The results of this study show a significant increase in the mean of nurse's knowledge scores in all 9 fields of end-of-life care knowledge after the intervention. These results are consistent with the findings of Glover et al . However, the present study and above study differed in the samples studied; the study by Glover et al, was conducted on final year nursing students, while the present study was performed on nurses working in the ICU. This can be the cause of differences between the results of these two studies. One of the most important differences is the greater clinical experience of nurses working in the ICU compared to students. Undoubtedly, employed nurses have had more exposure to patients at the end of their lives and have had more experience in providing care to patients and their families. This can be effective in improving the quality of knowledge and performance. The findings of the present study indicate that participation in ELNEC training courses has increased nurses' knowledge in all fields, especially in death and culture. However, in the study by Glover et al., the highest percentage of changes was related to palliative care, management of symptoms, communication, and elimination of grief-related loss . Numerous items in the questionnaire showed that nurses had a relatively high level of prior knowledge in various fields of end-of-life care such as pain assessment and management, as well as the basic principles of nursing such as healing, suffering, and QOL of patients and their families. This may be due to the nurses’ knowledge of the general principles of nursing that they have learned during their academic studies, or due to the similarity of the educational content to the principles they have performed in sedative care at the end of life in the ICU.
In relation to the role of experience, other researchers have found that experienced nurses scored higher than less experienced nurses, meaning that nursing training and experience led to overall knowledge about palliative care . These findings suggest that nurses can use the content of palliative care and end-of-life care education in the standard nursing curriculum using the ELNEC course, and any overlap in the content will have positive learning outcomes for them. Furthermore, nursing students may need to reinforce materials related to communication skills and grief in their courses [14, 15]. Previous researches have shown the nurse's desire to become more prepared to care for dying people [16, 17]. In this regard, the need for separate courses on these topics will decrease if the content of palliative care is included in student's curricula. The results of the present study are consistent with the results of the study conducted by Conner et al. They provided an online course on death and dying people and reported a significant improvement in nurse's attitudes toward caring for dying people . The results of the present study showed that nurses can use their knowledge of end-of-life care, which is a multimedia approach to promoting end-of-life care. This finding is consistent with the findings Jackson and Motley .
The second objective of the present study was to investigate the effect of education on nurse's performance in relation to end-of-life care. Among the 4 aspects studied, the training course was found to improve the performance of ICU nurses in the 3 aspects of preparation for palliative care, self-assessment of the ability to communicate with dying patients and their relatives, and self-assessment of knowledge and skills in palliative care. Only in the field of attitudes towards palliative care, no significant improvement was observed in the nurse's performance. This can be due to the established and stable attitudes of clinical nurses regarding their beliefs about palliative care. It seems that longer and deeper educational processes are required to induce more change in the attitudes of nurses. However, in areas in which communication and skill were desired, the ELNEC-based training course had a significant effect on improving nurse's performance. This significant effect may indicate that short-term training courses have a more favorable effect on skills than attitudes. The results of the present study are consistent with the findings of the study by Tamaki et al .
In this study, a training course was presented to improve the performance of nurses in the field of end-of-life care, and in the intervention group, improvement was observed in skills in physical performance assessment, psychological care, and confidence in providing end-of-life care. These results show that end-of-life care training enables nurses to enrich their skills in realistic situations . In confirmation of the findings of the present study, Luctkar-Flude et al, reported that training courses lead to valid emotional responses to realistic patient care scenarios and lead to their imitation in real clinical conditions . Heidari et al, found that posttest time is an important factor in the evaluation of training courses . In this study, the researcher decided that the posttest should be implemented 1 month after the end of the training course to control the effect of the short duration of education. This is one of the important differences between the present study and some other studies in this field, including the studies by Glover et al. and Tamaki et al. Further studies are required to compare several different educational strategies (both in the classroom and hospital) for end-of-life palliative care in order to identify their strengths and weaknesses. This will enable nursing educators to use the best educational approach or a combination of several strategies for nurses. In addition, it is recommended that future researches evaluate and develop interactive learning activities that improve nurse's ability in difficult clinical projects.