F. Educating the existential view to nurses in cancer care: A review.Iranian J Nursing Midwifery Res 2019;24:243-250


How to cite this URL:
Alavi NM, Hosseini F. Educating the existential view to nurses in cancer care: A review. Iranian J Nursing Midwifery Res [serial online] 2019 [cited 2019 Sep 22 ];24:243-250
Available from: http://www.ijnmrjournal.net/text.asp?2019/24/4/243/261598


Full Text



 Introduction



Existentialists believe that life is meaningless unless the individuals give meaning to it; human beings want to find the meaning of life and self-realization.[1],[2] Thinking about the meaning of life and death happens for everybody, regardless of his/her religion, culture, gender, or age. Rapid improvement of health and medicine has decreased the rate of sudden deaths and has prolonged the end of life period. This has made the existential questions more visible.[3],[4] Especially in chronic diseases, the end-stage period seems longer and the patients are facing with the questions about the meaning of their existence more frequently.[5],[6] Cancer patients suffer from several complications, such as changes in appearance, inability to work, losing social and family roles, and physical pain, but beyond that many times they have deeper concerns about the meaning of their lives.[7],[8] Existential concerns would cause suffering and lead to a kind of spiritual pain.[9],[10] This spiritual pain is associated with disappointment, losing the meaning of life, pessimistic views, personal dissatisfaction, social isolation, and fear of death,[7] which is called demoralization syndrome. Even individuals who do not believe any religion, might suffer from spiritual pains. Talking about these issues with family members is difficult and nurses are the professionals that can help patients during this difficult period. So, nurses' knowledge about existential concepts is necessary for providing comprehensive care to the terminal patients.[7],[11],[12] Nurses usually do not receive sufficient education about these topics during their undergraduate education.[13] Nursing students must deal with end-stage patients; while they are not well prepared and many times have not dealt with the fear of death, which can influence the quality of care in these patients.[4] Therefore, helping patients to find hope and meaning of life, which is one of the nurses' duties, might be neglected easily.[14],[15] Meanwhile, nurses are the key member of the medical team who spend most amount of time with the end-stage patients and patients feel more comfortable discussing existential issues with them.

Most of the existential questions are about death and life, hope and faith, freedom and choice and relationships, and privacy. For example “why am I suffering from this disease? Why I won't get well? How long should I continue the treatments? Why God doesn't help me? Am I sinful and should suffer for purification of my soul? I keep crying for God but why He doesn't answer me?”. These questions of the patients are in line with the theory of Yalom in 1980.[16],[17] Nurses usually feel confused when dealing with these questions because they have not been educated about existentialist concepts. They prefer not to respond to the patients' questions and be silent that cannot help patients.[14],[18] Patients may think that nurses are ignorant, and they may stop talking to them about their concerns.[19],[20] Lack of conversations about these topics might lead to patients' loneliness and isolation during the end-stage of life,[21],[22],[23],[24],[25] and cause dissatisfaction of emotional and spiritual care [14],[26]

On the contrary, inability to help end-stage patients would affect the nurses and they may have a sense of weakness and frustration.[5],[20] Being successful in taking care of these patients is dependent on nurses' ability to provide spiritual care [26],[27] and manage patient's concerns.[5],[27],[28] Therefore, it is necessary for the nurses to get familiar with appropriate communicative approaches for answering the existential questions of the patients;[29] this will increase the self-esteem in cancer patients and decrease patients' anxiety and depression. It also improves the patient's compatibility with their disease. Proper education can increase the self-esteem of nurses for speaking about existential issues. The aim of the present study was to review the studies about educating the existential concept to the nurses working in cancer car.

 Materials and Methods



In this review article, internet search was conducted to find the studies about the outcomes, methods, and contents of educating existential concepts to the nurses and patients from 1990 to 2018. At first, the papers published in English and Farsi databases of PubMed, Elsevier, Scopus, Web of Science, ProQuest, ERIC, Google Scholar and Ovid, MagIran and SID, from 1975 to 2018 were reviewed by two independent researchers. These databases were searched using the existential, meaning, loneliness, freedom, and death keywords and then the search was continued using “AND” and “OR” operators along with the education, nurse and cancer words. Considering the insensitivity of Farsi databases to the “AND” and “OR” operators, the Farsi database of MagIran and SID was first searched using the nursing, existential issues, and meaning, loneliness, freedom, and death keywords and then the keywords of education and cancer patients were added. [Figure 1]. The inclusion criteria were original articles with full text available in Farsi or English language about interventional studies, educating existential concepts to nurses or nursing students dealing with cancer patients.{Figure 1}

Initially, 1100 studies were retrieved. A total of 550 duplicated articles and case reports, scientific letters, review articles, and studies that were conducted on individuals other than nurses, and studies that their full texts were not available were excluded from the review. After screening the titles and abstracts, 628 studies were excluded as they were not appropriate according to the inclusion criteria. The full texts of the 22 remaining studies were then examined and two studies that were not in English or Farsi language were discarded. The quality of the 20 reviewed studies was independently evaluated by the two authors. One reviewer extracted and descriptively analyzed the characteristics of the articles of the included studies [Figure 1].

Experimental studies were evaluated using the Cochrane checklist.[30] Quasiexperimental studies were evaluated using the Greenhalgh checklist.[31] Therefore, if a study covered all or a part of the intended criteria, they were respectively assigned a score of 2 or 1; and if a study did not have any of the intended criteria or any of the necessary points, it was assigned a score of 0. Eventually, studies with a score of 0 were eliminated from the review. Then, the second reviewer checked the data extraction process through critical reading of the remaining 17 articles. Because there was a significant difference between the 17 studies [Figure 1] the following information was extracted from the remaining studies: author(s) and year of publication, setting, sample size, participants, study and teaching methodology, result and key findings. Statistical pooling of the outcomes was not performed [Table 1].{Table 1}

Ethical considerations

The researchers tried to act without bias for analysis of the information. Appropriate research method was selected. All the relevant studies were included in the study.

 Results



The main focus of this literature review was on how to educate the existential concepts to the nurses dealing with cancer patients (Research question). However, to optimize the interpretation of these effects, we would first clarify the methodological quality and characteristics of the educational methods and content of the studies. In this study, 17 articles were eligible for enrollment and were evaluated. Four studies were quasiexperimental [4],[32],[33],[34] three studies were mixed method,[21],[35],[36] and the rest were randomized clinical trials.[5],[21],[36],[37],[38],[39] These studies had two groups of intervention and control,[4],[5],[33],[35],[39] only one study was conducted on three intervention groups without a control.[36] The sample size varied in different studies from 28 nurses [40] to 149 nurses.[38] The number of sessions and duration of education varied in different studies from two to eight sessions [41] and the duration of education varied from 2 days [42] to 4 months.[37] For example in the study of Hench the intervention was conducted during five 90 min sessions.[28] In the study of Morita et al. in 2007 a 5 h workshop,[32] and eight 180 min workshops were conducted during four months, and in 2009 and 2014 the intervention was conducted as a 2 day workshop.[32] In the study of Edu et al. the intervention was conducted through five, 90 min sessions.[5] In the study of Chan et al. the intervention was performed as weekly workshops, once a week, for 3 consecutive weeks.[43] In the study of Yosuke Kubota et al. in 2016 the intervention group received 16 h of education through two 1 day sessions during 2 consecutive weeks.[44] Various methods were used for educating the existential concepts to the nurses including reflection,[5],[28],[36],[38] role play,[32],[33],[44] group discussion,[5],[36] lectures,[5],[35],[36],[42] and seminar.[35] Various educational methods have been used in different studies, although the main educational method in most of the studies was lecture. Considering that no studies were conducted using comparative method, it is not possible to conclude that how many hours in what duration were sufficient for educating the existential concepts. Most of the measurement tools were standard questionnaires, which were similarly used in most of the studies. For example, the multidimensional orientation toward dying and death inventory was designed in 1991.[33] This questionnaire was used as the measurement tool in most of the studies.[32] Also in some studies, along with the standard questionnaire, researcher-made questionnaires and interviews on focus groups were used for data gathering.[36] “Meaninglessness in chronic diseases” questionnaire was designed in the study of Morita et al. in 2007 and other studies also have used this scale.[32],[37] Other questionnaires that have been used were attitude toward patients feeling meaninglessness, the sense of dependence in the attitude toward death,[5],[28] the job burnout questionnaire,[37],[42],[44] evaluation of meaning in chronic diseases,[32] job satisfaction questionnaire,[37],[41],[44] self-report, self-esteem,[42] competence for working in the cancer department and orientation toward death and meaning in life,[43] benefits of working in the cancer department, emotional quality of life,[38] and attitude toward caring for patient feeling meaninglessness.[44] In general, self-report scales were used in these studies; however, it was better to use questionnaires to evaluate the change in the nurses' attitudes and performances in the clinical settings to determine the effects of the educational interventions. Lack of a measurement tools that evaluate the changes in nurses' knowledge about existential concepts in cancer was one of the weaknesses of the reviewed studies. Most of the studies were performed in Japan [32],[42] and Switzerland.[4],[28] This might decrease their generalizability. The educational contents of the conducted interventions were not clarified and no specific standard was used for educating these concepts to the nurses. For example in the studies that were conducted by Morita et al., they had used a conceptual theory in their own name, conceptual theory of Morita.[32],[37] In three studies, the authors made educational content had been used.[5],[28],[35] The theories of Yalom,[5],[21],[35] Sand,[36] Kubler-Ross,[33] Viktor Frankl,[38],[41] and the National Institute for Clinical Excellence (NICE) guideline, National Comprehensive Cancer Network (NCCN) guidelines, and Education in Palliative and of End-of-Life Care for Oncology (EPEC-O)

Some of the studies did not mention the details of the educational program.[33] However, some studies explained the details of the educational program to some extent.[5],[28],[37],[42],[43],[44] There was a considerable difference in the details of the educational program. For example in the study of Henoch et al. the first session of the education was about basic communicative skills.[28] In the study of Morita in 2009, three sessions were about establishing a communication with the patient and two sessions were for using the conceptual theory of creating meaning in life.[37] In the study of Udo, the first sessions were about the existentialism, life, death, loneliness, freedom, and meaning therapy discussions and the last session was focused on the reflection and discussion. Between the sessions, nurses were encouraged to use the learned communicative techniques in their daily work while talking to the patients about existential issues.[5] In the study of Chan et al. in 2016, in the first day of educational program, nurses expressed their attitudes and emotions; in second day, the participants practically experienced the symbolic loss of a family member in life. Then, they answered existential questions such as the meaning of life and also values and priorities. The third day was about the empowerment of personal skills by understanding one's needs and comparing them to the needs of the patients.[43],[42] The study of Yosuke Kubota contained four sessions about psychological problems in cancer patients, such as normal reactions, clinical reasons, suicidal thoughts, and delirium.[28],[44] In the study of Lise Fill Ionetal, the main goal of the first session was to introduce the characteristics of meaning and its sources.[38]

Results of the studies showed that educating two concepts of meaning and death would increase nurses' self-esteem when dealing with end-stage patients and improve their caring attitudes.[28],[32],[35],[44] Education would also enhance the ability of nurses' to understand [38] of religious beliefs and dealing with internal struggles.[32] Although the studies did not show the significant effect on the emotional and spiritual quality of life of the nurses,[28],[41],[43] and their job burnout.[44] Educational program encouraged nurses to establish a professional relationship with patients to improve their competency in dealing with sorrow and existential reactions of the end-stage patients.[28] Nurses could help patients to find meaning and hope in their life,[20] even though it would not solve their existential problems. Because of the difference between the studies in terms of the instruments, educational methods, sample size, and number of sessions, it was not possible to judge which method and content were more suitable and have more effective results.

 Discussion



Reviewing the existing studies showed that from the four existential concepts of meaning, death, loneliness, and freedom, only the two concepts of death and meaning were used for education and the other concepts had been ignored. Meaning therapy is effective in decreasing suffering and improving the meaning of life and can be applied to prevent existential conflicts and improve quality of life. Unanswered questions make patients anxious and even may increase the risk of suicide.[9]

Viktor Frankl believed that people could find meaning until their last moment of life and dying people are able to find the meaning of death.[23],[25] Nurses could help patients find their own interpretation of death based on their religion and culture.[24] Existentialists believe that people can and have the right to choose their roles in the society in a way that they believe as a human being.[1],[9] Especially for end-stage patients, collaborative decision-making is one of the basic principles for freedom and respecting patients' rights. Viewing freedom as an just intellectual issue leads to underestimation of its importance and neglecting the patients' needs.[26] This leads to making decisions for the patients instead of making decisions along with the patients. Patients need help in making difficult decisions in the terminal phase of the disease.[20] When the patients are given necessary information about their disease and their therapeutic methods and these issues are discussed with them, it means that their freedom of choice has been respected, which leads to better therapeutic outcomes.[26] After 3 decades of supporting decision-making by the patients, legal support for this issue has not been implemented in practice.[20],[26] Meaningful life has an important and undeniable role in coping with the events, and reducing the feeling of loneliness. Definitely, nurses are willing to support their patients through existential issues by gaining necessary information and knowledge.

It was not possible to judge which educational method and content was more suitable and had more effective results due to large heterogeneity exists between the studies. However, educating existential concepts had helped nurses to understand patients' reactions better, even though it had not solved their existential problems.

Despite the results of the studies, educating existential concepts is not considered in the current curriculum of the nursing students; this indicates the gap between the research and practice. On the contrary, to apply the results of the studies, the first step is to provide a clear definition of the structures and concepts that should be educated to the nurses and then to determine the appropriate method of education. This requires more comparative studies about the concepts and educational methods in existential concepts in nursing.

To design such educational program, it is necessary that the needs and viewpoints of patients are considered. The existing studies indicated the necessity of educating these concepts to the nurses. The limitations of the present study were the limited number of experimental studies and heterogeneity in their methodologies. So, the specific method or content of education cannot be recommended Also, in the present study, only the online studies that have been published in Farsi or English languages were used so there might be good quality studies in this topic that have not included in this study.

 Conclusion



It could be concluded that educating existential concepts to the nurses when dealing with end-stage cancer patients would increase their self-esteem and improve their competency in caring of patient that may feel meaninglessness. Caring of dying patients is a part of everyday nursing work and teaching existential views to nurses can be very helpful to increase the competency of nurses in dealing with end-stage patients. Our study showed that there have been a few programs in this crucial subject. We recommend in service educational programs with the objective of improving knowledge of existential concept in nurses working with cancer patients. We also suggest that the existential concept would be added to the nursing curriculums. There can be help nurses working with terminal patients to deepen their philosophical dimensions of the nursing care, a necessity that has been neglected in nursing profession. We also need a modern view to an old problem. Our study revealed the lack of new opinions and methods in managing philosophical issues in nursing care. We need more recent educational models to address the changing world of medicine and nursing.

Acknowledgements

We would like to thank Dr. Reza Hosseini for language revision of the manuscript and thank the staff of the information technology department of Kashan University of Medical Sciences for their help in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

Nothing to declare.

References

1Gale CL. A Study Guide for” Existentialism”. Gale: Cengage Learning; 2016; p. 33.
2Mahvelati AM, Pourshahriari M, Azerbaijani M. Viktor Frankl's view on anthropology and comparing it with Islam's approach. Int J Humanit Cult Stud 2016; 409-429.
3Purves D, Delon N. Meaning in the lives of humans and other animals. Philos Stud 2018;175:317-38.
4Mallory JL. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduate nursing students. J Prof Nurs 2003;19:305-12.
5Udo C, Melin-Johansson C, Henoch I, Axelsson B, Danielson E. Surgical nurses' attitudes towards caring for patients dying of cancer–A pilot study of an educational intervention on existential issues. Eur J Cancer Care 2014;23:426-40.
6Clarke G, Fistein E, Holland A, Barclay M, Theimann P, Barclay S. Preference's forcare towards the end of life when decision-making capacity may be impaired: A large scale cross-sectional survey of public attitudes in Great Britain and the United States. PLoS One 2017;12:e0172104.
7Khoshnood Z, Iranmanesh S, Rayyani M, Dehghan M. Getting out or remaining in the cage of inauthentic self: The meaning of existential challenges in patients' with cancer. Indian J Palliat Care 2018;24:131.
8Iwasaki M, Di Bianca MS, Nicholas DR. A forbidden topic at the end of life: “What about you after I'm gone?. Psychooncology 2018;27:2665-7.
9LeMay K, Wilson KG. Treatment of existential distress in life threatening illness: A review of manualized interventions. Clin Psychol Rev 2008;28:472-93.
10Rodrigues P, Crokaert J, Gastmans C. Palliative sedation for existential suffering: A systematic review of argument-based ethics literature. J Pain Symptom Manage 2018;55:1577-90.
11Tornoe KA, Danbolt LJ, Kvigne K, Sorlie V. The challenge of consolation: Nurses' experiences with spiritual and existential care for the dying-a phenomenological hermeneutical study. BMC Nursing 2015;14:62.
12Harden K, Price D, Duffy E, Galunas L, Rodgers C, Harden K, et al. Palliative care: Improving nursing knowledge, attitudes, and behaviors. Clin J Oncol Nurs 2017;21:E232-8.
13Donohue-Porter P, Forbes MO, White JH, Baumann SL. Transforming nursing education and the formation of students: Using the human becoming paradigm. Nurs Sci Q 2017;30:134-42.
14Liu H, Shi H, Yang Q, Rowlands A, Han M. Use of religion: An effective method of coping among Chinese patients with cancer. Open J Nurs 2015;893.
15Nierop-van Baalen C, Grypdonck M, Van Hecke A, Verhaeghe S. Hope dies last… A qualitative study into the meaning of hope for people with cancer in the palliative phase. Eur J Cancer Care 2016;25:570-9.
16Hoffman L, Vallejos L, Cleare-Hoffman HP, Rubin S. Emotion, relationship, and meaning as core existential practice: Evidence-based foundations. J Contemp Psychother 2015;45:11-20.
17Marziliano A, Pessin H, Rosenfeld B, Breitbart W. Measuring cohesion and self-disclosure in psychotherapy groups for patients with advanced cancer: An analysis of the psychometric properties of the group therapy experience scale. Int J Group Psychother 2018;68:407-27.
18van Meurs J, Smeets W, Vissers KC, Groot M, Engels Y. Nurses exploring the spirituality of their patients with cancer. Cancer Nurs 2018;41:E39.
19Kruizinga R, Hartog ID, Jacobs M, Daams JG, Scherer-Rath M, Schilderman JB, et al. The effect of spiritual interventions addressing existential themes using a narrative approach on quality of life of cancer patients: A systematic review and meta-analysis. Psychooncology 2016;25:253-65.
20Maria B, Ingela H, Christina M-J, Susann S, Ella D. Existential encounters: Nurses' descriptions of critical incidents in end-of-life cancer care. Eur J Oncol Nurs 2014;18:636-44.
21Strang S, Henoch I, Danielson E, Browall M, Melin-Johansson C. Communication about existential issues with patients close to death—nurses' reflections on content, process and meaning. Psychooncology 2014;23:562-8.
22Adams RN, Mosher CE, Abonour R, Robertson MJ, Champion VL, Kroenke K. Cognitive and situational precipitants of cancer patients' loneliness. A qualitative analysis. Oncol Nurs Forum 2016;43:156.
23Masterson M, Rosenfeld B, Breitbart W. Meaning-centered psychotherapy for cancer patients with advanced and terminal illness. In: Perspectives on Behavioral Interventions in Palliative and End-of-Life Care. Routledge; 2018. p. 80-102.
24Meier EA, Gallegos JV, Thomas LP, Depp CA, Irwin SA, Jeste Dv. defining a good death (successful dying): Literature review and a call for research and public dialogue. Am J Geriatr Psychiatry 2016;24:261-71.
25Wong PT. Viktor Frankl's meaning-seeking model and positive psychology. In: Meaning in Positive and Existential Psychology. New York, NY: Springer; 2014; 149-184.
26Gulbrandsen P, Clayman ML, Beach MC, Han PK, Boss EF, Ofstad EH, et al. Shared decision-making as an existential journey: Aiming for restored autonomous capacity. Patient Educ Couns 2016;99:1505-10.
27Reed FM, Fitzgerald L, Bish MR. A practice model for rural district nursing success in end-of-life advocacy care. Scand J Caring Sci 2018;32:746-55.
28Henoch I, Danielson E, Strang S, Browall M, Melin-Johansson C. Training intervention for health care staff in the provision of existential support to patients with cancer: A randomized, controlled study. J Pain Symptom Manage 2013;46:785-94.
29Fallowfield L, Saul J, Gilligan B. Teaching senior nurses how to teach communication skills in oncology. Cancer Nurs 2001;24:185-91.
30Koslowski N, Klein K, Arnold K, Koesters M, Schuetzwohl M, Salize HJ, et al. Effectiveness of interventions for adults with mild to moderate intellectual disabilities and mental health problems: Systematic review and meta-analysis. Br J Psychiatry 2016;209:469-74.
31Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Q 2004;82:581-629.
32Morita T, Murata H, Hirai K, Tamura K, Kataoka J, Ohnishi H, et al. Meaninglessness in terminally ill cancer patients: A validation study and nurse education intervention trial. J Pain Symptom Manage 2007;34:160-70.
33Frommelt KH. Attitudes toward care of the terminally ill: An educational Intervention. Am J Hosp Palliat Care 2003;20:13-22.
34Frommelt KH. The effects of death education on nurses' attitudes toward caring for terminally ill persons and their families. Am J Hosp Palliat Care 1991;8:37-43.
35Udo C, Danielson E, Henoch I, Melin-Johansson C. Surgical nurses' work-related stress when caring for severely ill and dying patients in cancer after participating in an educational intervention on existential issues. Eur J Oncol Nurs 2013;17:546-53.
36Sand L, Olsson M, Strang P. Supporting in an existential crisis: A mixed-methods evaluation of a training model in palliative care. Palliat Support Care 2018;16:470-8.
37Morita T, Murata H, Kishi E, Miyashita M, Yamaguchi T, Uchitomi Y. Meaninglessness in terminally ill cancer patients: a randomized controlled study. J Pain Symptom Manage 2009;37:649-58.
38Fillion L, Duval S, Dumont S, Gagnon P, Tremblay I, Bairati I, et al. Impact of a meaning-centered intervention on job satisfaction and on quality of life among palliative care nurses. Psychooncology 2009;18:1300-10.
39Henoch I, Strang S, Browall M, Danielson E, Melin-Johansson C. Development of an existential support training program for healthcare professionals. Palliat Support Care 2015;13:1701-9.
40Hainsworth DS. The effect of death education on attitudes of hospital nurses toward care of the dying. Oncol Nurs Forum 1996;23:963-7.
41Fillion L, Dupuis R, Tremblay I, De Grâce GR, Breitbart W. Enhancing meaning in palliative care practice: A meaning-centered intervention to promote job satisfaction. Palliat Support Care 2006;4:333-44.
42Morita T, Tamura K, Kusajima E, Sakai S, Kawa M, Imura C,et al. Nurse education program on meaninglessness in terminally ill cancer patients: A randomized controlled study of a novel two-day workshop. J Palliat Med 2014;17:1298-305.
43Chan, WC, Tin AF, Wong KL. Effectiveness of an experiential workshop for enhancing helping professionals' self-competence in death work in Hong Kong: A randomized controlled trial. Health Soc Care Community 2017;25:1070-9.
44Kubota Y, Okuyama T, Uchida M, Umezawa S, Nakaguchi T, Sugano K, et al. Effectiveness of a psycho-oncology training program for oncology nurses: a randomized controlled trial. Psychooncology 2016;25:712-8.