Learning Palliative Care in practice: a meta-ethnography of nurses’ experiences in the clinical setting

Learning Palliative Care in practice: a meta-ethnography of nurses’ experiences in the clinical setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Learning Palliative Care in practice: a meta-ethnography of nurses’ experiences in the clinical setting Julie Young, Anna Buckby, Erna Haraldsdottir, Giorgos Tsiris This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9214411/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract BACKGROUND An ageing population and the rising prevalence of chronic conditions demand greater capacity and the provision of palliative care. The role of the nurse is key to meeting this need; however, the widespread lack of nurses' knowledge in palliative care and increasing challenges in accessing formal education create a barrier. What is missing in the literature is an explanation of how nurses learn palliative care in real practice, not just what they should know. The purpose of this study was to undertake a systematic synthesis of qualitative research on nurses' perspectives and experiences of learning palliative care in the clinical practice environment. AIM To deepen the understanding of nurses’ development of palliative care knowledge within the clinical practice environment. METHODS The review adopted a meta-ethnographic approach, following the PRISMA guidelines and the eMERGE guidelines, which operationalise Noblit and Hare’s 7-stage approach to meta-ethnography. A systematic search across MEDLINE, CINAHL, and ERIC databases in July 2025 identified nine relevant studies. The quality of the studies was assessed using the CASP Checklist, and concepts across studies were interpreted and translated to generate new insights. RESULTS Together, the synthesis and analysis yielded a higher‑order interpretation presented as three interrelated themes: (1) Learning through relationships with people with palliative care needs ; (2) Learning through relationships with colleagues ; and (3) Learning through relationships between organisations . Aligned with person-centred care principles, these themes underscore the impact of relationships, reflection, and organisational culture on shaping nurses’ learning. CONCLUSION This meta‑ethnography offers a new conceptual explanation of how nurses learn palliative care in everyday practice: learning is relationally enacted with patients and colleagues, across organisational interfaces, enabled by reflective spaces and shaped by organisational culture, strengthening nurses’ capacity to deliver person-centred palliative care. Understanding these conditions provides actionable insights for designing palliative‑care education, workforce development, and cross-setting collaboration. meta-ethnography nurses experiences learning education palliative care end-of-life-care work-based learning clinical practice environment Figures Figure 1 INTRODUCTION The changing landscape of palliative care demands increased capacity and provision of effective care to those facing a life-limiting illness. Worldwide, people are living longer, and the prevalence of chronic conditions is increasing, a trend that is expected to continue, and, by 2030, approximately one in six people globally will be aged 60 or older. 1 This proportion is expected to increase to one in five by 2050, with the population aged 80 and above projected to reach 426 million, nearly three times its current size 1 . Access to palliative care is inconsistent, including within high-income countries, 2 prompting global calls for universal provision. 3 The experience of living with a life-limiting illness is deeply personal and varies significantly from one individual to another. Palliative care supports people with life-limiting illnesses and is widely recognised for its person-centred approach, aligning care with a person's unique values, goals and preferences. 4 , 5 Nurses, often the primary caregivers in palliative care, 3 play a significant role in caring for people with palliative care needs, 6 however, their limited knowledge has been identified as a primary barrier to high-quality palliative care. 7 , 8 As workload demands continue to rise and workforce shortages persist, clinical settings face growing pressure to ensure staff possess adequate knowledge. 5 Research has shown that educational programmes effectively improve knowledge, attitudes, and confidence in palliative care. 6 , 7 However, it is significant that, with limited opportunities to release nurses from clinical duties, formal programmes reach only a fraction of the workforce. 9 The absence of a clearly defined solution has hindered efforts to address the issue. The importance of learning within the clinical environment is increasingly highlighted in evidence, with experiential and situated learning having a profound influence on nurses’ knowledge development. However, despite this recognition, limited research explores how such learning occurs within palliative care contexts. Notably, there is no existing synthesis of primary qualitative research that examines how nurses engage with and acquire palliative care competencies in clinical practice environments. This study aims to meet this gap, generating a new, comprehensive understanding that can inform educational practice and enhance person-centred care. AIM To systematically review and synthesise findings from qualitative primary studies exploring nurses' perspectives and experiences of learning about palliative care within the clinical practice environment. STUDY DESIGN A meta-ethnography was conducted to develop a deeper understanding of nurses’ perspectives on learning about palliative care within the clinical practice environment. By synthesising the findings of existing qualitative research, a meta-ethnography aims to create third-order constructs , 10 which are key themes derived from second-order constructs (the studies’ authors’ themes) and first-order constructs (the participants’ perspectives and experiences). The conduct of this meta-ethnography adhered to the PRISMA guidelines and the eMERGE guidelines, 11 which operationalise Noblit and Hare’s 10 7-stage approach to meta-ethnography. SEARCH STRATEGY The following electronic databases were searched in July 2025: CINAHL, MEDLINE, and ERIC. The Population Exposure Outcome (PEO) framework 12 supported the development of key search words relevant to “nurses”, “palliative care”, “knowledge development” and “perceptions”, which were combined using Boolean operators (AND, OR). The papers were screened through stages: (1) titles, (2) abstracts, and (3) full texts. In addition, the reference lists of all included studies were screened by title. INCLUSION AND EXCLUSION CRITERIA Studies qualified for inclusion if they fulfilled the following criteria: (1) reported nurses' perspectives or experiences of learning about palliative care in the clinical environment, (2) used qualitative methods, (3) published in peer-reviewed academic journals, and (4) published in English. Studies were excluded for the following: (1) did not include nurses’ perspectives, (3) only included quantitative methods (3) full text was unavailable. The type of learning intervention, if stated in a research study, did not influence the study’s eligibility. Similarly, no studies were excluded based on sample size. An inclusive approach was taken to ensure a broad representation of nurses’ perspectives and experiences. The open publication time frame reflects the novelty of this meta-ethnography in this area. A PRISMA 13 figure presents the stages of the search (Fig. 1 ), including the total studies identified, screened, assessed for eligibility, excluded, and ultimately included in the synthesis. Nine studies were included; Table 1 summarises the key characteristics of each study. Table 1 Summary of included studies Author/ Year Location Aim Sample Details of learning Intervention (if applicable) Setting Methodology/Data Collection CASP score Bagaragaza et al 15 France Explore perceived outcomes of critical companionship in supporting the integration of a palliative approach in the care of residents in nursing homes n = 49 11 nurses 3 critical companions (palliative care nurses) supporting 6 nursing homes over a period of 10 months. Critical companions worked alongside the nursing home staff, offering guidance and support. 6 nursing homes Multiple Case study Focus Groups Semi-Structured Interviews 19 Frey et al 16 New Zealand Explore palliative care nurse specialists’ experiences regarding the benefits of and barriers to the implementation of a palliative care educational intervention n = 3 Palliative care clinical nurse specialists 1-year-long palliative care education intervention: Records review, role modelling, coaching, education planning and debriefing. 20 long-term care facilities Inductive content Analysis of participants reflective logs 18 Hegarty et al 22 Australia Explore health professionals' experiences in developing capacity for supporting people with refractory suffering n = 17 (10 nurses) No intervention 2 specialist palliative care services Exploratory study Semi-structured interviews Questionnaires 20 Hockley 19 UK To explore the impact of debriefing sessions in promoting high-quality end-of-life care. n = 34 Nurses, healthcare assistants 10 reflective debriefing groups led by a specialist palliative care nurse with a focus on end-of-life care in care homes 2 care homes Action Research Debriefing sessions 20 Johansen and Helgesen 24 Norway Explore experiences of the resource nurse role within nursing home settings. n = 7 Resource nurses Care homes were assigned resource nurses: with the intention to: Act as a resource, improve services & disseminate knowledge. 2 nursing homes An Exploratory Study Semi-structured interviews 19 Johnston et al 17 UK Describe and explore nurses’ experiences of engaging in a peer-mentoring initiative. n = 52 26mentor 26mentees 3-month peer mentoring programme supporting registered nurses new to the hospice nursing service. Community Palliative Care An evaluation study Qualitative questionnaire 9 Kilbertus et al 23 Canada To explore health professionals memorable palliative care learning experience for rural healthcare professionals. n = 17 7 nurses; 7 GP’s No intervention Community, long-term care facilities, hospice & hospital A Narrative Study Both observational and verbal methods. 20 Rabbetts 25 Australia To explore the experiences of nurses working alongside a research assistant in the facilitation of using a new assessment process. n = 10 registered nurses, enrolled nurses and midwives A research assistant was assigned to a medical ward with the intention to: work alongside the nurses and facilitate using a newly introduced clinical symptom assessment form for patients receiving palliative care. A medical ward in a large regional hospital Focus groups 19 Whiting et al 18 UK To explore nurses’ experience participating in a rotation programme between paediatric hospice and hospital palliative care settings. n = 5 3 hospice nurses and 2 acute hospital nurses 8-month rotational programme were hospice nurses and hospital nurses swap roles. Children's hospice and a children’s hospital ward Appreciative Inquiry Semi-structured interviews 19 QUALITY APPRAISAL The quality and rigour of the studies were assessed using the CASP Qualitative Research Checklist. 14 Each question was assigned a score, (yes = 2, unclear = 1, no = 0), where the highest attainable score is 20 (Table 1 ). This appraisal did not serve as a criterion for exclusion, but rather informed the interpretation and synthesis of findings. Generally, studies with a greater score assigned provided more detail on data collection and analysis processes. Four of the studies did not report the relationship between the participants and the researcher, impacting the integrity of their work. 15 – 18 This is an emerging area of research, where all studies have the potential to offer insights into the research question. All studies make a valuable contribution to understanding nurses’ perspectives and experiences as they learn about palliative care in the clinical environment. DATA EXTRACTION The nine included studies present qualitative data on nurses’ perspectives and experiences of learning about palliative care in the clinical setting. Differing opinions on how studies should be read and synthesised are found in the literature. 11 Given the absence of a clear explanation for a preference for one over the other, the study adopts a chronological approach. The individual papers were read and re-read, and the data concerning the characteristics and the main findings from each study were identified (see Table 1 ). The data extraction process involved gathering participants’ own words (first‑order constructs) and the authors’ interpretations (second‑order constructs) from all included studies (Table 2). 10 Table 2: Data Extraction, Abstraction and Synthesis: Key components of nurses’ perspectives of learning with illustrative quotes Sample Participant Quotes (First-order constructs) Key Components Experiences (Second-order constructs) (Third-order constructs) “This is the moment you don't forget … He grabbed me and pulled me over that day and … he said … he found [the medication] really frightening, and the nightmares, and the way the drug made him feel … My angst comes from what happened in his psyche and his emotions … how much did he suffer?” (Kilbertus et al 23 ) -An action-reflection model can support the development -A positive organisational culture is essential, promoting collaboration, mutual respect, and effective information sharing. -Reflecting on death reduced nurses’ anxiety and led to knowledge development in recognising dying. -Novel or unfamiliar situations sparked reflection that contributed to memorable learning, changes in understanding of self and others, emotions and behaviours going forward. Learning through interaction with people with palliative care needs “we learn from those we respect” (Hegarty 22 ) “I think it is great working together with others who hold the same basic view. We discuss, we might disagree; that is the way it should be, but we basically agree on how we want it to be”. (Johansen and Helgesen 24 ) -The Specialist nurse can provide support and reinforcement. -The high staff turnover and under-resourcing negatively impact documentation and the care of the residents. -The mentor/mentee relationship supports reciprocal learning and generates confidence -Shared values within the team are essential for aligning professional goals and establishing a common language around palliative care. -staff have a preference to seek answers from people over textbook or the internet. Learning through relationships with colleagues “The collaboration with our partners is more fluid, and this is thanks to the bridge built with the project”. (Bagaragaza et al 15 ) -Facilitated a shared vision, timely approach and improved symptom management. -Enhanced multi-disciplinary collaboration. -Improved organisational practices and processes, and enhanced collaboration between healthcare organisations. -Support was crucial to success of rotations. -Nurses held anxieties over their level of clinical competence in a new area. Learning through relationships between organisations DATA ABSTRACTION Data abstraction then enabled comparison across studies by organising these constructs into more succinct conceptual summaries that captured both the similarities and distinctions in nurses’ experiences and perceptions of palliative care learning in the clinical environment. The studies spanned the period 2010 to 2024, and the data were gathered from 194 health professionals, of whom more than 112 were registered nurses (the study by Hockley 19 does not specify how many of its 34 participants were nurses). Studies were collected across the United Kingdom (3), Australia (2), Canada (1), France (1), New Zealand (1), and Norway (1). Seven of the nine studies sought nurses' perspectives and experiences of a learning intervention in the clinical environment, interventions explored where debriefing, role modelling, clinical coaching, rotation, peer mentoring, resource nurses and research nurse roles. Of the two studies without an intervention, one focused on nurses' learning experiences and perceptions of developing capacity for supporting people with refractory suffering, and the final study focused on nurses’ memorable learning experiences in palliative care. SYNTHESIS During synthesis, special care was taken to preserve the context of the original studies 20 while using interpretive language to identify patterns and relationships relevant to nurses' learning in the clinical environment. Integrating these abstracted concepts through reciprocal, refutational and line-of-argument translation 10 , while ensuring the original context of the studies was retained, 21 three themes emerged (third-order constructs ),10 provided a new overarching interpretation that transcends the primary studies (Table 2). 11 RESULTS Three themes emerged from the synthesis: (1) Learning through relationships with people with palliative care needs; (2) Learning through relationships with colleagues ; (3) Learning through relationships between organisations . Each theme captured a different dimension of this from the nurses’ perspectives and experiences. Together, they demonstrate how relationships in the clinical practice environment support nurses in learning about palliative care from and with others and learning from others leads to a desire to share knowledge with others. Sharing knowledge and learning through collaboration increases nurses’ knowledge and confidence. The findings from each theme will now be presented. Learning through relationships with people with palliative care needs Through relationships with their patients, nurses across a range of settings developed knowledge beyond the clinical or factual, providing valuable, real-world learning that enhanced their ability to support. 22 , 19 , 23 The process of reflection was key to achieving this learning, enabling one to express feelings about what a person is expected to have done and to embed new thoughts for nurses, including how to do things differently in the future. The method of reflection adopted varied significantly across studies, ranging from slowing down and taking time to think during interactions with people with palliative care needs, 22 to engaging in spontaneous discussions with colleagues about specific cases, 15,22–24 and participating in structured, planned, facilitated group discussions. 15 , 19 , 24 Participants in the study by Hegarty et al, 22 identified patients and families as important contributors to nurses' understanding of what it means to be living with suffering, with nurses relaying moments when they felt ‘out of depth’ and how these moments ultimately supported their ability to work with a multidisciplinary team and develop capacity for effective, sustainable palliative care practice. Similarly, the study in nursing homes by Hockley 19 found that participation in facilitated, group reflection following a resident's death led to knowledge sharing and shared learning, and, over time, nurses changed their approach to providing care to people at the end of life. In turn, nurses developed a new way of talking about death and dying that helped to make dying part of the nursing home culture. In the study by Kilbertus et al, 23 nurses found value in reflecting on situations they found complex or challenging. It was during those moments of disruption, when nurses challenged or doubted their ability to act in ways they aspired to, that the need to make and accept compromises and the importance of ‘being’ rather than ‘doing,’ triggered transformational learning and changes in understanding of self. This demonstrates the significance of the dissonance between the ideals nurses aspire to and the lived reality of working in a clinical setting, as well as its role in triggering disruption during transformative learning. The findings extend beyond identifying the role of reflection in nurses’ knowledge development, suggesting that reflexivity influences changes in ideas, approaches, perceptions, emotions, and actions. Learning through relationships with people with palliative care needs entailed emotional labour and being open and honest took courage. Organisational culture was central to the success of the reflective process, with insufficient staffing frequently cited as a barrier. 16 , 22 , 24 Learning through relationships with colleagues The implementation of mentorship processes, as well as more informal relationships with colleagues in the clinical setting, led to learning. Six studies focused on nurses’ experiences and perceptions of an introduced mentor role, 15–18.24.25 the role of mentor varied in format; a peer-mentoring programme for nurses new to their role in community palliative care, 17 a created role to enable the implementation of a specific palliative care assessment form; 25 palliative care nurses in nursing homes 15 , 24 and rotation programmes between two organisations. 16 , 18 The mentor provided opportunities for nurses to learn through demonstrating good practice, providing support and encouragement, facilitating knowledge exchange, challenging interests, being available, and facilitating reflection and collaboration. 15 , 17 , 28 , 24 , 25 Establishing relationships was identified as a crucial step in the mentor-mentee process across all six studies, and as even more significant in the two rotation programmes between organisations. 16 , 18 In the study by Frey et al, 16 establishing relationships between hospice and long-term care nurses was crucial for fostering mutual trust and shared understanding of hospice's role and scope within care. Interestingly, increased connection between the external mentor and mentee led to closer relationships among long-term care nurses and their colleagues. This fostered a mutual sense of ‘family’ and collaborative relationships. 16 Whiting et al, 18 highlighted that nurses participating in a rotation programme encountered additional challenges acclimatising to an unfamiliar environment and adapting to different drug regimes, leading to feelings of anxiety. Despite this, rotational programmes offered unique, valuable opportunities for mutual appreciation of roles and increased understanding of the patient and family journey. 16 , 18 Notably, both studies emphasise the importance of managerial support. Bagaragaza et al. 15 demonstrated the collaborative and co-creative foundations of a critical companionship programme, modelling a high challenge, high support approach, facilitated cultural transformation, promoting the embedding of person-centred principles across individual, team, and organisational levels. The findings of the studies point to evidence of reciprocal learning 15 – 18 , 24 and situated contributions where the mentor’s deliberate presence created plentiful moments where discussion, learning and teaching, and changes in attitudes and practice. 15 – 19 , 24 , 25 In the study by Johnston et al, 17 mentors reported experiencing increased workload pressure due to their role, yet found joy in it. They identified the experience as enriching their knowledge. Three studies focused on less formalised, organic learning through interaction with colleagues in the clinical setting. 19 , 22 , 23 Interestingly, the findings are similar to those studies with an official mentor present. That said, limited knowledge was evident in the literature; perhaps due to nurses' lack of awareness of their role modelling in everyday practice. Resource constraints and staff turnover negatively influenced nurses’ ability to learn through interactions with colleagues. 16 , 18 , 22 , 24 Repeated staff changes proved challenging for establishing trusting relationships between the mentors and mentees. 16 , 24 In the study by Johansen and Helgesen, 24 mentors felt their competence was limited and reported that they would have benefited from allocated time to devote to their learning. In the same study, some mentors reported feeling challenged by colleagues who were not receptive to new ideas, which led to frustration when they were unable to influence others. Learning through relationships between organisations Formal agreements between organisations forged collaborative relationships; supported reciprocal learning; challenged misconceptions; promoted a desire to learn, develop professionally and help others to learn. The agreements took the form of reciprocal clinical coaching, 16 a rotational programme, 18 critical companionship 15 and regular reflective debriefing sessions. 19 They involved collaboration between the hospice and the acute hospital, 18 hospice and long-term care facilities, 16 and specialist palliative care nurses and nursing care homes. 15 , 19 Developing a connection and acceptance of an external presence in the clinical setting was key; trust was associated with sharing and collaboration as relationships developed. 15 , 16 , 19 The relationships forged supported a willingness for ongoing collaboration between organisations. Significantly, the more nurses from different organisations interacted with one another, the stronger the knowledge base on both sides. 16 , 18 In the studies by Frey et al 16 and Bagaragaza et al, 15 the presence of a hospice nurse in a long-term care facility provided an opportunity to model difficult conversations, leading to increased confidence among facility nurses to begin discussions about advanced care planning. The support and reinforcement identified knowledge gaps and potential ways to enhance practice. 15 , 16 , 18 , 19 This extended beyond the individual nurse to encompass the wider team's role and ways of working. The results of the study by Bagaragaza et al 15 suggest the critical companionship relationship fostered a shared understanding of palliative care, which, in turn, supported the development of organisational processes and the delivery of personalised and timely care within the nursing home setting. Learning through organisational relationships was linked to nurses' personal and professional development. Where the desire for nurses to develop professionally was evident, it had been fostered through collaboration. 15 , 16 , 18 , 19 In the studies by Frey et al 16 and Whiting et al, 18 this desire extended to a wish to share their expertise with others. Developing a relationship fostered a sense of trust and understanding of the hospice, its role and the patient journey. Working with nurses from other organisations allowed individuals to recognise and challenge their misconceptions, 15,16,18 and ‘status quo’. 19 In the study by Whiting et al, 18 nurses in the hospital setting had not previously appreciated the range of services a hospice offers; their new knowledge helped them when advising patients and families. The literature demonstrates challenges for organisations working together to support nurses in learning about palliative care, both at organisational and personal levels. Staff turnover and insufficient staffing, reduced opportunities to learn from one another. 16,18,19 Interestingly, in the study by Hockley, 19 senior nurses' regular attendance at debriefing sessions was found to support them and their team in recognising their value and was thought to positively influence attitudes. DISCUSSION The existing gap in nurses' palliative care knowledge directly affects the quality of care delivered. With increasing demand and emphasis on workforce education, clinical settings can provide opportunities for nurses to learn from and with others. This meta-ethnography identifies three key factors that advocate a person-centred approach to palliative care education: establishing relationships, engaging in reflection, and adopting a learning culture within the organisation. Collectively, these are interdependent systems in which relationships foster key learning experiences for nurses, providing formative encounters and reflection that enable meaning-making, and an organisational culture that allows both to flourish. The study identifies the benefits of this approach, including opportunities that promote critical thinking, increased confidence, understanding, desire to learn, effective and sustainable practice, and reduced anxiety and isolation. The benefits gained go beyond individuals to include the creation of an environment that enables learning, stronger teams, greater collaboration, and improved quality of care. Considered a key component of high-quality care, 26 person-centredness is well established within global healthcare policy 1 and as a key competency in health professionals. 1 Highlighting that nurses’ qualities and capabilities are best realised within environments that actively support person-centred approaches to practice. The outcomes of this meta-ethnography resonate with the principles of a person-centred approach to palliative care. 27 Person-centred theory helps explain why developing relationships with people requiring palliative care, relational engagement with people with palliative care needs, and colleagues, nurtures greater sensitivity and ethical awareness. 27 In organisational environments where safeguarding time, psychological safety, and cross-boundary collaboration, reflective learning tends to become routine; in their absence, learning becomes unstable and inconsistently developed. Transformative learning theory demonstrates how both structured and informal reflection can prompt shifts in understanding and perspective. 28 Thus, palliative care capability emerges not as simply something individuals acquire, but as a relational–organisational achievement embedded in everyday practice. The findings also align with Lave and Wenger’s 29 account of learning as participation in communities of practice, where capability develops through relational engagement, through gradual participation, and evolving identity rather than through isolated or context-free learning. 29 They indicate that nurses’ relationships with people requiring palliative care and colleagues are the primary areas of participation and reflection, which then lead to shared understanding. A learning organisational culture within the organisation provides the access, time, and psychological safety that sustain participation. Under this framing, palliative care capability is not merely a personal skill, but a relational–organisational achievement arising from ongoing engagement in cross-setting, practice communities. Establishing Relationships The findings revealed that relationships in the clinical setting offer nurses opportunities to develop palliative care knowledge. These relationships support nurses’ learning from others; in so doing, they develop a desire to share their knowledge. Dame Cicely Saunders, widely recognised as the key founder of modern hospice care, developed the philosophy of palliative care based on her thoughts, values and beliefs, creating new assumptions that underpin healthcare for those with palliative care needs. 30 Key to the development of this model of care was Saunders's relationships with the people she cared for; they supported her in focusing on what mattered to the individual and helped her gain insight into specific conditions and situations. Saunders's philosophy of palliative care has always had person-centred practice at its core, 4 with the recognition that effective communication is crucial for engaging authentically, identifying and assessing individual needs, and supporting shared decision making. 30 The WHO 31 highlight establishing relationships not only as a condition for learning, but also as a cornerstone of a person-centred approach to care and professional development. The person-centred framework 27 considers the nurses’ preparation from a lifelong learning perspective. It identifies that being one’s authentic self is essential to creating relationships, particularly in the clinical setting. 32 From this perspective, our attitudes, beliefs, and behaviours underpin how we communicate with people and develop a therapeutic relationship. 4 This requires nurses to be open to new ways of thinking and aligns with the review findings, creating opportunities for nurses to share experiences, explore their values, reflect, and learn. This sheds light on the conclusions of the study by Johansen and Helgesen, 24 in which mentors reported feeling challenged and frustrated by those who were not interested in learning. Mutual respect, shared decision-making, 27 and trust 32 are identified as necessary attributes of an authentic relationship; together, these support transformational learning. 32 This correlates with the principal finding of this meta-ethnography: that nurses' relationships with patients, colleagues, and organisations support their learning about palliative care. Mezirow 28 identifies that when learners become aware of their habitual ways through reflection, it leads to Transformational Learning, a concept attributed to nurses reaching their full potential and advocated for in education. 33 The Process of Reflection Reflecting within the clinical environment enabled nurses to explore their emotional responses to practice and to embed a new understanding into their professional role, encompassing understanding, empathy, and insight. This emphasis on reflective practice is supported by the WHO, 31 which advocates for education that fosters critical thinking, emotional intelligence, and professional growth, including those related to palliative care. When aligned with a person-centred approach, reflection becomes a transformative process that not only enhances clinical competence but also nurtures the values and relational capacities essential to compassionate palliative care. Person-centred theory recognises how knowing and becoming through reflective learning can help nurses better understand the professional and personal challenges they encounter in the clinical setting. 27 The findings demonstrate that the process of reflection supported nurses in working with the uncertainty of knowing and becoming more person-centred in practice. Talking through their reflections helped nurses connect with others and develop knowledge through communicative action. Being open to the process of reflection with others and adopting a learning culture are key to nurses connecting the concept of their self and personhood, situating the moment of learning within their story of becoming. 27 , 28 , 34 This approach reflects principles of Transformative Learning Theory and person-centred practice development methodologies, in which deep reflective engagement leads to shifts in perspective and practice. 28 , 31 , 35 Adopting a learning culture within the organisation The findings highlight the organisational conditions necessary for learning in practice: fostering relationships, encouraging reflection, promoting growth, providing space, encouraging collaboration, and adopting flexible learning practices. This demonstrates that adopting a person-centred culture supports sustainable personal growth, person-centred learning, and practice. Stuart et al 36 identify that adopting this approach to learning offers the opportunity to recognise and celebrate nurses' expertise and capacities. The meta-ethnography identified that this is associated with nurses feeling recognised and valued as a person, having a sense of belonging, and feeling integrated within the team, with positive learning experiences. Nurses welcomed opportunities to share ideas and insights, to participate in shared decision-making. Individual, team and organisational commitment are key to meeting this need, conditions recognised as synonymous with meeting nurses' educational needs and a nurse's ability to flourish within their role. 37 Learning in Context These findings offer valuable insight into how nurses learn and adapt within clinical practice environments, reinforcing the relevance of exploring nurses’ perspectives and experience of learning about palliative care in such settings, the central aim of this paper. Learning in context is a critical dimension of nurses’ professional development in palliative care, particularly in the dynamic, emotionally charged environments of clinical practice. This study found that nurses developed a new way of being, doing, and practising palliative care, reflecting a deep integration of learning into their professional identity. This transformation aligns with Transformational Learning Theory, 28 which posits that adult learners undergo a fundamental shift in worldview through critical reflection and engagement with challenging experiences. In the context of palliative care, such transformation often arises from emotionally intense and ethically complex situations that prompt nurses to re-evaluate their assumptions and values. This theory emphasises the importance of critical reflection and dialogue in enabling learners to reassess assumptions and transform their understanding of care. 38 These experiences are not isolated; they are embedded within social and relational contexts, aligning with Social Learning Theory’s emphasis on observation, modelling, and shared practice, 39 and Lave and Wenger’s concept of the Community of Practice, which sees learning as situated in real-world activity, context, and culture. 29 In clinical settings, nurses co-construct knowledge through interactions with patients, families, and interdisciplinary teams, learning not only from direct experience but also from observing and engaging with others. 40 The situated nature of this learning underscores the importance of context-sensitive educational strategies that support experiential, reflective, and collaborative learning processes, enabling nurses to integrate palliative care principles more holistically into their practice. Taken together, these three dimensions, relational learning, reflective sensemaking, and organisational culture, form the relational–organisational explanation of palliative care learning identified in this review. This integrated perspective extends current understandings that focus primarily on individual competencies or formal training pathways. These findings challenge competency-based assumptions that position palliative care learning as an individual endeavour, instead highlighting the relational and organisational context required to support nurses’ development in everyday practice. LIMITATIONS OF THE REVIEW This meta-ethnography has some limitations which should be considered when interpreting the findings. All included studies were conducted in Western countries; studies from other contexts could have provided more varied perspectives. Only studies written in the English language were included. In addition, despite employing a comprehensive search strategy, some relevant studies might have been missed due to limitations in database access and the possibility that certain studies were not indexed in the databases we used. While all studies included registered nurses, several also involved participants from other professional roles, and the small number of eligible studies may constrain the generalisability of the findings. IMPLICATIONS FOR PRACTICE The findings of this meta-ethnography emphasise that organisations can foster palliative care learning by intentionally strengthening the relationships that support it. Several means of supporting this are identified: providing structured mentoring, shadowing or buddy systems, fostering collaboration and informal peer learning, and, understanding and valuing relationship building as a meaningful learning opportunity, not merely as service provision. The synthesis highlights reflective spaces as essential learning conditions. Practical implications include dedicating time to reflection and debriefing. integrating reflective practice into team discussions or handovers, providing opportunities for clinical supervision, and creating a supportive and psychologically safe environment for these discussions to take place. You can state that this supports person-centred palliative care because it helps nurses interpret complex emotional and ethical encounters. The findings emphasise the value of developing organisational cultures that enable learning and identify several ways this can be achieved: It is important for leaders to recognise the value of practice-based learning, seeking opportunities for collaboration between healthcare settings, strengthening learning infrastructures, including time and staffing levels; ensuring policies reflect both the relational nature of learning and competency. The findings of the meta-ethnography highlight the following implications for curriculum/practice developments: Higher Education programmes for nurses should embed relational clinical learning, competency frameworks could incorporate relational capabilities and organisational understanding, and support should be provided for students and novice nurses to participate in palliative care provision, with appropriate guidance and opportunities for supported reflection. IMPLICATIONS FOR FUTURE RESEARCH This meta-ethnography highlights several gaps in the existing research literature. Firstly, there is a lack of literature examining informal learning in clinical settings. Further research is needed to identify the types of learning that take place and the forms they take. Secondly, existing literature tends to focus on specific clinical settings within organisations rather than on the organisations as a whole. Providing detailed insights into learning within and across organisations could help establish a more comprehensive understanding of palliative care education. This meta-ethnography demonstrates that nurses’ learning about palliative care is shaped by culture and systems. Future research could explore how workplace cultures act as enablers or barriers to learning, and how organisational pressures affect practice-based learning. Because relationships and organisational structures vary across contexts, further research is needed to understand how learning unfolds across different settings and how relationships between organisations can influence learning opportunities. Future research could assess the impact of interventions that enhance relational learning on learning outcomes and person-centred palliative care. Extended or observational studies could shed light on how nurses develop palliative care competence and the relational factors that influence it. CONCLUSION Each theme captured a different dimension of nurses' experience, offering valuable insight into how nurses learn within the clinical practice environment. Together, they suggest that the clinical setting offers nurses an opportunity to learn from others. Benefits for nurses extend beyond increased knowledge of palliative care to include promoting critical thinking, increased confidence, reduced isolation and anxiety, and, beyond individuals, enhanced team strength and quality of care. Nurses developed a way of being, doing, and practising palliative care that reflects a deep integration of learning into their professional identity, emphasising the importance of reflection, observation, and modelling in this context-specific process. Adopting a person-centred approach to learning, through establishing relationships, reflection, and fostering a culture of learning within the organisation, was crucial to the success of nurses’ learning in the clinical setting. However, the emphasis is on research on situated learning in the clinical setting, with limited exploration of spontaneous learning moments or the range of social learning opportunities within individual clinical practice environments. These gaps indicate that creating such knowledge is crucial to identifying ways to maximise the nurses’ potential to expand their knowledge and positively influence the delivery of palliative care. While separate studies highlight specific aspects of learning, including peer support, organisational barriers, and relationships with patients, this review is the first to demonstrate how these components come together to produce the environment in which nurses learn to provide person-centred palliative care. By combining these insights, this meta-ethnography introduces a new explanation of palliative care learning in practice settings. This theoretical contribution enhances current understandings of palliative care education and provides a basis for cultivating learning environments that are more responsive to relational and organisational realities. Declarations Ethics Approval and consent to participate: N/A Consent for Publication: N/A Availability of Data: No datasets were generated or analysed during the current study Competing Interests: The Authors declare no competing interests Funding: Nil Author's contributions: JY led the study design, developed the search strategy, undertook the literature search, screening, quality appraisal, and data extraction, and conducted the full meta‑ethnographic synthesis. JY drafted the manuscript. AB, GT, and EH provided supervisory oversight, advised on methodological decisions, contributed to the interpretation of the synthesis, and reviewed the manuscript. Acknowledgements: Nil Authors' Information: JY, the Lead author, is a registered nurse, a lecturer in palliative care, and the education lead within a hospice organisation. Their clinical and educational roles have fostered a strong commitment to addressing the ongoing need for improved palliative care knowledge among healthcare professionals. This meta-ethnography was conducted as part of JY’s PhD research, which focuses on identifying effective ways to support the development of palliative care competencies in practice across clinical settings. The coauthors are JY’s PhD supervisors and academic colleagues. Together, they bring extensive expertise in palliative care research, creative arts-based inquiry, and person-centred research methodologies. Their diverse professional perspectives contributed to the rigour, reflexivity, and interpretive depth of the study. References World Health Organisation. State of the World’s Nursing Report 2025. Geneva: World Health Organisation.. 2025. 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Understanding Palliative Care Learning: A Narrative Inquiry exploring health care professionals’ memorable experiences. Qualitative Res Health. 2022;2:100098. Johansen H, Helgesen A. Palliative care in the community – the role of the resource nurse, a qualitative study. BMC Palliat Care 2021; 20,1, 157. Rabbetts L. Peer mentoring supports the learning needs of nurses providing palliative care in a rural acute care setting. Int J Palliat Nurs. 2017;23(6):280–6. Giusti A, Pukrittayakamee P, Alarja G, Farrant L, Hunter J, Mzimkulu O, et al. Developing a global practice–based framework of person–centred care from primary data: a cross–national qualitative study with patients, caregivers and healthcare professionals. BMJ Glob Health. 2022;7:e008843. McCormack B, McCance T. Person-centred practice in Nursing and Healthcare: Theory and Practice. Wiley-Blackwell; 2017. Mezirow J. Understanding Transformation Theory. Adult Educ Q. 1994;4:222–32. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press; 1991. Metzger A. Shelter from the abyss: exploring Cicely Saunders’ vision of hospice care through the concept of worldview. Palliat Care Social Pract. 2023;17:1–12. World Health Organisation. Global Strategic Directions for Nursing and Midwifery: 2021–2025. Geneva: World Health Organisation. 2021; Accessed on 3rd May 2025: https://doi.org/10.12968/ijpn.2021.27.1.20 Irvine L, Gillen P, Barr O et al. Being a lifelong learner. In: McCormack, B., McCance, T., Bulley, C. Fundamentals of person-centred healthcare practice. 2021;319–330. Wiley-Blackwell. Mackay M, O’Donnell D, Espie A et al. Person-centredness in Nursing Education Research. In J. Dewing, B. McCormack, and T. McCance. Person-centred Nursing Research: Methodology, Methods and Outcomes . 2021; 139–149. Springer. Brown D, Mountain K. Knowing and Becoming through reflective learning. In: McCance T, Brown D, McCormack B, et al. editors. Fundamentals of Person-centred Healthcare Practice. Wiley-Blackwell; 2021. Mackay M, Jans C. Facilitating person-centred learning between nursing students and clinical supervisors in practice: Guideline and programme development. Int Pract Dev J. 2022;12:1. Stuart F, Ramsey L, Lynch J et al. Developing and supporting practice educators. In McCormack, B., McCance, T., Bulley, C. Fundamentals of Person-Centred Healthcare Practice. 2021; 299–307. Wiley-Blackwell. Bevini C, Mazzoli R, Privitera VE, Rocchi M, Palandri L, Santunione AL, et al. Palliative care perceptions and well–being in nurses across healthcare settings: a comparative study from Reggio Emilia, Northern Italy. BMC Palliat Care. 2025;24:264. Lee CN, Lee G, Aw FC, Zulkifle NB, Tan YS, et al. Enhancing end-of-life care nursing competency: a nursing education quality improvement project in general medical wards. BMJ Open Qual. 2025;14(1):e003228. Bandura A. Social learning theory. Englewood Cliffs (NJ): Prentice Hall; 1977. Powell MJ, Froggatt K, Giga S. Resilience in inpatient palliative care nursing: a qualitative systematic review. BMJ Support Palliat Care. 2020;10(1):79–90. 10.1136/bmjspcare–2018–001693 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 27 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers invited by journal 20 Apr, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 25 Mar, 2026 First submitted to journal 24 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9214411","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":630210282,"identity":"dce658d3-2fef-4655-acda-e0209a53caa8","order_by":0,"name":"Julie Young","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBAC9hkJIEpCDi4iQUgLI0SLhTEJWnoOgKiKxAbitbQ3H5Mu+CWR3nftjAHDjxqGxJkNhLQ0s6VJz+yTyJ15O8eAsecYQ+JsgrY085hJ8/ZI5G4AamHgbWBInEeslnQDkC1/idEiCNLC80MiAaSFGWQLQYdJM7MlW/M2SBjOvJ1WcFjmmIQxQe/zMTMfvM3zp06e73byxodvamxkZxwgZA3YQ21A4gAYEYwVGPgD0TIKRsEoGAWjACsAACRKO0I3f4bfAAAAAElFTkSuQmCC","orcid":"","institution":"Queen Margaret University","correspondingAuthor":true,"prefix":"","firstName":"Julie","middleName":"","lastName":"Young","suffix":""},{"id":630210283,"identity":"1b47b259-376e-4d48-a6ce-b77b1ce94d32","order_by":1,"name":"Anna Buckby","email":"","orcid":"","institution":"Queen Margaret University","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Buckby","suffix":""},{"id":630210284,"identity":"43c57d2f-4a1e-4787-9b77-a1adb1cc94ae","order_by":2,"name":"Erna Haraldsdottir","email":"","orcid":"","institution":"Queen Margaret University","correspondingAuthor":false,"prefix":"","firstName":"Erna","middleName":"","lastName":"Haraldsdottir","suffix":""},{"id":630210285,"identity":"ad685425-09c0-4b31-9b96-7b3f57ea89c4","order_by":3,"name":"Giorgos Tsiris","email":"","orcid":"","institution":"Queen Margaret University","correspondingAuthor":false,"prefix":"","firstName":"Giorgos","middleName":"","lastName":"Tsiris","suffix":""}],"badges":[],"createdAt":"2026-03-24 16:24:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9214411/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9214411/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108383757,"identity":"64fa008a-45d8-44e9-a06d-c30ce7d52263","added_by":"auto","created_at":"2026-05-04 05:48:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61550,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flowchart\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9214411/v1/b6ff2491867d90365584da11.png"},{"id":108493448,"identity":"0f7a45a2-7f08-409e-9745-df61a47cfe4b","added_by":"auto","created_at":"2026-05-05 10:00:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":415854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9214411/v1/dbf922d1-60f9-47c6-967e-ebce61488df2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Learning Palliative Care in practice: a meta-ethnography of nurses’ experiences in the clinical setting","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe changing landscape of palliative care demands increased capacity and provision of effective care to those facing a life-limiting illness. Worldwide, people are living longer, and the prevalence of chronic conditions is increasing, a trend that is expected to continue, and, by 2030, approximately one in six people globally will be aged 60 or older.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e This proportion is expected to increase to one in five by 2050, with the population aged 80 and above projected to reach 426\u0026nbsp;million, nearly three times its current size\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Access to palliative care is inconsistent, including within high-income countries,\u003csup\u003e2\u003c/sup\u003e prompting global calls for universal provision.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe experience of living with a life-limiting illness is deeply personal and varies significantly from one individual to another. Palliative care supports people with life-limiting illnesses and is widely recognised for its person-centred approach, aligning care with a person's unique values, goals and preferences.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Nurses, often the primary caregivers in palliative care,\u003csup\u003e3\u003c/sup\u003e play a significant role in caring for people with palliative care needs,\u003csup\u003e6\u003c/sup\u003e however, their limited knowledge has been identified as a primary barrier to high-quality palliative care.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e As workload demands continue to rise and workforce shortages persist, clinical settings face growing pressure to ensure staff possess adequate knowledge.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Research has shown that educational programmes effectively improve knowledge, attitudes, and confidence in palliative care.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e However, it is significant that, with limited opportunities to release nurses from clinical duties, formal programmes reach only a fraction of the workforce.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The absence of a clearly defined solution has hindered efforts to address the issue.\u003c/p\u003e \u003cp\u003eThe importance of learning within the clinical environment is increasingly highlighted in evidence, with experiential and situated learning having a profound influence on nurses\u0026rsquo; knowledge development. However, despite this recognition, limited research explores how such learning occurs within palliative care contexts. Notably, there is no existing synthesis of primary qualitative research that examines how nurses engage with and acquire palliative care competencies in clinical practice environments. This study aims to meet this gap, generating a new, comprehensive understanding that can inform educational practice and enhance person-centred care.\u003c/p\u003e"},{"header":"AIM","content":"\u003cp\u003eTo systematically review and synthesise findings from qualitative primary studies exploring nurses' perspectives and experiences of learning about palliative care within the clinical practice environment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTUDY DESIGN\u003c/h2\u003e \u003cp\u003eA meta-ethnography was conducted to develop a deeper understanding of nurses\u0026rsquo; perspectives on learning about palliative care within the clinical practice environment. By synthesising the findings of existing qualitative research, a meta-ethnography aims to create third-order constructs\u003csup\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e which are key themes derived from second-order constructs (the studies\u0026rsquo; authors\u0026rsquo; themes) and first-order constructs (the participants\u0026rsquo; perspectives and experiences). The conduct of this meta-ethnography adhered to the PRISMA guidelines and the eMERGE guidelines,\u003csup\u003e11\u003c/sup\u003e which operationalise Noblit and Hare\u0026rsquo;s\u003csup\u003e10\u003c/sup\u003e 7-stage approach to meta-ethnography.\u003c/p\u003e \u003c/div\u003e"},{"header":"SEARCH STRATEGY","content":"\u003cp\u003eThe following electronic databases were searched in July 2025: CINAHL, MEDLINE, and ERIC. The Population Exposure Outcome (PEO) framework\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e supported the development of key search words relevant to \u0026ldquo;nurses\u0026rdquo;, \u0026ldquo;palliative care\u0026rdquo;, \u0026ldquo;knowledge development\u0026rdquo; and \u0026ldquo;perceptions\u0026rdquo;, which were combined using Boolean operators (AND, OR). The papers were screened through stages: (1) titles, (2) abstracts, and (3) full texts. In addition, the reference lists of all included studies were screened by title.\u003c/p\u003e"},{"header":"INCLUSION AND EXCLUSION CRITERIA","content":"\u003cp\u003eStudies qualified for inclusion if they fulfilled the following criteria: (1) reported nurses' perspectives or experiences of learning about palliative care in the clinical environment, (2) used qualitative methods, (3) published in peer-reviewed academic journals, and (4) published in English. Studies were excluded for the following: (1) did not include nurses\u0026rsquo; perspectives, (3) only included quantitative methods (3) full text was unavailable.\u003c/p\u003e \u003cp\u003eThe type of learning intervention, if stated in a research study, did not influence the study\u0026rsquo;s eligibility. Similarly, no studies were excluded based on sample size. An inclusive approach was taken to ensure a broad representation of nurses\u0026rsquo; perspectives and experiences. The open publication time frame reflects the novelty of this meta-ethnography in this area. A PRISMA\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e figure presents the stages of the search (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), including the total studies identified, screened, assessed for eligibility, excluded, and ultimately included in the synthesis. Nine studies were included; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the key characteristics of each study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor/\u003c/p\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAim\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDetails of learning Intervention (if applicable)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMethodology/Data Collection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCASP\u0026nbsp;score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBagaragaza\u0026nbsp;et al\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExplore perceived outcomes of critical companionship in supporting the integration of a palliative approach in the care of residents in nursing homes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026nbsp;= 49\u003c/p\u003e \u003cp\u003e11 nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026nbsp;critical companions (palliative care nurses) supporting 6\u0026nbsp;nursing\u0026nbsp;homes over a period of 10 months.\u003c/p\u003e \u003cp\u003eCritical companions worked alongside the\u0026nbsp;nursing\u0026nbsp;home\u0026nbsp;staff, offering guidance and support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u0026nbsp;nursing\u003c/p\u003e \u003cp\u003ehomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMultiple Case study\u003c/p\u003e \u003cp\u003eFocus Groups\u003c/p\u003e \u003cp\u003eSemi-Structured Interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrey et al\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew\u003c/p\u003e \u003cp\u003eZealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExplore palliative care nurse specialists\u0026rsquo; experiences\u0026nbsp;regarding\u0026nbsp;the benefits of and barriers to the implementation of a palliative care educational intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 3\u003c/p\u003e \u003cp\u003ePalliative\u0026nbsp;care\u0026nbsp;clinical\u0026nbsp;nurse specialists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1-year-long palliative care education intervention:\u003c/p\u003e \u003cp\u003eRecords review, role modelling, coaching, education\u0026nbsp;planning\u0026nbsp;and\u003c/p\u003e \u003cp\u003edebriefing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u0026nbsp;long-term care facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInductive content\u0026nbsp;Analysis of participants reflective logs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHegarty et al \u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExplore health professionals' experiences\u0026nbsp;in developing capacity for supporting people with refractory suffering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 17\u003c/p\u003e \u003cp\u003e(10 nurses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 specialist palliative care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExploratory study\u003c/p\u003e \u003cp\u003eSemi-structured interviews\u003c/p\u003e \u003cp\u003eQuestionnaires\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHockley\u0026nbsp;\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore the impact of debriefing sessions\u0026nbsp;in\u0026nbsp;promoting\u0026nbsp;high-quality end-of-life care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 34\u003c/p\u003e \u003cp\u003eNurses, healthcare assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 reflective debriefing groups led by a specialist palliative care nurse with a focus on end-of-life care in care homes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 care homes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAction Research\u003c/p\u003e \u003cp\u003eDebriefing sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJohansen and Helgesen\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExplore experiences\u0026nbsp;of the\u0026nbsp;resource nurse role within nursing home settings.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 7\u003c/p\u003e \u003cp\u003eResource nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCare homes were assigned resource nurses:\u0026nbsp;\u0026nbsp;with\u0026nbsp;the\u0026nbsp;intention to:\u0026nbsp;Act as a resource, improve services\u0026nbsp;\u0026amp;\u0026nbsp;disseminate\u003c/p\u003e \u003cp\u003eknowledge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u0026nbsp;nursing\u003c/p\u003e \u003cp\u003ehomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAn Exploratory Study\u003c/p\u003e \u003cp\u003eSemi-structured interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJohnston et al\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescribe and explore\u0026nbsp;nurses\u0026rsquo;\u0026nbsp;experiences of engaging in a\u0026nbsp;peer-mentoring initiative.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 52\u003c/p\u003e \u003cp\u003e26mentor\u003c/p\u003e \u003cp\u003e26mentees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3-month peer mentoring programme supporting registered nurses new to\u0026nbsp;the hospice nursing service.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCommunity Palliative Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAn evaluation study\u003c/p\u003e \u003cp\u003eQualitative\u0026nbsp;questionnaire\u0026nbsp;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKilbertus et al\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo\u0026nbsp;explore health professionals memorable palliative care learning experience for rural healthcare professionals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 17\u003c/p\u003e \u003cp\u003e7 nurses; 7 GP\u0026rsquo;s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCommunity, long-term care facilities, hospice\u0026nbsp;\u0026amp;\u003c/p\u003e \u003cp\u003ehospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eA Narrative Study\u003c/p\u003e \u003cp\u003eBoth\u0026nbsp;observational\u0026nbsp;and verbal methods.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRabbetts\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore\u0026nbsp;the experiences of nurses working alongside a research assistant in the facilitation of using a new assessment\u0026nbsp;process.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 10\u003c/p\u003e \u003cp\u003eregistered nurses, enrolled\u0026nbsp;nurses\u0026nbsp;and midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA\u0026nbsp;research\u0026nbsp;assistant was assigned to a medical ward with the intention to:\u003c/p\u003e \u003cp\u003ework alongside the nurses and\u0026nbsp;facilitate\u0026nbsp;using a newly introduced clinical symptom assessment form for patients receiving palliative care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA medical ward in a large regional hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFocus\u0026nbsp;groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhiting et al\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo\u0026nbsp;explore nurses\u0026rsquo; experience\u0026nbsp;participating\u0026nbsp;in\u0026nbsp;a rotation programme between paediatric hospice and hospital\u0026nbsp;palliative care settings.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 5\u003c/p\u003e \u003cp\u003e3\u0026nbsp;hospice nurses\u0026nbsp;and 2 acute\u0026nbsp;hospital nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8-month rotational programme were hospice nurses and hospital nurses swap roles.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChildren's hospice and a children\u0026rsquo;s hospital ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAppreciative Inquiry\u003c/p\u003e \u003cp\u003eSemi-structured interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"QUALITY APPRAISAL","content":"\u003cp\u003eThe quality and rigour of the studies were assessed using the CASP Qualitative Research Checklist.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Each question was assigned a score, (yes\u0026thinsp;=\u0026thinsp;2, unclear\u0026thinsp;=\u0026thinsp;1, no\u0026thinsp;=\u0026thinsp;0), where the highest attainable score is 20 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This appraisal did not serve as a criterion for exclusion, but rather informed the interpretation and synthesis of findings. Generally, studies with a greater score assigned provided more detail on data collection and analysis processes. Four of the studies did not report the relationship between the participants and the researcher, impacting the integrity of their work.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e This is an emerging area of research, where all studies have the potential to offer insights into the research question. All studies make a valuable contribution to understanding nurses\u0026rsquo; perspectives and experiences as they learn about palliative care in the clinical environment.\u003c/p\u003e"},{"header":"DATA EXTRACTION","content":"\u003cp\u003eThe nine included studies present qualitative data on nurses\u0026rsquo; perspectives and experiences of learning about palliative care in the clinical setting. Differing opinions on how studies should be read and synthesised are found in the literature.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Given the absence of a clear explanation for a preference for one over the other, the study adopts a chronological approach. The individual papers were read and re-read, and the data concerning the characteristics and the main findings from each study were identified (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The data extraction process involved gathering participants\u0026rsquo; own words (first‑order constructs) and the authors\u0026rsquo; interpretations (second‑order constructs) from all included studies (Table\u0026nbsp;2).\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u003c/b\u003e \u003c/p\u003e \u003cp\u003e2: Data Extraction, Abstraction and Synthesis: Key components of nurses\u0026rsquo; perspectives of learning with illustrative quotes\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSample Participant Quotes (First-order constructs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey Components Experiences (Second-order constructs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(Third-order constructs)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;This is the moment you don't forget \u0026hellip; He grabbed me and pulled me over that day and \u0026hellip; he said \u0026hellip; he found [the medication] really frightening, and the nightmares, and the way the drug made him feel \u0026hellip; My angst comes from what happened in his psyche and his emotions \u0026hellip; how much did he suffer?\u0026rdquo;\u003c/em\u003e (Kilbertus et al\u003csup\u003e23\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-An action-reflection model can support the development\u003c/p\u003e \u003cp\u003e-A positive organisational culture is essential, promoting collaboration, mutual respect, and effective information sharing.\u003c/p\u003e \u003cp\u003e-Reflecting on death reduced nurses\u0026rsquo; anxiety and led to knowledge development in recognising dying.\u003c/p\u003e \u003cp\u003e-Novel or unfamiliar situations sparked reflection that contributed to memorable learning, changes in understanding of self and others, emotions and behaviours going forward.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning through interaction with people with palliative care needs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;we learn from those we respect\u0026rdquo;\u003c/em\u003e (Hegarty\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e)\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think it is great working together with others who hold the same basic view. We discuss, we might disagree; that is the way it should be, but we basically agree on how we want it to be\u0026rdquo;.\u003c/em\u003e (Johansen and Helgesen\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-The Specialist nurse can provide support and reinforcement.\u003c/p\u003e \u003cp\u003e-The high staff turnover and under-resourcing negatively impact documentation and the care of the residents.\u003c/p\u003e \u003cp\u003e-The mentor/mentee relationship supports reciprocal learning and generates confidence\u003c/p\u003e \u003cp\u003e-Shared values within the team are essential for aligning professional goals and establishing a common language around palliative care.\u003c/p\u003e \u003cp\u003e-staff have a preference to seek answers from people over textbook or the internet.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning through relationships with colleagues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The collaboration with our partners is more fluid, and this is thanks to the bridge built with the project\u0026rdquo;.\u003c/em\u003e (Bagaragaza et al\u003csup\u003e15\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Facilitated a shared vision, timely approach and improved symptom management.\u003c/p\u003e \u003cp\u003e-Enhanced multi-disciplinary collaboration.\u003c/p\u003e \u003cp\u003e-Improved organisational practices and processes, and enhanced collaboration between healthcare organisations.\u003c/p\u003e \u003cp\u003e-Support was crucial to success of rotations.\u003c/p\u003e \u003cp\u003e-Nurses held anxieties over their level of clinical competence in a new area.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning through relationships between organisations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eDATA ABSTRACTION\u003c/h2\u003e \u003cp\u003eData abstraction then enabled comparison across studies by organising these constructs into more succinct conceptual summaries that captured both the similarities and distinctions in nurses\u0026rsquo; experiences and perceptions of palliative care learning in the clinical environment. The studies spanned the period 2010 to 2024, and the data were gathered from 194 health professionals, of whom more than 112 were registered nurses (the study by Hockley\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e does not specify how many of its 34 participants were nurses). Studies were collected across the United Kingdom (3), Australia (2), Canada (1), France (1), New Zealand (1), and Norway (1). Seven of the nine studies sought nurses' perspectives and experiences of a learning intervention in the clinical environment, interventions explored where debriefing, role modelling, clinical coaching, rotation, peer mentoring, resource nurses and research nurse roles. Of the two studies without an intervention, one focused on nurses' learning experiences and perceptions of developing capacity for supporting people with refractory suffering, and the final study focused on nurses\u0026rsquo; memorable learning experiences in palliative care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"SYNTHESIS","content":"\u003cp\u003eDuring synthesis, special care was taken to preserve the context of the original studies \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e while using interpretive language to identify patterns and relationships relevant to nurses' learning in the clinical environment. Integrating these abstracted concepts through reciprocal, refutational and line-of-argument translation\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, while ensuring the original context of the studies was retained,\u003csup\u003e21\u003c/sup\u003e three themes emerged (third-order constructs\u003csup\u003e),10\u003c/sup\u003e provided a new overarching interpretation that transcends the primary studies (Table\u0026nbsp;2).\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThree themes emerged from the synthesis: (1) \u003cem\u003eLearning through relationships with people with palliative care needs;\u003c/em\u003e (2) \u003cem\u003eLearning through relationships with colleagues\u003c/em\u003e; (3) \u003cem\u003eLearning through relationships between organisations\u003c/em\u003e. Each theme captured a different dimension of this from the nurses\u0026rsquo; perspectives and experiences. Together, they demonstrate how relationships in the clinical practice environment support nurses in learning about palliative care from and with others and learning from others leads to a desire to share knowledge with others. Sharing knowledge and learning through collaboration increases nurses\u0026rsquo; knowledge and confidence. The findings from each theme will now be presented.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLearning through relationships with people with palliative care needs\u003c/h2\u003e \u003cp\u003eThrough relationships with their patients, nurses across a range of settings developed knowledge beyond the clinical or factual, providing valuable, real-world learning that enhanced their ability to support.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e The process of reflection was key to achieving this learning, enabling one to express feelings about what a person is expected to have done and to embed new thoughts for nurses, including how to do things differently in the future.\u003c/p\u003e \u003cp\u003eThe method of reflection adopted varied significantly across studies, ranging from slowing down and taking time to think during interactions with people with palliative care needs,\u003csup\u003e22\u003c/sup\u003e to engaging in spontaneous discussions with colleagues about specific cases,\u003csup\u003e15,22\u0026ndash;24\u003c/sup\u003e and participating in structured, planned, facilitated group discussions.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eParticipants in the study by Hegarty et al,\u003csup\u003e22\u003c/sup\u003e identified patients and families as important contributors to nurses' understanding of what it means to be living with suffering, with nurses relaying moments when they felt \u0026lsquo;out of depth\u0026rsquo; and how these moments ultimately supported their ability to work with a multidisciplinary team and develop capacity for effective, sustainable palliative care practice. Similarly, the study in nursing homes by Hockley\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e found that participation in facilitated, group reflection following a resident's death led to knowledge sharing and shared learning, and, over time, nurses changed their approach to providing care to people at the end of life. In turn, nurses developed a new way of talking about death and dying that helped to make dying part of the nursing home culture.\u003c/p\u003e \u003cp\u003eIn the study by Kilbertus et al,\u003csup\u003e23\u003c/sup\u003e nurses found value in reflecting on situations they found complex or challenging. It was during those moments of disruption, when nurses challenged or doubted their ability to act in ways they aspired to, that the need to make and accept compromises and the importance of \u0026lsquo;being\u0026rsquo; rather than \u0026lsquo;doing,\u0026rsquo; triggered transformational learning and changes in understanding of self. This demonstrates the significance of the dissonance between the ideals nurses aspire to and the lived reality of working in a clinical setting, as well as its role in triggering disruption during transformative learning.\u003c/p\u003e \u003cp\u003eThe findings extend beyond identifying the role of reflection in nurses\u0026rsquo; knowledge development, suggesting that reflexivity influences changes in ideas, approaches, perceptions, emotions, and actions. Learning through relationships with people with palliative care needs entailed emotional labour and being open and honest took courage. Organisational culture was central to the success of the reflective process, with insufficient staffing frequently cited as a barrier.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLearning through relationships with colleagues\u003c/h2\u003e \u003cp\u003eThe implementation of mentorship processes, as well as more informal relationships with colleagues in the clinical setting, led to learning. Six studies focused on nurses\u0026rsquo; experiences and perceptions of an introduced mentor role,\u003csup\u003e15\u0026ndash;18.24.25\u003c/sup\u003e the role of mentor varied in format; a peer-mentoring programme for nurses new to their role in community palliative care,\u003csup\u003e17\u003c/sup\u003e a created role to enable the implementation of a specific palliative care assessment form;\u003csup\u003e25\u003c/sup\u003e palliative care nurses in nursing homes\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and rotation programmes between two organisations.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The mentor provided opportunities for nurses to learn through demonstrating good practice, providing support and encouragement, facilitating knowledge exchange, challenging interests, being available, and facilitating reflection and collaboration.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEstablishing relationships was identified as a crucial step in the mentor-mentee process across all six studies, and as even more significant in the two rotation programmes between organisations.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In the study by Frey et al,\u003csup\u003e16\u003c/sup\u003e establishing relationships between hospice and long-term care nurses was crucial for fostering mutual trust and shared understanding of hospice's role and scope within care. Interestingly, increased connection between the external mentor and mentee led to closer relationships among long-term care nurses and their colleagues. This fostered a mutual sense of \u0026lsquo;family\u0026rsquo; and collaborative relationships.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhiting et al,\u003csup\u003e18\u003c/sup\u003e highlighted that nurses participating in a rotation programme encountered additional challenges acclimatising to an unfamiliar environment and adapting to different drug regimes, leading to feelings of anxiety. Despite this, rotational programmes offered unique, valuable opportunities for mutual appreciation of roles and increased understanding of the patient and family journey.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Notably, both studies emphasise the importance of managerial support. Bagaragaza et al.\u003csup\u003e15\u003c/sup\u003e demonstrated the collaborative and co-creative foundations of a critical companionship programme, modelling a high challenge, high support approach, facilitated cultural transformation, promoting the embedding of person-centred principles across individual, team, and organisational levels.\u003c/p\u003e \u003cp\u003eThe findings of the studies point to evidence of reciprocal learning\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and situated contributions where the mentor\u0026rsquo;s deliberate presence created plentiful moments where discussion, learning and teaching, and changes in attitudes and practice.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e In the study by Johnston et al,\u003csup\u003e17\u003c/sup\u003e mentors reported experiencing increased workload pressure due to their role, yet found joy in it. They identified the experience as enriching their knowledge.\u003c/p\u003e \u003cp\u003eThree studies focused on less formalised, organic learning through interaction with colleagues in the clinical setting.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Interestingly, the findings are similar to those studies with an official mentor present. That said, limited knowledge was evident in the literature; perhaps due to nurses' lack of awareness of their role modelling in everyday practice.\u003c/p\u003e \u003cp\u003eResource constraints and staff turnover negatively influenced nurses\u0026rsquo; ability to learn through interactions with colleagues.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Repeated staff changes proved challenging for establishing trusting relationships between the mentors and mentees.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e In the study by Johansen and Helgesen,\u003csup\u003e24\u003c/sup\u003e mentors felt their competence was limited and reported that they would have benefited from allocated time to devote to their learning. In the same study, some mentors reported feeling challenged by colleagues who were not receptive to new ideas, which led to frustration when they were unable to influence others.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLearning through relationships between organisations\u003c/h2\u003e \u003cp\u003eFormal agreements between organisations forged collaborative relationships; supported reciprocal learning; challenged misconceptions; promoted a desire to learn, develop professionally and help others to learn. The agreements took the form of reciprocal clinical coaching,\u003csup\u003e16\u003c/sup\u003e a rotational programme,\u003csup\u003e18\u003c/sup\u003e critical companionship\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and regular reflective debriefing sessions.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e They involved collaboration between the hospice and the acute hospital,\u003csup\u003e18\u003c/sup\u003e hospice and long-term care facilities,\u003csup\u003e16\u003c/sup\u003e and specialist palliative care nurses and nursing care homes.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Developing a connection and acceptance of an external presence in the clinical setting was key; trust was associated with sharing and collaboration as relationships developed.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe relationships forged supported a willingness for ongoing collaboration between organisations. Significantly, the more nurses from different organisations interacted with one another, the stronger the knowledge base on both sides.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In the studies by Frey et al\u003csup\u003e16\u003c/sup\u003e and Bagaragaza et al,\u003csup\u003e15\u003c/sup\u003e the presence of a hospice nurse in a long-term care facility provided an opportunity to model difficult conversations, leading to increased confidence among facility nurses to begin discussions about advanced care planning. The support and reinforcement identified knowledge gaps and potential ways to enhance practice.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This extended beyond the individual nurse to encompass the wider team's role and ways of working. The results of the study by Bagaragaza et al\u003csup\u003e15\u003c/sup\u003e suggest the critical companionship relationship fostered a shared understanding of palliative care, which, in turn, supported the development of organisational processes and the delivery of personalised and timely care within the nursing home setting.\u003c/p\u003e \u003cp\u003eLearning through organisational relationships was linked to nurses' personal and professional development. Where the desire for nurses to develop professionally was evident, it had been fostered through collaboration.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e In the studies by Frey et al\u003csup\u003e16\u003c/sup\u003e and Whiting et al,\u003csup\u003e18\u003c/sup\u003e this desire extended to a wish to share their expertise with others.\u003c/p\u003e \u003cp\u003eDeveloping a relationship fostered a sense of trust and understanding of the hospice, its role and the patient journey. Working with nurses from other organisations allowed individuals to recognise and challenge their misconceptions,\u003csup\u003e15,16,18\u003c/sup\u003e and \u0026lsquo;status quo\u0026rsquo;.\u003csup\u003e19\u003c/sup\u003e In the study by Whiting et al,\u003csup\u003e18\u003c/sup\u003e nurses in the hospital setting had not previously appreciated the range of services a hospice offers; their new knowledge helped them when advising patients and families.\u003c/p\u003e \u003cp\u003eThe literature demonstrates challenges for organisations working together to support nurses in learning about palliative care, both at organisational and personal levels. Staff turnover and insufficient staffing, reduced opportunities to learn from one another. \u003csup\u003e16,18,19\u003c/sup\u003e Interestingly, in the study by Hockley,\u003csup\u003e19\u003c/sup\u003e senior nurses' regular attendance at debriefing sessions was found to support them and their team in recognising their value and was thought to positively influence attitudes.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe existing gap in nurses' palliative care knowledge directly affects the quality of care delivered. With increasing demand and emphasis on workforce education, clinical settings can provide opportunities for nurses to learn from and with others. This meta-ethnography identifies three key factors that advocate a person-centred approach to palliative care education: establishing relationships, engaging in reflection, and adopting a learning culture within the organisation. Collectively, these are interdependent systems in which relationships foster key learning experiences for nurses, providing formative encounters and reflection that enable meaning-making, and an organisational culture that allows both to flourish. The study identifies the benefits of this approach, including opportunities that promote critical thinking, increased confidence, understanding, desire to learn, effective and sustainable practice, and reduced anxiety and isolation. The benefits gained go beyond individuals to include the creation of an environment that enables learning, stronger teams, greater collaboration, and improved quality of care.\u003c/p\u003e \u003cp\u003eConsidered a key component of high-quality care,\u003csup\u003e26\u003c/sup\u003e person-centredness is well established within global healthcare policy\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and as a key competency in health professionals.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Highlighting that nurses\u0026rsquo; qualities and capabilities are best realised within environments that actively support person-centred approaches to practice. The outcomes of this meta-ethnography resonate with the principles of a person-centred approach to palliative care.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Person-centred theory helps explain why developing relationships with people requiring palliative care, relational engagement with people with palliative care needs, and colleagues, nurtures greater sensitivity and ethical awareness.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e In organisational environments where safeguarding time, psychological safety, and cross-boundary collaboration, reflective learning tends to become routine; in their absence, learning becomes unstable and inconsistently developed. Transformative learning theory demonstrates how both structured and informal reflection can prompt shifts in understanding and perspective.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Thus, palliative care capability emerges not as simply something individuals acquire, but as a relational\u0026ndash;organisational achievement embedded in everyday practice.\u003c/p\u003e \u003cp\u003eThe findings also align with Lave and Wenger\u0026rsquo;s \u003csup\u003e29\u003c/sup\u003e account of learning as participation in communities of practice, where capability develops through relational engagement, through gradual participation, and evolving identity rather than through isolated or context-free learning.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e They indicate that nurses\u0026rsquo; relationships with people requiring palliative care and colleagues are the primary areas of participation and reflection, which then lead to shared understanding. A learning organisational culture within the organisation provides the access, time, and psychological safety that sustain participation. Under this framing, palliative care capability is not merely a personal skill, but a relational\u0026ndash;organisational achievement arising from ongoing engagement in cross-setting, practice communities.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEstablishing Relationships\u003c/h2\u003e \u003cp\u003eThe findings revealed that relationships in the clinical setting offer nurses opportunities to develop palliative care knowledge. These relationships support nurses\u0026rsquo; learning from others; in so doing, they develop a desire to share their knowledge. Dame Cicely Saunders, widely recognised as the key founder of modern hospice care, developed the philosophy of palliative care based on her thoughts, values and beliefs, creating new assumptions that underpin healthcare for those with palliative care needs.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Key to the development of this model of care was Saunders's relationships with the people she cared for; they supported her in focusing on what mattered to the individual and helped her gain insight into specific conditions and situations. Saunders's philosophy of palliative care has always had person-centred practice at its core,\u003csup\u003e4\u003c/sup\u003e with the recognition that effective communication is crucial for engaging authentically, identifying and assessing individual needs, and supporting shared decision making.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe WHO\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e highlight establishing relationships not only as a condition for learning, but also as a cornerstone of a person-centred approach to care and professional development. The person-centred framework \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e considers the nurses\u0026rsquo; preparation from a lifelong learning perspective. It identifies that being one\u0026rsquo;s authentic self is essential to creating relationships, particularly in the clinical setting.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e From this perspective, our attitudes, beliefs, and behaviours underpin how we communicate with people and develop a therapeutic relationship.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e This requires nurses to be open to new ways of thinking and aligns with the review findings, creating opportunities for nurses to share experiences, explore their values, reflect, and learn. This sheds light on the conclusions of the study by Johansen and Helgesen,\u003csup\u003e24\u003c/sup\u003e in which mentors reported feeling challenged and frustrated by those who were not interested in learning.\u003c/p\u003e \u003cp\u003eMutual respect, shared decision-making,\u003csup\u003e27\u003c/sup\u003e and trust \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e are identified as necessary attributes of an authentic relationship; together, these support transformational learning.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e This correlates with the principal finding of this meta-ethnography: that nurses' relationships with patients, colleagues, and organisations support their learning about palliative care. Mezirow \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e identifies that when learners become aware of their habitual ways through reflection, it leads to Transformational Learning, a concept attributed to nurses reaching their full potential and advocated for in education.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe Process of Reflection\u003c/h2\u003e \u003cp\u003eReflecting within the clinical environment enabled nurses to explore their emotional responses to practice and to embed a new understanding into their professional role, encompassing understanding, empathy, and insight. This emphasis on reflective practice is supported by the WHO,\u003csup\u003e31\u003c/sup\u003e which advocates for education that fosters critical thinking, emotional intelligence, and professional growth, including those related to palliative care.\u003c/p\u003e \u003cp\u003eWhen aligned with a person-centred approach, reflection becomes a transformative process that not only enhances clinical competence but also nurtures the values and relational capacities essential to compassionate palliative care. Person-centred theory recognises how knowing and becoming through reflective learning can help nurses better understand the professional and personal challenges they encounter in the clinical setting.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe findings demonstrate that the process of reflection supported nurses in working with the uncertainty of knowing and becoming more person-centred in practice. Talking through their reflections helped nurses connect with others and develop knowledge through communicative action. Being open to the process of reflection with others and adopting a learning culture are key to nurses connecting the concept of their self and personhood, situating the moment of learning within their story of becoming.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e This approach reflects principles of Transformative Learning Theory and person-centred practice development methodologies, in which deep reflective engagement leads to shifts in perspective and practice.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eAdopting a learning culture within the organisation\u003c/h2\u003e \u003cp\u003eThe findings highlight the organisational conditions necessary for learning in practice: fostering relationships, encouraging reflection, promoting growth, providing space, encouraging collaboration, and adopting flexible learning practices. This demonstrates that adopting a person-centred culture supports sustainable personal growth, person-centred learning, and practice.\u003c/p\u003e \u003cp\u003eStuart et al \u003csup\u003e36\u003c/sup\u003e identify that adopting this approach to learning offers the opportunity to recognise and celebrate nurses' expertise and capacities. The meta-ethnography identified that this is associated with nurses feeling recognised and valued as a person, having a sense of belonging, and feeling integrated within the team, with positive learning experiences. Nurses welcomed opportunities to share ideas and insights, to participate in shared decision-making. Individual, team and organisational commitment are key to meeting this need, conditions recognised as synonymous with meeting nurses' educational needs and a nurse's ability to flourish within their role.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLearning in Context\u003c/h2\u003e \u003cp\u003eThese findings offer valuable insight into how nurses learn and adapt within clinical practice environments, reinforcing the relevance of exploring nurses\u0026rsquo; perspectives and experience of learning about palliative care in such settings, the central aim of this paper. Learning in context is a critical dimension of nurses\u0026rsquo; professional development in palliative care, particularly in the dynamic, emotionally charged environments of clinical practice. This study found that nurses developed a new way of being, doing, and practising palliative care, reflecting a deep integration of learning into their professional identity. This transformation aligns with Transformational Learning Theory,\u003csup\u003e28\u003c/sup\u003e which posits that adult learners undergo a fundamental shift in worldview through critical reflection and engagement with challenging experiences. In the context of palliative care, such transformation often arises from emotionally intense and ethically complex situations that prompt nurses to re-evaluate their assumptions and values.\u003c/p\u003e \u003cp\u003eThis theory emphasises the importance of critical reflection and dialogue in enabling learners to reassess assumptions and transform their understanding of care.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e These experiences are not isolated; they are embedded within social and relational contexts, aligning with Social Learning Theory\u0026rsquo;s emphasis on observation, modelling, and shared practice,\u003csup\u003e39\u003c/sup\u003e and Lave and Wenger\u0026rsquo;s concept of the Community of Practice, which sees learning as situated in real-world activity, context, and culture.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e In clinical settings, nurses co-construct knowledge through interactions with patients, families, and interdisciplinary teams, learning not only from direct experience but also from observing and engaging with others.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e The situated nature of this learning underscores the importance of context-sensitive educational strategies that support experiential, reflective, and collaborative learning processes, enabling nurses to integrate palliative care principles more holistically into their practice.\u003c/p\u003e \u003cp\u003eTaken together, these three dimensions, relational learning, reflective sensemaking, and organisational culture, form the relational\u0026ndash;organisational explanation of palliative care learning identified in this review. This integrated perspective extends current understandings that focus primarily on individual competencies or formal training pathways. These findings challenge competency-based assumptions that position palliative care learning as an individual endeavour, instead highlighting the relational and organisational context required to support nurses\u0026rsquo; development in everyday practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS OF THE REVIEW\u003c/h2\u003e \u003cp\u003eThis meta-ethnography has some limitations which should be considered when interpreting the findings. All included studies were conducted in Western countries; studies from other contexts could have provided more varied perspectives. Only studies written in the English language were included. In addition, despite employing a comprehensive search strategy, some relevant studies might have been missed due to limitations in database access and the possibility that certain studies were not indexed in the databases we used. While all studies included registered nurses, several also involved participants from other professional roles, and the small number of eligible studies may constrain the generalisability of the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eIMPLICATIONS FOR PRACTICE\u003c/h2\u003e \u003cp\u003eThe findings of this meta-ethnography emphasise that organisations can foster palliative care learning by intentionally strengthening the relationships that support it. Several means of supporting this are identified: providing structured mentoring, shadowing or buddy systems, fostering collaboration and informal peer learning, and, understanding and valuing relationship building as a meaningful learning opportunity, not merely as service provision.\u003c/p\u003e \u003cp\u003eThe synthesis highlights reflective spaces as essential learning conditions. Practical implications include dedicating time to reflection and debriefing. integrating reflective practice into team discussions or handovers, providing opportunities for clinical supervision, and creating a supportive and psychologically safe environment for these discussions to take place. You can state that this supports person-centred palliative care because it helps nurses interpret complex emotional and ethical encounters.\u003c/p\u003e \u003cp\u003eThe findings emphasise the value of developing organisational cultures that enable learning and identify several ways this can be achieved: It is important for leaders to recognise the value of practice-based learning, seeking opportunities for collaboration between healthcare settings, strengthening learning infrastructures, including time and staffing levels; ensuring policies reflect both the relational nature of learning and competency.\u003c/p\u003e \u003cp\u003eThe findings of the meta-ethnography highlight the following implications for curriculum/practice developments: Higher Education programmes for nurses should embed relational clinical learning, competency frameworks could incorporate relational capabilities and organisational understanding, and support should be provided for students and novice nurses to participate in palliative care provision, with appropriate guidance and opportunities for supported reflection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eIMPLICATIONS FOR FUTURE RESEARCH\u003c/h2\u003e \u003cp\u003eThis meta-ethnography highlights several gaps in the existing research literature. Firstly, there is a lack of literature examining informal learning in clinical settings. Further research is needed to identify the types of learning that take place and the forms they take. Secondly, existing literature tends to focus on specific clinical settings within organisations rather than on the organisations as a whole. Providing detailed insights into learning within and across organisations could help establish a more comprehensive understanding of palliative care education.\u003c/p\u003e \u003cp\u003eThis meta-ethnography demonstrates that nurses\u0026rsquo; learning about palliative care is shaped by culture and systems. Future research could explore how workplace cultures act as enablers or barriers to learning, and how organisational pressures affect practice-based learning.\u003c/p\u003e \u003cp\u003eBecause relationships and organisational structures vary across contexts, further research is needed to understand how learning unfolds across different settings and how relationships between organisations can influence learning opportunities.\u003c/p\u003e \u003cp\u003eFuture research could assess the impact of interventions that enhance relational learning on learning outcomes and person-centred palliative care. Extended or observational studies could shed light on how nurses develop palliative care competence and the relational factors that influence it.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eEach theme captured a different dimension of nurses' experience, offering valuable insight into how nurses learn within the clinical practice environment. Together, they suggest that the clinical setting offers nurses an opportunity to learn from others. Benefits for nurses extend beyond increased knowledge of palliative care to include promoting critical thinking, increased confidence, reduced isolation and anxiety, and, beyond individuals, enhanced team strength and quality of care. Nurses developed a way of being, doing, and practising palliative care that reflects a deep integration of learning into their professional identity, emphasising the importance of reflection, observation, and modelling in this context-specific process. Adopting a person-centred approach to learning, through establishing relationships, reflection, and fostering a culture of learning within the organisation, was crucial to the success of nurses\u0026rsquo; learning in the clinical setting. However, the emphasis is on research on situated learning in the clinical setting, with limited exploration of spontaneous learning moments or the range of social learning opportunities within individual clinical practice environments. These gaps indicate that creating such knowledge is crucial to identifying ways to maximise the nurses\u0026rsquo; potential to expand their knowledge and positively influence the delivery of palliative care.\u003c/p\u003e \u003cp\u003eWhile separate studies highlight specific aspects of learning, including peer support, organisational barriers, and relationships with patients, this review is the first to demonstrate how these components come together to produce the environment in which nurses learn to provide person-centred palliative care. By combining these insights, this meta-ethnography introduces a new explanation of palliative care learning in practice settings. This theoretical contribution enhances current understandings of palliative care education and provides a basis for cultivating learning environments that are more responsive to relational and organisational realities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate:\u0026nbsp;\u003c/strong\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data:\u0026nbsp;\u003c/strong\u003eNo datasets were generated or analysed during the current study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe Authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s contributions:\u0026nbsp;\u003c/strong\u003eJY led the study design, developed the search strategy, undertook the literature search, screening, quality appraisal, and data extraction, and conducted the full meta‑ethnographic synthesis. JY drafted the manuscript. AB, GT, and EH provided supervisory oversight, advised on methodological decisions, contributed to the interpretation of the synthesis, and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Information:\u0026nbsp;\u003c/strong\u003eJY, the Lead author, is a registered nurse, a lecturer in palliative care, and the education lead within a hospice organisation. Their clinical and educational roles have fostered a strong commitment to addressing the ongoing need for improved palliative care knowledge among healthcare professionals. This meta-ethnography was conducted as part of JY\u0026rsquo;s PhD research, which focuses on identifying effective ways to support the development of palliative care competencies in practice across clinical settings.\u003c/p\u003e\n\u003cp\u003eThe coauthors are JY\u0026rsquo;s PhD supervisors and academic colleagues. Together, they bring extensive expertise in palliative care research, creative arts-based inquiry, and person-centred research methodologies. Their diverse professional perspectives contributed to the rigour, reflexivity, and interpretive depth of the study.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. State of the World\u0026rsquo;s Nursing Report 2025. Geneva: World Health Organisation.. 2025. Accessed on 8th March 2026: State of the world's nursing report 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHigginson I, Ramjeeawon P. 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Wiley-Blackwell; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMezirow J. Understanding Transformation Theory. Adult Educ Q. 1994;4:222\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press; 1991.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetzger A. Shelter from the abyss: exploring Cicely Saunders\u0026rsquo; vision of hospice care through the concept of worldview. Palliat Care Social Pract. 2023;17:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organisation. Global Strategic Directions for Nursing and Midwifery: 2021\u0026ndash;2025. Geneva: World Health Organisation. 2021; Accessed on 3rd May 2025: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12968/ijpn.2021.27.1.20\u003c/span\u003e\u003cspan address=\"10.12968/ijpn.2021.27.1.20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrvine L, Gillen P, Barr O et al. Being a lifelong learner. In: McCormack, B., McCance, T., Bulley, C. \u003cem\u003eFundamentals of person-centred healthcare practice.\u003c/em\u003e 2021;319\u0026ndash;330. Wiley-Blackwell.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMackay M, O\u0026rsquo;Donnell D, Espie A et al. Person-centredness in Nursing Education Research. In J. Dewing, B. McCormack, and T. McCance. \u003cem\u003ePerson-centred Nursing Research: Methodology, Methods and Outcomes\u003c/em\u003e. 2021; 139\u0026ndash;149. Springer.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown D, Mountain K. Knowing and Becoming through reflective learning. In: McCance T, Brown D, McCormack B, et al. editors. Fundamentals of Person-centred Healthcare Practice. Wiley-Blackwell; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMackay M, Jans C. Facilitating person-centred learning between nursing students and clinical supervisors in practice: Guideline and programme development. Int Pract Dev J. 2022;12:1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStuart F, Ramsey L, Lynch J et al. Developing and supporting practice educators. In McCormack, B., McCance, T., Bulley, C. \u003cem\u003eFundamentals of Person-Centred Healthcare Practice.\u003c/em\u003e 2021; 299\u0026ndash;307. Wiley-Blackwell.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBevini C, Mazzoli R, Privitera VE, Rocchi M, Palandri L, Santunione AL, et al. Palliative care perceptions and well\u0026ndash;being in nurses across healthcare settings: a comparative study from Reggio Emilia, Northern Italy. BMC Palliat Care. 2025;24:264.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee CN, Lee G, Aw FC, Zulkifle NB, Tan YS, et al. Enhancing end-of-life care nursing competency: a nursing education quality improvement project in general medical wards. BMJ Open Qual. 2025;14(1):e003228.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura A. Social learning theory. Englewood Cliffs (NJ): Prentice Hall; 1977.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell MJ, Froggatt K, Giga S. Resilience in inpatient palliative care nursing: a qualitative systematic review. BMJ Support Palliat Care. 2020;10(1):79\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjspcare\u0026ndash;2018\u0026ndash;001693\u003c/span\u003e\u003cspan address=\"10.1136/bmjspcare\u0026ndash;2018\u0026ndash;001693\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"meta-ethnography, nurses, experiences, learning, education, palliative care, end-of-life-care, work-based learning, clinical practice environment","lastPublishedDoi":"10.21203/rs.3.rs-9214411/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9214411/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eAn ageing population and the rising prevalence of chronic conditions demand greater capacity and the provision of palliative care. The role of the nurse is key to meeting this need; however, the widespread lack of nurses' knowledge in palliative care and increasing challenges in accessing formal education create a barrier. What is missing in the literature is an explanation of \u003cem\u003ehow\u003c/em\u003e nurses learn palliative care in real practice, not just what they should know. The purpose of this study was to undertake a systematic synthesis of qualitative research on nurses' perspectives and experiences of learning palliative care in the clinical practice environment.\u003c/p\u003e\u003ch2\u003eAIM\u003c/h2\u003e \u003cp\u003eTo deepen the understanding of nurses\u0026rsquo; development of palliative care knowledge within the clinical practice environment.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003e The review adopted a meta-ethnographic approach, following the PRISMA guidelines and the eMERGE guidelines, which operationalise Noblit and Hare\u0026rsquo;s 7-stage approach to meta-ethnography. A systematic search across MEDLINE, CINAHL, and ERIC databases in July 2025 identified nine relevant studies. The quality of the studies was assessed using the CASP Checklist, and concepts across studies were interpreted and translated to generate new insights.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eTogether, the synthesis and analysis yielded a higher‑order interpretation presented as three interrelated themes: (1) \u003cem\u003eLearning through relationships with people with palliative care needs\u003c/em\u003e; (2) \u003cem\u003eLearning through relationships with colleagues\u003c/em\u003e; and (3) \u003cem\u003eLearning through relationships between organisations\u003c/em\u003e. Aligned with person-centred care principles, these themes underscore the impact of relationships, reflection, and organisational culture on shaping nurses\u0026rsquo; learning.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eThis meta‑ethnography offers a new conceptual explanation of how nurses learn palliative care in everyday practice: learning is relationally enacted with patients and colleagues, across organisational interfaces, enabled by reflective spaces and shaped by organisational culture, strengthening nurses\u0026rsquo; capacity to deliver person-centred palliative care. Understanding these conditions provides actionable insights for designing palliative‑care education, workforce development, and cross-setting collaboration.\u003c/p\u003e","manuscriptTitle":"Learning Palliative Care in practice: a meta-ethnography of nurses’ experiences in the clinical setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 05:48:13","doi":"10.21203/rs.3.rs-9214411/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-27T09:49:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142998671427497338827172788315747917436","date":"2026-04-27T08:55:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-20T18:23:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T12:57:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T06:17:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2026-03-24T16:13:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"650ae8d8-b0a7-4c9f-841e-1c2ecad7afdd","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T05:48:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 05:48:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9214411","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9214411","identity":"rs-9214411","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}