How to prepare Chinese-born nurses to care for patients at the end-of-life in Western settings: A discussion paper

  • Ruishuang Zheng
    Corresponding author: School of Nursing and Midwifery, Monash University, Frankston 3199, Australia Tel: +86 022-23340123-3080.
    School of Nursing and Midwifery, Monash University, Frankston 3199, Victoria, Australia

    Department of Hepatobiliary Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
    Search for articles by this author
  • Qiaohong Guo
    School of Nursing, Capital Medical University, Beijing 100069, China
    Search for articles by this author
  • Susan F Lee
    School of Nursing and Midwifery, Monash University, Frankston 3199, Victoria, Australia
    Search for articles by this author
  • Melissa J Bloomer
    School of Nursing and Midwifery, Griffith University, Queensland 4111, Australia

    Princess Alexandra Hospital, Metro South Health, Queensland Health, Queensland 4102, Australia

    Menzies Health Institute Queensland, Griffith University, Queensland 4222, Australia
    Search for articles by this author



      As a result of globalisation, many Chinese-born nurses choose to work outside China. They are expected to be competent in providing end-of-life care and dealing with dying and death within the new country, where cultural beliefs, attitudes, and values towards dying and death may differ from their own. It is essential to consider the influence of Chinese culture on nurses’ confidence and preparedness for end-of-life care, especially for dealing with dying and death.


      To discuss Chinese perspectives on dying and death, and death education and training in mainland China, from which we propose recommendations for nurse educators, clinical mentors and researchers in Western settings on how to prepare Chinese-born nurses to care for patients at end-of-life.


      Chinese-born nurses likely encounter significant cultural challenges when providing end-of-life care to dying patients in Western settings. Chinese-born nurses’ perspectives, attitudes and values toward dying and death are shaped by Chinese cultural and social beliefs, practices and expectations, which contrast with those of Western settings. Nurse educators, clinical mentors and researchers in Western settings are encouraged to support and guide Chinese-born nurses in building their cross-cultural understanding and world view to an international view of nursing; essential foundations to the provision of end-of-life care, and nurse coping with dying and death in Western settings.


      The development of death education programs and training to support Chinese-born nurses to attain their cultural competence is a priority in Western countries, to better promote these nurses’ competency in providing high-quality end-of-life care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Collegian
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Australian Commission on Safety and Quality in Health Care
        National consensus statement: Essential elements for safe and high-quality end-of-life care.
        ACSQHC: Canberra. Retrieved from. 2015;
        • Balante J.
        • Broek D.V.D.
        • White K.
        How does culture influence work experience in a foreign country? An umbrella review of the cultural challenges faced by internationally educated nurses.
        International Journal of Nursing Studies. 2021; 118103930
        • Butow P.N.
        • Sze M.
        • Eisenbruch M.
        • Bell M.L.
        • Aldridge L.J.
        • Abdo S.
        • et al.
        Should culture affect practice? A comparison of prognostic discussions in consultations with immigrant versus native-born cancer patients.
        Patient Education and Counseling. 2013; 92: 246-252
        • Cannity K.M.
        • Banerjee S.C.
        • Hichenberg S.
        • Leon-Nastasi A.D.
        • Howell F.
        • Coyle N.
        • et al.
        Acceptability and efficacy of a communication skills training for nursing students: Building empathy and discussing complex situations.
        Nurse Education in Practice. 2021; 50: 1-7
        • Chan J.
        • Kayser-Jones J.
        The experience of dying for Chinese nursing home residents: cultural considerations.
        Journal of Gerontological Nursing. 2005; 31: 26-32
        • Cheng H.W.B.
        • Shek P.K.
        • Man C.W.
        • Chan O.M.
        • Chan C.H.
        • Lai K.M.
        • et al.
        Dealing with death taboo: Discussion of do-not-resuscitate directives with Chinese patients with noncancer life-limiting illnesses.
        American Journal of Hospice & Palliative Medicine. 2019; 36: 760-766
        • Chew Y.J.M.
        • Ang S.L.L.
        • Shorey S.
        Experiences of new nurses dealing with death in a paediatric setting: A descriptive qualitative study.
        Journal of Advanced Nursing. 2021; 77: 343-354
        • Chi X.
        Death taboo and death education.
        Medicine and Philosophy. 2018; 39: 65-67
        • Chua J.Y.X.
        • Shorey S.
        Effectiveness of end-of-life educational interventions at improving nurses and nursing students' attitude toward death and care of dying patients: A systematic review and meta-analysis.
        Nurse Education Today. 2021; 101104892
        • Ge N.
        • Qu X.
        • Ning X.H.
        • Liu X.H.
        Needs of continuing education on hospice and palliative care in China: A questionnaire-based survey. Zhongguo Yi Xue Ke Xue Yuan Xue Bao.
        Acta Academiae Medicinae Sinicae. 2018; 40: 390-394
        • Green A.
        • Jerzmanowska N.
        • Green M.
        • Lobb E.A.
        ‘Death is difficult in any language’: A qualitative study of palliative care professionals’ experiences when providing end-of-life care to patients from culturally and linguistically diverse backgrounds.
        Palliative Medicine. 2018; 32: 1419-1427
        • Hahne J.
        • Liang T.
        • Khoshnood K.
        • Wang X.
        • Li X.
        Breaking bad news about cancer in China: Concerns and conflicts faced by doctors deciding whether to inform patients.
        Patient Education and Counseling. 2020; 103: 286-291
        • Hancock P.K.
        Nurse migration: the effects on nursing education.
        International Nursing Review. 2008; 55: 258-264
        • Hao Y.
        • Zhan L.
        • Huang M.
        • Cui X.
        • Zhou Y.
        • Xu E.
        Nurses' knowledge and attitudes towards palliative care and death: A learning intervention.
        BMC Palliative Care. 2021; 20 (-50): 50
        • Huang H.
        • Liu H.
        • Zeng T.
        • Pu X.
        Preference of Chinese general public and healthcare providers for a good death.
        Nursing Ethics. 2015; 22: 217-227
        • Huang Q.
        • Wang Y.
        The developing situation of China's hospice care and new attempts in recent years.
        Current Politics and Economics of Northern and Western Asia. 2018; 28: 507-527
        • Li L.
        • He X.
        • Hu J.
        • Wu Q.
        Nursing experience of medical staff providing terminal care in China: A Meta-analysis of qualitative studies.
        Chinese Medical Ethics. 2020; 33: 1075-1080 issn. 1001-8565.2020.09.10
        • Liu Y.
        • van Schalkwyk G.J.
        Death preparation of Chinese rural elders.
        Death Studies. 2019; 43: 270-279
        • Lu Y.
        • Gu Y.
        • Yu W.
        Hospice and palliative care in China: Development and challenges.
        Asia Pacific Journal of Oncology Nursing. 2018; 5: 26-32
        • Luo Y.
        • Zhang H.
        A prospective analysis of death education at home and abroad.
        Journal of Nursing Administration. 2018; 18: 175-184
        • Malone L.D.
        • Anderson J.
        • Croxon L.
        Are newly graduated nurses ready to deal with death and dying? A literature review.
        Nursing and Palliative Care. 2016; 1: 89-93
        • McClatchey I.S.
        • King S
        The impact of death education on fear of death and death anxiety among human services students.
        Omega (Westport). 2015; 71: 343-361
        • McNeely S.
        Stress and death attitudes in nurses. (Publication.
        University of Leicester, 1998 (No.U106306)[Doctoral dissertation])
      1. National Health and Family Planning Commission of the People's Republic of China. (2017). Palliative care practice guidelines (trial). Retrieved from

        • Robbins R.A.
        Death competency: A study of hospice volunteers.
        Death Studies. 1992; 16: 557-569
        • Sansó N.
        • Galiana L.
        • Oliver A.
        • Pascual A.
        • Sinclair S.
        • Benito E.
        Palliative care professionals' inner life: Exploring the relationships among awareness, self-care, and compassion satisfaction and fatigue, burnout, and coping with death.
        Journal of Pain and Symptom Management. 2015; 50: 200-207
        • Scammell J.
        Nurse migration and the EU: How are UK nurses prepared?.
        British Journal of Nursing. 2016; 25 (-764): 764
        • Shi B.
        Hospice and palliative care in China.
        Chinese Journal of Practical Nursing. 2019; 35: 1521-1525
      2. Socha-Dietrich, K., & Dumont, J.-C. (2021). International migration and movement of nursing personnel to and within OECD countries - 2000 to 2018. Retrieved from

        • Tang Y.
        Death attitudes and truth disclosure: A survey of family caregivers of elders with terminal cancer in China.
        Nursing Ethics. 2019; 26: 1968-1975
      3. Wells, C. M. (2018). The influence of compassion satisfaction, compassion fatigue and death anxiety on role ambiguity and role conflict in ICU nurses providing care at end of life. (Publication No. 2249961669)[Doctoral dissertation, Adelphi University].

        • White D.
        • Meeker M.A.
        Guiding the process of dying: The personal impact on nurses.
        Journal of Hospice and Palliative Nursing. 2019; 21: 390-396
        • Willemsen A.M.
        • Paal P.
        • Zhang S.
        • Mason S.
        • Elsner F.
        Chinese medical teachers' cultural attitudes influence palliative care education: A qualitative study.
        BMC Palliative Care. 2021; 20 (-14): 14
        • Xu Y.
        Death and dying in the Chinese culture: Implications for health care practice.
        Home Health Care Management & Practice. 2007; 19: 412-414
        • Xu Y.
        Strangers in strange lands: A meta-synthesis of lived experiences of immigrant Asian nurses working in Western countries.
        ANS: Advances in Nursing Science. 2007; 30: 246-265
        • Zheng R.
        • Bloomer M.J.
        • Guo Q.
        • Lee S.F.
        New graduate nurses' coping with death and the relationship with death self-efficacy and death anxiety: A multicentre cross-sectional study.
        Journal of Advanced Nursing. 2021; 72: 795-804
        • Zheng R.
        • Guo Q.
        • Dong F.
        • Gao L.
        Death self-efficacy, attitudes toward death and burnout among oncology nurses: A multicenter cross-sectional study.
        Cancer Nursing. 2022; 45: E388-E396
        • Zheng R.
        • Guo Q.
        • Dong F.
        • Owens R.G.
        Chinese oncology nurses' experience on caring for dying patients who are on their final days: A qualitative study.
        International Journal of Nursing Studies. 2015; 52: 288-296
        • Zheng R.
        • Guo Q.
        • Chen Z.
        • Ma L.
        • McClement S.
        An exploration of the challenges for oncology nurses in providing hospice care in mainland China: A qualitative study.
        Asia Pacific Journal of Oncology Nursing. 2021; 8: 139-146
        • Zheng R.
        • Lee S.F.
        • Bloomer M.J.
        How nurses cope with patient death: A systematic review and qualitative meta-synthesis.
        Journal of Clinical Nursing. 2018; 27: e39-e49
        • Zhong Y.
        • McKenna L.
        • Copnell B.
        What are Chinese nurses' experiences whilst working overseas? A narrative scoping review.
        International Journal of Nursing Studies. 2017; 74: 101-111
        • Zhou Y.
        • Li Q.
        • Zhang W.
        Undergraduate nursing students’ knowledge, attitudes and self-efficacy regarding palliative care in China: A descriptive correlational study.
        Nursing Open. 2021; 8: 343-353
        • Zhou Y.
        • Roscigno C.
        • Sun Q.
        Why do China-educated nurses emigrate? A qualitative exploration.
        International Journal of Nursing Studies. 2016; 53: 163-172