American Journal of Hospice and Palliative
Medicine
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Efficacy of the End-of-Life Nursing Care Continuing Education Program for Nurses in General Wards inJapan
Saori Yoshioka, Michiko Moriyama and Yumiko Ohno
AM J HOSP PALLIAT CARE published online 16 June 2013
DOI: 10.1177/1049909113491133
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Nursing Manuscript

Efficacy of the End-of-Life Nursing
Care Continuing Education Program
for Nurses in General Wards in Japan

American Journal of Hospice& Palliative Medicine®
00(0) 1-8
ª The Author(s) 2013
Reprints and permission:
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DOI: 10.1177/1049909113491133
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Saori Yoshioka, RN, PhD1, Michiko Moriyama, RN, PhD2, andYumiko Ohno, RN, MSN, CNS3

Abstract
This study aimed to examine effectiveness of the End-of-life nursing care continuing education program for general ward nurses. A
nonrandomized, before-after trial was conducted. The program was implemented for 25 nurses. The contents of the program
consisted of the family assessment, general symptom management and practical use of theories and models regarding end-oflife nursing care. The primary outcome, implementation ability of end-of-life nursing care, was significantly improved after the
program; improvements continued even at 2 months after. Similar results were obtained for nurses’ confidence andknowledge concerning end-of-life nursing care. As for attitude toward end-of-life care, participants’ scores were further
elevated after the program. The participants rated the usefulness of the program as high. The effectiveness of the program
was suggested from these results. In the future, this program should be widely used for in-service training.
Keywords
end-of-life care, end-stage cancer, nursing, general ward, continuing education, evaluation

IntroductionMore than 3 00 000 people in Japan die of cancer annually, andabout 90% of such deaths occur in general wards.1 This means thatmost patients with cancer and their families spend their end-of-lifedays in acute care hospitals. These situations occur against a background of inadequate hospices/palliative care facilities and homecare-support systems. As a result of these situations, general ward
nurses are required to provide high-quality end-of-life care toenhance the quality of life of patients and their families.
Although the importance of quality end-of-life nursing care
implemented by general ward nurses has been emphasized, previous studies have revealed that psychosocial care and support
for families at patients’ end of life have been insufficient.2-6
Indicated reasons for insufficient care included nurses’ anxiety
over death and negative views of life and death.7 Furthermore,
the lack of continuing education regarding end-of-life care has
been emphasized.8,9 As mentioned in the studies discussed earlier, many barriers remain to the achievement of good-quality
end-of-life nursing care in general wards. Therefore, it isimportant to develop a continuous educational program on
end-of-life nursing care for general ward nurses.
An example of continuous education programs is the End-ofLife Nursing Education Consortium (ELNEC).10 This programis intended to foster leadership in end-of-life nursing care andefforts to prepare a Japanese version of ELNEC have been undertaken with the same objective as that of the original ELNEC—totrain leaders.11 A similar program in Japan is the Educational Curriculum for Hospice Nurses Engaged in Palliative Care, whichtakes 3 years to complete.12 The Japanese Nursing Association’s
Palliative Care Training Course for Nurses consists of about
6 weeks of full-time lectures, and clinical practice.13
In general, the contents of these existing programs are structured according to a general curriculum but might not necessarily focus on urgently needed improvements in the quality ofcare implemented by general ward nurses. Moreover, someof these programs require that participants have a certain levelof skills or commitment to learning for a long period; this creates difficulties in concurrently managing their regular jobs.
Therefore, in accordance with the results of our preceding
study,14 we developed an end-of-life nursing care continuing
education program through integration of essential educational
elements for nurses in general wards.

1
Department of Nursing, School of Nursing and Rehabilitation Sciences at
Odawara, International University of Health and Welfare, Kanagawa, Japan
2
Graduate School of Health Sciences, Hiroshima University, Hiroshima, Japan3
Department of Nursing, Osaka University Hospital, Osaka, Japan

Corresponding Author:
Saori Yoshioka, RN, PhD, Department of Nursing, School of Nursing andRehabilitation Sciences at Odawara, International University of Health andWelfare, 1-2-25 Shiroyama, Odawara, Kanagawa 250-8588, Japan.
Email: s-yoshioka@iuhw.ac.jp

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American Journal of Hospice & Palliative Medicine® 00(0)2BeforeSessionContent of lecture

Time

Content of discussion

Time

90
min

・Problems and issues in implementation of daily
end-of-life care・Current situation and issues regarding family care

30
min

1

・Introduction of the program
Presentation of the overview of program (objective and method)
Explanation of concept of end-of-life nursing care・Basic knowledge about care for family
How to understand family situations (based on family system
nursing theory) , family needs, significance of caring for family・Basic knowledge about theories/models related to end-of-life
nursing care

2・Basic knowledge about family assessment
How to understand family situations (review), understanding of
circular relationships, understanding of issues related to family
lifecycle and evolution
・Actual cases of family assessment (explanation by using simulated
patients)
Introduction of family assessment sheet, how to utilize the sheet

3[Presentation of case studies based on family assessments]
150
・Presentation from each ward concerning introduction of the case, process of family assessment, family needs, and necessary caremin・Discussion regarding the presentation contents

4・Symptom manegement
Basic knowledge about pain management

・Current situation and problems in pain management120–
30–
in the ward
150
60
・Q&A on how pain should be handled, andmin
minconsultation

・General symptom management
Basic knowledge on management of major symptoms
Alternative treatments and actual care that can be provided bynurses・Current situation and problems in symptom
120–
management in the ward
150
・Q&A on how symptoms should be handled, andmin
consultation

5・Family assessment in the simulated case example
・Possibility of utilization of the family assessment
sheet in own ward
60
min [Homework]
・Assessment of the actual family of the end-of-life
patient
・Preparation of the presentation[Wrap-up for the program]・Review of the content of the program
・Lessons learned, impressions about the entire program, and future prospects for implementation

60
min

30–
60
min
30
min

After

2 months later

Figure 1. Overview of the program.

Accordingly, the objective of this study was to compare theevaluation indicators before and after the intervention to assess
the educational effectiveness of the program.

End-of-Life Nursing Care Continuing Education Program for General Ward Nurses

theories and models. In accordance with these results, family
assessment, general symptom management, and practical useof theories and models regarding end-of-life nursing care
were adopted as the educational contents of the program. Further, since evaluation of the nurse’s own team had the greatest
influence on attitude, groups were organized with the memberof the same ward in the learning activity.

Background of the Program
Prior to this study, factors related to end-of-life nursing carein general wards in Japan were determined.14 According to
the results of previous studies, a nurse’s subjective evaluationof his or her own team, existence of a role model, positive attitudes toward caring for dying persons, and view of life anddeath are factors related to attitudes toward end-of-life nursing care. Subjective evaluation of the nurse’s own team had
the greatest influence on attitude. Moreover, family assessment, general symptom management, abstract judgment, andparticipation in seminars on end-of-life care were determined
as factors related to knowledge and skills. Abstract judgment
means the development of a nursing process that utilizes

Overview of the Program
Figure 1 provides an overview of the program. The first halfof the program was dedicated to basic knowledge aboutfamily nursing and family assessment.15 The family assessment sheet was prepared for use in general wards; it focusedon essential elements such as family construction, circularcommunication, and developmental family assessment (Figure 2).15 In the third session, participants were asked topresent the results of their case studies (which they conducted using the assessment sheet). The second half of the
program was dedicated to lectures regarding the management of patients’ symptoms by a certified nurse specialist

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Yoshioka et al

3Assessment sheet to support the patient's family
Step 1. Worrisome problems at present
Step 2. What is happening? Find clues among the signs.
■ Draw up the genogram.

■ Circular communication pattern
between family members (Draw acircular pattern diagram.)■ Developmental life cycle ofthe family and the events
that occurred in the past

■ Opinions, thoughts, desires,and beliefs of each family member

Participants
The participants were nurses working in hospital A—the regional
cancer treatment center in western part of Japan—who wereassigned to the general wards, where end-of-life cancer nursing
care was provided. The participants were required to be generalists with no qualifications as specialized or certified nurses.
Power analysis revealed that the appropriate sample size
would be 17 to 21. Considering the possibility of dropout,
25 nurses were chosen. Anticipating that group work with 5 members would be efficiently facilitated, we selected 5 nurses fromeach of the 5 wards at hospital A. To ensure homogeneity of members among the groups, the basic group structure consisted of 1
veteran nurse, 2 mid-career nurses, and 2 novice nurses.

Study Design■ Health status of the family■ Circular communication pattern
between family members andhealth professionals (Draw acircular pattern diagram.)

A nonrandomized, before–after trial was conducted.

Evaluation Indicators and Points
The evaluation was completed before, immediately after, and2 months after intervention. The details of the evaluation indicators were as follows.

Step 3. Goal (including how to spend the last days)

Figure 2. Family assessment sheet used in this project.

in cancer nursing. The introduction of a symptom management model,16 assessment techniques for pain, and basic
knowledge about narcotics were included in the contentsof the lecture. The physical conditions often found in endstage patients with cancer, such as fatigue, dyspnea, anddelirium, as well as intervention techniques that can be usedby nurses, were also included in the lecture. In the discussion sessions, participants discussed the current status andproblems of their implementation of end-of-life care andhad the opportunity to ask questions to or consult with thelecturer.
The duration of the program was set at about 2 months, considering workload management and the psychological burdens
on relevant staff members and their wards. The lecturers
prepared all of the presentation materials and additional
documents. In the first session, each participant received aworkbook for management that could be used even after the
program.

End-of-Life Nursing Care. End-of-life nursing care ability is theprimary end point measure of this study. The Mitori care scale
was used to evaluate nurses’ end-of-life care ability. Mitori is aJapanese word specifically related to care provided to a dying
person by family caregivers at any given location.17 ‘‘Mitoricare’’ is defined as nurses’ care activities to support dying
patients and family caregivers from the viewpoint of the family
as a care unit.18 This 22-item scale was developed as a selfevaluation measurement scale of Mitori care for nurses; it iscomposed of 5 subscales: care facilitating death without regret,spiritual care, assurance of palliative care, supporting decision
making with appropriate information, and arrangement ofavailable care.18 The reliability of the Mitori care scale has
been showed by a Cronbach a coefficient of .91 (subscales¼ .67–.83) and a test–retest reliability coefficient of .74. The
criterion related and construct validity of this scale were verified using factor analysis and the known group technique.

Study Period

Self-Efficacy Toward End-of-Life Nursing Care. Negative view andlack of self-confidence about the end-of-life nursing care are
relevant to its implementation.7,19 Therefore, it was necessary
to include self-efficacy items in the evaluation indicators. Eightoriginal items were created for this study to determine participants’ ‘‘self-confidence in conducting end-of-life nursing
care’’ that reflected the educational content of the program.
After principal component analysis confirmed the 1dimensional nature of these items, the scores were added andassigned to relevant scales.

The participants were enrolled in the program in June to July
2010. The third evaluation of the program was conducted in
September 2010.

Attitude Toward End-of-Life Care. In this study, attitudes were
measured by the Frommelt Attitudes Toward Care of the Dying
Scale Form B Japanese version (FATCOD-B-J), which is

Methods

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American Journal of Hospice & Palliative Medicine® 00(0)4composed of 2 subscales (30 items): positive attitudes towardcaring for dying persons and recognition of caring for thepivot dying persons and their families.20 The reliability of
FATCOD-B-J has been indicated by a Cronbach a coefficientof .85 (subscales: .73, .65) and a test–retest reliability coefficient of .85. The construct validity of the scale has beenverified by factor analysis. As these scales were designed
specifically to investigate participants’ willingness and values
regarding care, the scales were considered to be suitable for themeasurement of the educational effects of the program; thus,
they were added as evaluation indicators.
Subjective Evaluation Regarding the Nurses’ Own Team. As the nursing team was the base unit for the learning program, the teamevaluation items were included in the evaluation indicators.
Subjective evaluation items regarding the nurses’ own team
(10 items) were formulated to reflect the formation of nurses’
own values related to end-of-life nursing care within a teamthrough high-quality information sharing and interaction
among team members. These items evaluated the interrelationships among team members and teams’ styles of dealing withissues, including the procedures/contents of team conferences,
relationships with physicians, and decision making. After principal component analysis confirmed the 1-dimensional natureof these items, the scores were added and assigned to relevant
scales.
Nurses’ Knowledge Regarding End-of-Life Care
Subjective Evaluation Items Regarding the Level of Knowledge
About End-of-Life Care. These items were formulated to determine nurses’ level of knowledge about end-of-life care. This
19-item scale is composed of 5 subscales: general symptom
management, pain management, family assessment, social
resources, and nursing theories or models regarding end-stage
patients with cancer and their families. After factor analysis
confirmed the structure of 5 factors, they were used as
subscales.
Symptom Management Quiz. Ross et al’s21 palliative carequiz for nursing was referenced during the discussion among
researchers while the 20-item quiz was formulated. Participants
were asked to choose correct/incorrect for each question.
In addition to the above evaluation indicators, the researchers
invited the participants’ comments concerning each program
session. After the last session, the participants’ satisfaction
regarding the program content, implementation method, andduration were evaluated on a 5-point scale.

Data Collection
At each evaluation point, a questionnaire was distributed to theparticipants who completed it anonymously. An ID number
was randomly assigned to each participant, which was enteredin the slot given in the questionnaire sheet, so that both privacy
protection and data matching would be assured.

Data Analysis
After the normality of the distributions of the evaluation indicators was verified with the Shapiro-Wilk test, repeatedmeasures analysis of variance was conducted. The SPSS(v. 17.0J; SPSS, Tokyo, Japan) was used for analysis, and thesignificance level was set at <5%.

Ethical Considerations
This study was approved by the administrator of A hospital.
The contents and methods of the program, study objectives,protection of privacy, and publication of results were explained
to the participants in detail. The voluntary nature of participation in this study was emphasized, and all participants’ consent
was obtained in writing.

Results
While a total of 25 nurses participated in the program,1 dropped out due to a health problem, and 2 who failed to givecorrect responses to several questions were also excluded; thus,
the data of 22 participants were analyzed.

Characteristics of Participants
The participants’ mean age was 30.8 + 9.1 years. The majority
had graduated from diploma school (Table 1). About 70% had
previously taken in-service seminars on palliative care, and at
least 40% had been engaging in continuing self-study in someform or other. Meanwhile, about 30% said that they had neverlearned about the provision of nursing care for families.

Analysis of the Effectiveness of the Program
Table 2 shows the results of the evaluation indicators at eachtime point.
As indicated by total Mitori care scores and all subscale factor
scores, implementation ability for end-of-life nursing care(which was the primary outcome measure of the study) significantly improved immediately after the program and at 2 months
after the program compared with preintervention (P < .01, P <.05). Further, outcome scores immediately after the program
were approximately equal to those at 2 months after the program.
Scores of self-efficacy items toward end-of-life nursing careshowed the same result with Mitori care scores (P < .01).
As for attitudes toward end-of-life nursing care, total scoreson the FATCOD-B-J and scores for positive attitudes towardcaring for dying persons were significantly elevated immediately after the program but significantly lowered at 2 months
after the program compared with immediately after levels (P< .01 and P < .05). Recognition of caring for the pivot dying
persons and their families significantly increased immediately
after the program (P < .05), but no significant changes wereobserved 2 months after the program.
Scores for subjective evaluation regarding the nurses’ own
team increased slightly from the preintervention period to

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Yoshioka et al

5

Table 1. Characteristics of Participants (N ¼ 22).
nAge, years
GenderMale
FemaleClinical experience, years
<5
5–15
>15
Position
Vice head nurse
Team leader
Staff
Educational background
Bachelor’s degree
Associate’s degree
Diploma%

M + SD
30.8 + 9.1

2
20

9.1
90.9

7
11
4

31.8
50.0
18.2

2
3
17

9.1
13.6
77.3

5
1
16

22.7
4.5
72.7

Abbreviation: SD, standard deviation.

2 months after intervention, although the differences were notsignificant. However, the following comments were given by avice head nurse and a veteran nurse, respectively, at 2 months
after the program: ‘‘the nurses have become more proactive inmaking contact with the patient’s family’’ and ‘‘the nurses havebecome more proactive in talking to the family to get information.’’ These comments from participants in supervisory positions reflected the changes attained by the entire team.
Scores for knowledge about end-of-life nursing care weresignificantly elevated both immediately after and 2 months
after the program compared with preintervention levels (P <.01 and .05), and the scores immediately after the program wereapproximately equal to those at 2 months after the program.

Overall Evaluation of the Program
Overall, satisfaction with the program and the appropriatenessof its content were highly rated. Time allocation and quantity ofcontent were assessed as ‘‘not so good’’ by 4 (18.2%) participants for the following reasons: ‘‘more time should have been
allocated to family nursing,’’ ‘‘we wanted to spend more timeon symptom management,’’ ‘‘the program was too long,’’ and‘‘the session’s timing after daytime work was too hard’’; thesecomplaints presented both positive aspects that reflected their
willingness to study and negative aspects derived from physicaland psychological burdens. The usefulness of the program was
rated as ‘‘useful’’ and ‘‘fairly useful’’ by a combined 100% ofparticipants (Table 3).

Discussion
Efficacy of the End-of-Life Nursing Care Continuing
Education Program
As a result of program implementation, end-of-life nursing care
implementation
ability—the
primary
outcome—was

significantly elevated after the end of the program and persisted
until 2 months after the program. Such a significant outcome
indicated that this program was effective for the improvementof end-of-life nursing care implementation ability in generalward nurses. The results on general ward nurses’ selfefficacy regarding end-of-life nursing care showed the same
pattern as those on end-of-life nursing care implementation
ability. Self-efficacy has been proven to be a source of inspiration to pursue actions without worry regarding failure or difficulties22; therefore, the results of this study—which indicatedimprovement in end-of-life nursing care implementation ability
coupled with the betterment and retention of self-efficacy—are
promising in terms of future retention and improvement inparticipants’ abilities.
Attitudes toward end-of-life nursing care were significantly
improved immediately after the program, while total scores andpositive attitude toward caring for dying persons decreased topreintervention levels by 2 months after the end of the program.
The FATCOD-B-J scores observed in this study were higher
than those seen in our preceding study.14 Since the participantsof this program were collected from among nurses who wanted
to join and voluntarily applied for the program, their interest in
end-of-life nursing care is likely to be high. Furthermore, theattitudes measured by FATCOD-B-J reflected that they had
positive attitudes and a strong sense of values concerning
end-of-life nursing care; these elements were likely to increase
temporarily after program participation. However, significant
decreases in those elements 2 months after the program might
indicate that the participants’ judgment became more objectivewith the passing time. Further, as the score of FATCOD-B-J
immediately after the program was >4 on a 5-point scale, themore increase in score may have been inappropriate from theperspective of data reliability.
No significant changes were observed in the subjective
evaluation regarding the nurses’ own team. In this study, theparticipants’ evaluations regarding their own team were lower
than that indicated by the preceding results.14 This result
reflects participants’ tendency to evaluate their own teams
more strictly because of their high level of awareness toward
end-of-life care. Although the expected results regarding
nurses’ recognition of their own teams were not fully obtained,
a positive change did occur in their qualitative evaluations of
their own teams. As mentioned earlier, the evaluation method
regarding the team should have been considered more.
Knowledge about end-of-life nursing care significantly
increased immediately after the end of the program, and thislevel was maintained for 2 months after the program. Steginga
et al23 discussed the importance of small group discussions andcreative program structure in addition to lectures for theenhancement of educational effectiveness. In our program, discussion and case study sessions after the lectures were considered effective for the acquisition and absorption of knowledge.
A number of researchers have mentioned that the educational
system for end-of-life nursing care should be improved and thatthe continuity of the program is important; for these reasons,our program should be widely implemented.

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American Journal of Hospice & Palliative Medicine® 00(0)6Table 2. Results of the Evaluation Indicators at Each Time Point (N ¼ 22).a(a) BeforeSD(b) AfterMean(c) 2 months after

P value

Indicator

Mean

SD

Mean

SD

(a)(b) (b)(c) (a)(c)Mitori care scale
Care facilitation death without regret
Spiritual care
Assurance of palliative care
Supporting decision making with appropriate information
Arrangement of available careSelf-efficacy toward end-of-life nursing care
FATCOD-B-J
Positive attitudes toward caring for dying persons
Recognition of caring for the pivot dying persons andtheir families
Subjective evaluation regarding the nurses’ own teamNurses’ knowledge regarding end-of-life care
Subjective evaluation regarding the level of knowledge
about end-of-life care
Family assessment
General symptom management
Nursing theories or models
Pain management
Social resources
Symptom management quiz

62.36 12.00 72.95 10.60
18.91 3.70 21.59 3.20
9.77 2.96 12.64 3.71
12.91 2.16 14.14 1.91
11.14 2.83 13.73 2.29
9.64 2.38 10.86 1.73
23.41 5.79 29.41 5.53
118.73 10.10 126.09 11.69
62.95 7.93 67.50 8.34
51.86 4.19 54.86 4.02

74.91
21.55
13.95
14.59
13.82
11.00
27.82
121.45
63.77
53.91

15.51
4.80
4.51
2.54
3.30
2.07
7.29
13.89
8.78
6.00

<.001b<.001b<.001b.040c<.001b.020c<.001b
.001d
.003d
.016c

.576
.996
.106
.620
.986
.948
.239
.042c
.015c
.630

<.001b<.001b<.001b.003d<.001b.009d<.001b
.314
.797
.132

29.59

6.56

29.95

6.95

30.36

7.35

.946

.932

.778

53.41 11.16

73.32

7.53

71.55

11.46

<.001b.597<.001b

9.05
15.41
11.23
13.55
4.18
12.33

16.41
19.50
15.14
16.14
6.14
13.86

1.89
2.30
2.05
2.01
2.01
2.23

16.09
19.14
14.32
15.73
6.27
13.73

2.64
2.75
3.26
2.78
1.91
2.21

<.001b<.001b<.001b<.001b<.001b
.018c

.872
.802
.423
.686
.895
.964

<.001b<.001b<.001b<.001b<.001b
.034c

3.15
2.78
3.39
3.05
1.94
2.56

Abbreviations: FATCOOD-B-J, Frommelt Attitudes Toward Care of the Dying scale Form B Japanese version; SD, standard deviation.
aRepeated-measures analysis of variance, Tukey honestly significant difference post-hoc tests. Mitori care scale (Yoshioka et al4) measured end-of-life nursing careability. All scales are 5-point Likert-type scale except self-efficacy toward end-of-life nursing care. Self-efficacy toward end-of-life nursing care is 6 on the Likert-type
scale. 1 ¼ strongly disagree; 2 ¼ disagree; 3 ¼ relatively disagree; 4 ¼ relatively agree; 5 ¼ agree; 6 ¼ strongly agree (self-efficacy toward end-of-life nursing care).
b
P < .001.
c
P < .05.
d
P < .01.

Table 3. Overall Evaluation of the Program (N ¼ 22).a
Evaluation
Parameter

Good

Relatively good

Neither

Relatively bad

Bad

The degree of satisfaction with the program
Appropriateness of the contents of the program
Appropriateness of the duration of the program
Usefulness of the program

8 (36.4)
6 (27.3)
6 (27.3)
10 (45.5)

14 (63.6)
15 (68.2)
8 (36.4)
12 (54.5)

0 (0.0)1 (4.5)4 (18.2)
0 (0.0)0 (0.0)0 (0.0)4 (18.2)
0 (0.0)0 (0.0)0 (0.0)0 (0.0)0 (0.0)an (%).

Validity of the Method of Program Development
Kolb24 experiential learning theory is one of the most wellknown and influential learning theories in the fields of education, medical science, and corporate management. Kolb
defined the learning as one that the process whereby knowledge
is created through the transformation of experience and divided
the formational process of learning ability into 4 stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation. A fourth-stage active
experimentation has turned into a first-stage concrete experience, which begins the next cyclic process. These stages canbe considered in the context of our program as follows: the participants, who brought in their ‘‘concrete experience’’ withdaily clinical activities, joined the program and became awareof their deficiencies in nursing activities or knowledge throughlectures and group discussions; these led to ‘‘reflective observation.’’ After they acquired knowledge by listening to lectures
regarding theories and concepts, ‘‘abstract conceptualization’’
may have occurred and have been utilized in a case study orpresentation, which was subsequently translated into ‘‘active
experimentation.’’ They could then adopt the next theme, reaffirmation of the importance of symptom management, whichpermeated the latter half of the program. Therefore, the structure of the program was appropriate in light of the learning process and may have contributed to its educational effectiveness.
As for the selection of group members, we requested that thenurses working in the same ward be included and that the group

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Yoshioka et al7

consists of 1 veteran nurse, 2 mid-career nurses, and 2 novice
nurses. Thus, the participants did not have to form new relationships; this made it easier to begin the learning sessions.
Nicol and Reid25 emphasized the importance of mutual learning—which includes informal learning elements, such asreflection, mentorship, and preceptorship—in palliative careeducation. As each group in this program comprises different
generations of nurses, reflection was conducted from diverse
perspectives, and mentorship took place, indicating a progression of informal, interactive learning. Further, Hersey et al26
advocated that the person leading the change should change
first in order to reform the behavior of the entire group. The
participants in our program were the prospective persons leading the change in promoting end-of-life nursing care; accordingly, the method implemented to launch our program wasconsidered effective in the generation of organizationalchanges.
On the bases of the above mentioned observations, this program was deemed capable of contributing to the advancementof participants’ end-of-life nursing care ability. Furthermore,
the program’s method of implementation was thought toenhance its educational effects.

Feasibility of the Program
The program was evaluated highly by the participants in termsof satisfaction, content, and duration. All the participants
appreciated the usefulness of the program, with 100% callingit ‘‘fairly helpful’’ or ‘‘helpful.’’ In the free answer questionnaire administered 2 months after the end of the program, someparticipants gave forward-looking opinions about end-of-life
nursing care, suggesting that their high levels of interest in
end-of-life nursing care had been preserved. In this respect, theprogram was considered useful.
However, some participants said, ‘‘attending a class after a
day shift was hard,’’ or ‘‘the course was too long.’’ In the
future, the program environment should be improved so that
hospital nurses find it easier to participate.

Study Limitations and Future Implementation
The participants in this study were those who wanted to join
and voluntarily applied for the program. As the participants
were generally interested in end-of-life nursing care, the program began smoothly, and it was easy to obtain educational
results in this group. There were certain selection biases. However, this study and program were still at a trial stage, and when
the burden on participants taken into consideration, voluntary
application for the program was considered inevitable. In the
future, our program should be introduced as an in-service training course in collaboration with internal specialist nurses.
Acknowledgments
We would like to express our sincere gratitude to all the participants inthis study.

Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect tothe research, authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This research
was funded by a Grant-in-aid for Young Scientists (B), No.
22792207 from the Japan Society for the Promotion of Science.

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