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An Interprofessional End-of-Life Simulation to Improve Knowledge and Attitudes of End-of-Life Care Among Nursing and Physical Therapy Students

Campbell, Denise DNP, RN, ACNS-BC, CEN, CHSE1; Trojanowski, Suzanne PT, DPT2; Smith, Leslie M. PT, DPT3

Author Information
doi: 10.1097/01.REO.0000000000000192
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As people age, they often develop many chronic illnesses that require complex care. As chronic illnesses become more debilitating and patients approach the end of life (EOL), hospice and palliative care (HPC) can provide this complex care. Hospice and palliative care is best provided by interdisciplinary care teams and is focused on using evidence-based care decisions to enhance quality of life.1 According to the National Hospice and Palliative Care Organization, in 2016, 1.43 million Medicare beneficiaries received hospice care.2 As the population is aging, it is important for students within a health care curriculum to feel comfortable caring for patients who are receiving HPC.

A review of the literature indicates that many health care students feel uncomfortable and unprepared in providing EOL care.3 In addition, EOL education in health care tends to be inadequate, leaving a gap in the students' knowledge and understanding to adequately manage a patient who is dying.4

Attitudes toward a dying patient can affect the quality of care being provided. A student who feels unprepared to care for the dying patient may avoid the patient and family members, promoting a feeling of isolation for the patient.

Nursing has long been involved in EOL care. Recently, the contributions of physical therapy to the EOL care team have been promoted.5–8 End-of-life care is now incorporated into physical therapy education.9,10 Multiple initiatives have called for a better coordinated plan for EOL care. The American Colleges of Nursing has identified 16 palliative competencies that health care students should attain prior to graduation.3 One of these competencies is the use of teamwork. Ideally, using interprofessional (IP) teamwork will allow students to assist patients in the transition from acute to palliative care, ensuring a meaningful death for the patient.

One approach to assisting students in IP care of the dying patient is simulation. Simulation-based learning experience (SBLE) is a pedagogical approach that has gained widespread use for both students and health care providers. It can assist with handling emotional situations such as EOL care. In addition, having an IP team of students working together within the SBLE promotes teamwork, enhances communication, and improves students' attitudes.11

Interprofessional education (IPE) is a growing focus in the education of health care professionals. The World Health Organization promotes IPE as a necessary step in preparing health care students who will work collaboratively in an IP team to deliver the highest evidence-based quality of care to patients, families, and communities.12 The Interprofessional Education Collaborative (IPEC) Core Competencies for IP Collaborative Practice offer aptitudes to include when developing IPE opportunities for students.13 In addition, the Institute of Medicine of the National Academies further calls for all clinicians across disciplines who care for people at the EOL to receive education in palliative care, including communication skills, IP collaboration, and symptom management.14

The purpose of this project was to describe an IPE EOL SBLE for nursing and physical therapist students and to evaluate the changes in the students' knowledge and attitudes toward participation in EOL care.


This project used a quasi-experimental repeated-measures pre/posttest design to evaluate attitudes, awareness, and behaviors of students before and after participation in a simulated IPE EOL experience. Institutional Review Board approval was obtained from the university where the project took place. Participants in this SBLE, focusing on the EOL care of patients and families, were a convenience sample of bachelor of science in nursing (BSN) students from an accelerated medical/surgical II course as well as doctor of physical therapy (DPT) students enrolled in a geriatrics course in year 2 of their program.

Students were asked to complete the Frommelt Attitudes Toward Care of the Dying Scale—Form B (FATCOD-B) before attending their SBLE. This tool has been used nationally and internationally in prior research.3,15–20 It has been shown to be both valid and reliable with a Pearson's coefficient computed as 0.90.3 The FATCOD-B is a self-reported questionnaire consisting of 30 items using a 5-point Likert scale with responses being “strongly disagree,” “disagree,” “uncertain,” “agree,” and “strongly agree.” Items on the questionnaire relate to the attitudes of health care students of the dying patient as well as their attitudes toward the patient's family and the family's role in the care of the patient. Some of the questions were modified to include physical therapy as well as nursing for the care of the patients.

An EOL scenario was developed by the authors. The vision statement created for this SBLE was to use a simulation IPE experience to allow students the opportunity to understand and demonstrate patient- and family-centered care related to EOL. Student performance objectives for this SBLE were as follows: (1) students will understand the complexities of EOL issues from multiple perspectives; and (2) students will demonstrate appropriate communication during an IPE EOL simulation. The first objective was measured using the FATCOD-B and the second objective was measured using reflective writing, which is described later.

The simulation scenario consisted of a patient with a diagnosis of end-stage lung cancer. The patient decided to transfer to hospice care. The patient had 5 children and 2 were present in the room, one who lived locally and the other who lived out of state. During the scenario, there was conflict between the 2 siblings related to their father's wishes for EOL care. In addition, family training in preparation for discharge planning was occurring. The nurse was providing information on comfort measures and medications, and the physical therapist was educating the family on transfer techniques prior to the patient going home. The actors in the simulation were played by the students, who were provided background information and a written script the day before the SBLE. Verbal cues were also given to the students regarding their role on the day of the event. The patient in the scenario was male and 68 years old. When scheduling the students, male nursing or physical therapist students were assigned the role of the patient. The patient's children in the scenario did not have a prescribed gender. The course instructors randomly assigned the students to the roles of nurse or physical therapist dependent on their discipline. As there was only 1 nurse and 1 physical therapist per simulation experience, the remaining students were assigned the role of family members. Each student only performed 1 role during the simulation.

The IPE EOL simulation session was 70 minutes in length and included a 10-minute prebriefing session as well as a 30-minute debriefing session, using the 3D debriefing method (Defusing, Discovering, and Deepening) immediately after the SBLE.21 Prebriefing followed the recommendations of INACSL Standards of Best Practice: Simulation.22 The prebriefing session consisted of discussing the objectives and expectations of the SBLE, an orientation of participants to the simulation environment, and an opportunity for the 2 disciplines to discuss each's role in relation to participation within the simulation. Debriefing sessions were integrated with nursing and physical therapist students together and were coded by the faculty in both the nursing and physical therapy programs to ensure the perspective of each discipline was represented. Students were encouraged to reflect on their own feelings and role within the SBLE as well as their interaction with the other health care discipline. Support for this SBLE was provided by a total of 6 faculty members and 2 simulation technicians, for 1 full day. One of the coauthors was a certified health care simulation educator and the other 2 were simulation and IPE trained through various seminars. All 3 coauthors had extensive experience using simulation as a teaching/learning strategy. The 2 simulation technicians were both certified health care simulation operation specialists (CHSOS). The coauthors led the SBLE sessions, while the other 3 faculty members present provided additional insight into role and responsibilities, EOL care, and communication. Seventeen sessions were scheduled to accommodate all of the students.

The students completed the FATCOD-B post-SBLE. Evaluation metrics for this project compared the change in responses on the FATCOD-B pre- and post-SBLE. Students were required to complete a reflection on their experience and role played within the SBLE.


Demographic data was calculated using frequency counts. IBM SPSS Statistics 24 was used to analyze the FATCOD-B, employing a paired t test to compare pre- and posttest results. Student reflections were qualitatively analyzed and were coded to align with the IPEC competencies of values and ethics, communication, teams and teamwork, and roles and responsibility.13 A subtheme of patient-centered care was also included. Student reflections were coded by 2 authors to ensure accuracy and reliability. A third author provided coding when the original 2 authors disagreed. See the Figure for the process used for qualitative review of the data.

Process used for qualitative review of student reflection papers. IPEC indicates Interprofessional Education Collaborative.



A total of 83 students participated in the IPE EOL simulation. Data were obtained from a survey engine, and the respondents were matched by a participant code to determine pre- and posttest survey participation. Seventy-seven students completed the presimulation survey, 62 students completed the postsimulation survey, and 58 students completed both surveys. Eleven BSN students and 47 DPT students completed both the pre- and post-IPE EOL simulation FATCOD-B, for a response rate of 68.7% (DPT = 79.7%; BSN = 45.8%). Demographic data are provided in Table 1.

TABLE 1 - Demographic Data of the Participants
Age Average for All students Gender Gender By Program Personal Experience With Death and Dying Issues Professional experience With Death and Dying
27.07 Female total (n = 49) 15 RN, 34 PT 43 yes 13 yes
Male total (n = 34) 9 RN, 25 PT 12 no 40 no
3 unsure 5 unsure
bbreviations: PT, physical therapist; RN, registered nurse.

Frommelt Attitudes Toward Care of the Dying Scale—Form B

Mean scores of the FATCOD-B were obtained using the protocol described by Frommelt.23 The FATCOD-B has an equal number of positively and negatively worded items. The positive items were scored with a 1 for “strongly disagree” to a 5 for “strongly agree.” Conversely, the negatively worded questions were scored with a 1 for “strongly agree” to a 5 for “strongly disagree.” Using this scoring strategy allowed the data to suggest that higher scores reflect a more positive attitude. A 2-tailed P value (P = .0003) showed that pre-SBLE mean score on the FATCOD-B was 3.88, with the post-SBLE mean score being 4.02 demonstrating a significant improvement overall on the scores from pre-SBLE to post-SBLE.

The following 2 items on the FATCOD-B showed the greatest improvement in mean scores: question 2, “Death is not the worst thing that can happen to a person,” and question 11, “When a patient asks, ‘Am I dying?’ I think it best to change the subject to something more cheerful.” Question 2 pre-SBLE mean score was 3.62 and post-SBLE score was 4.09, with a difference of 0.47 (P = .0018). Question 11 used reverse scoring, so lower numbers were a more positive response. The pre-SBLE mean score was 2.14 and the post-SBLE score was 1.78, with a difference of 0.36 (P = .0001). Two additional questions were found to be significant as well: question 7, “The length of time required to give care to a dying person would frustrate me”; and question 8, “I would be upset when the dying person I was caring for gave up hope of getting better.” See Table 2 for the full results.

TABLE 2 - Frommelt Attitudes Toward Care of the Dyinga
FATCOD-B (N = 83) Pretest Score Posttest Score Δ P
1. Giving care to the dying person is a worthwhile learning experience. 4.47 4.55 0.08
2. Death is not the worst thing that can happen to a person. 3.62 4.09 0.47 .0018
3. I would be uncomfortable talking about impending death with the dying person. 2.72 3.03 0.31 .0254
4. Care for the patient's family should continue throughout the period of grief and bereavement. 4.33 4.41 0.08
5. I would not want to be assigned to care for a dying person. 3.38 3.62 0.24
6. The nurse/physical therapist should not be the one to talk about death with the dying person. 3.78 3.74 0.04
7. The length of time required to give care to a dying person would frustrate me. 3.84 4.12 0.28 .0038
8. I would be upset when the dying person I was caring for gave up hope of getting better. 3.03 3.34 0.31 .0082
9. It is difficult to form a close relationship with the family of a dying person. 3.78 3.83 0.05
10. There are times when death is welcomed by the dying person. 4.41 4.52 0.09
11. When a patient asks, “Am I dying?” I think it best to change the subject to something more cheerful. 3.86 4.22 0.36 .0001
12. The family should be involved in the physical care of the dying patient. 4.21 4.34 0.13
13. I would hope the person I am caring for dies when I am not present. 2.67 2.78 0.11
14. I am afraid to become friends with a dying person. 3.84 3.90 0.06
15. I would feel like running away when the person actually died. 3.53 3.69 0.16
16. Families need emotional support to accept the behavior changes of the dying person. 4.36 4.33 0.03
17. As a patient nears death, the nurse/physical therapist should withdraw from his/her involvement with the patient. 4.19 4.29 0.1
18. Families should be concerned about helping their dying member make the best of his/her remaining life. 4.31 4.33 0.02
19. The dying person should not be allowed to make decisions about his/her physical care. 4.60 4.41 0.19
20. Families should maintain as normal an environment as possible for their dying member. 3.98 4.16 0.18
21. It is beneficial for the dying person to verbalize his/her feelings. 4.59 4.59 0
22. Care should extend to the family of the dying person. 4.26 4.5 0.24
23. Nurses/physical therapists should permit dying persons to have flexible visiting schedules. 4.21 4.36 0.15
24. The dying person and his/her family should be the in-charge decision makers. 4.22 4.38 0.16
25. Addiction to pain relieving medication should not be a concern when dealing with a dying person. 3.52 3.57 0.05
26. I would be uncomfortable if I entered the room of a terminally ill person and found him/her crying. 3.21 3.19 0.02
27. Dying persons should be given honest answers about their condition. 4.21 4.28 0.07
28. Educating families about death and dying is not a nursing/physical therapist responsibility. 3.78 3.91 0.13
29. Family members who stay close to a dying person often interfere with the professionals' job with the patient. 3.47 3.72 0.25
30. It is possible for nurses/physical therapists to help patients prepare for death. 4.12 4.26 0.14
bbreviation: FATCOD-B, Frommelt Attitudes Toward Care of the Dying Scale—Form B.
Negatively worded questions are highlighted in gray.

Qualitative Data

Qualitative data from the students' reflection papers showed an overall positive response to the SBLE. As the reflections were an assignment for 1 specific nursing and physical therapy course, 80 reflections were completed. The physical therapy department had 3 students from the part-time track attend the simulation, but their course did not ask them to write a reflection on their experience. Some examples of this positive response are as follows:

While not all situations are just like this simulation, there are valuable lessons in patient and family communication that could be gained from this experience.

I think it's great that the school has provided us with some experience on death and dying because in the article by ... the discussion explains how many who are not prepared have trouble with the emotional impact of death in the clinical setting. Although our simulation was not so emotional, it was an experience that I was be [sic] able to learn from. I feel like I got good insight from the “patient” and “family” during debriefing.

It gave exposure to ways to handle and diffuse conflict between family members while also teaching to not forget to keep the focus on the patient and respecting their wishes. I enjoyed partnering with the physical therapy [sic] and thought I [sic] the simulation was a good experience.

The BSN and DPT students' coded reflections included a determination of the frequency that the students reflected on each of the IPEC competencies. See Table 3 for the results by discipline. Of the 4 IPEC competencies, “values and ethics” was identified by most of the students (83.8%) with the subthemes of patient-centered care and respect. Examples of student reflections of values and ethics are as follows:

TABLE 3 - Qualitative Coding of Frequencies (and Percentages) of the Interprofessional Education Collaborative Competencies in Student Reflections
Values and Ethics Interprofessional Communication Teams and Teamwork Roles and Responsibilities
Entire group (N = 80) 67 (83.8%) 43 (66.3%) 31 (38.8%) 56 (70.0%)
BSN (n = 24) 15 (62.5%) 14 (58.0%) 9 (37.5%) 12 (50.0%)
DPT (n = 52) 52 (92.9%) 39 (69.6%) 22 (39.3%) 44 (78.6%)
bbreviations: BSN, bachelor of science in nursing; DPT, doctor of physical therapy.

Some insights into discharge planning issues during end-of-life care that I gained were that it is a skill to navigate family dynamics and that sometimes respecting the patient means respecting that they don't want to continue spending all their time in appointments just to prolong their life a little longer.

When a patient is nearing the end of life, there are certain tasks and precautions that a nurse must consider when working with a patient. But above all, giving the person a chance of dying with dignity allows the patient their unconditional quality of human worth. Establishing what kind of care exactly the patient wants should be a top priority.

Seventy percent of students reflected on roles and responsibilities, with a majority reflecting on their own role with EOL care. Examples are as follows:

I felt reasonably confident during the experience in my ability to care for the patient. However, I was unprepared to handle an argumentative family member and instantly became protective of my patient instead of focusing my attention on educating the family member.

The connections I made were that physical therapy is important throughout the span of life, not just the recovery portions of it. Maintaining a person's quality of life is an extremely important role in physical therapy and simple treatment can go a long way in helping a person's outlook and mood during their end of life treatment.

Sixty-six percent of the students reflected on the importance of IP communication not only with the team but also including the patient and family members. Examples are as follows:

There were times it was awkward and he [patient] had unanswered questions, but I felt grateful to be a listening ear during his experience because I know that it is such a hard decision to make for some people.

Cook and Rocker24 explain how clear communication can help with satisfying the family during care at the EOL and how usually at the EOL the health care team does more listening than talking.

I learned that communication between all members of the patient's care team is extremely important. In addition, I think patient-centered care and listening to what the patient wants should be the top priority.

Finally, “teams and teamwork” was the least mentioned competency, with 38.8% of the students reflecting on it. Two examples are as follows:

I learned that it most definitely requires an interprofessional team who works well together.

This simulation added to my knowledge base of how its help to [sic] have a multidisciplinary team to assist with patient's end-of-life care to make the patient as comfortable as possible and have a smooth transition home.


Results from the FATCOD-B showed an overall significant improvement in attitudes toward the care of a dying patient. This finding is consistent with other studies that showed simulation improves student attitudes regarding EOL care.3,17,19,20 However, only 4 of the 30 questions had significant improvements individually. This may be a result of a ceiling effect, as 13 of the 30 questions on the presimulation survey had a higher score than 4 (indicating a positive attitude), which left very little room for improvement. Another possible effect on this score could be that 75% of the students reported they had a personal experience with death and dying. Grubb and Arthur19 also noted this result in their study. Ten of the questions asked about families and family needs and support. The presimulation mean score of these questions was 4.07, indicating that the students agree that families need support. This is in contrast to the study conducted by Dimoula et al25 in which results showed that half of the study participants viewed family members as interfering with health care providers' patient care.

The first student performance objective was met as demonstrated in the overall improvement in the mean FATCOD-B scores. This may translate into improved attitudes toward providing EOL care to patients and their family members. In their study, Kirkpatrick et al16 found improved scores on the FATCOD-B to support better attitudes as precursors to a higher level of quality of care. As previously discussed, current literature shows that students feel unprepared in providing EOL care.3 Lindemulder et al4 and Wellmon et al11 described gaps in the education of EOL care. Our study supports the growing body of literature that demonstrates simulation may improve student comfort with EOL care.

The qualitative results indicated the students reflected on the IPEC competencies and recognized their importance in delivering IP care in an EOL scenario. “Teams and teamwork” was the least mentioned IPEC competency. One possibility for this low percentage is the way the reflection assignment was designed, not allowing for students to expand upon the teamwork needed during EOL care. Another possibility was the design of the SBLE scenario did not allow for team development and addressing the patient and family members' needs as a team. Future IPE EOL SBLE could increase focus on teams and teamwork, as the current health care climate requires professionals to collaborate with multiple disciplines when providing patient care.

The second performance objective was partially met regarding communication with the patient but not communication among professionals. Possible reasons for this lack of IP communication include the absence of focused expectations during the student preparation and prebriefing session as well as the imbalance between the number of nursing and physical therapist students. Because there was a greater number of physical therapist students (59 compared with 24 nursing students), they often played the role of either the patient or family members. This potentially allowed for an increased comfort level in communicating with their classmates as opposed to the nursing student.

Although many nursing and physical therapist students reflected on the IPEC competencies, most thoughts were focused on patient-and family-centered care, with little discussion of IP collaboration between the 2 professions. The patient and family members are at the center of the IP team; however, this simulation design may not have fostered professional collaboration. In the future, intentional planning of the simulation design will focus on developing IP relationships, communication, and teamwork.

Future research in this area could focus on how to use simulation to encourage the patient and family members to become partners with their health care teams. In addition, research could explore how simulations including the patient and family members impact health care providers in EOL care as they transition into practice.


The limitations of this study were the unequal number of students representing each of the professions, an inequality of the training of all of the facilitators, different reflective assignments given to the different professions, and lack of intentional planning of the students to be in an IP team. Other limitations include a convenience sample from a single institution and no long-term plan to evaluate whether student attitudes continue to transform as they move through their respective academic programs.


An IPE EOL SBLE has shown to improve the knowledge and attitudes of nursing and physical therapist students toward participation in EOL care. The vision of this simulation was met by providing the students with an opportunity to participate in an EOL SBLE. As shown in the reflections, students focused on providing patient- and family-centered care. In the absence of EOL experiences within the clinical education setting, simulation can assist with preparing health care students with IPE and ensuring high-quality EOL care.


The authors thank Ronald T. Streetman, BA, EMT-B, CHSOS, James McTiernan, CHSOS, Sharon Roy, PT, Lynette Bourne, MSN, RN, and the university for granting availability of the simulation center.


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attitudes; collaborative practice; hospice and palliative care

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