Knowledge, attitude, and practice toward oral frailty management among nursing staff and its determinant factors: a multicentre cross-sectional study.

The latest China Statistical Yearbook shows that China’s population aged 65 years or above reached 200 million by the end of 2022, making up 14.9% of the national population, up 0.7 percentage points from 2021 (). As the population ages and chronic disease and cancer become more common, demand for accessible and competent end-of-life care continues to grow. Personal views of mortality shape emotional and behavioral responses when individuals are confronted with the death of others (). Nurses often provide direct care to patients near death while also supporting families during the dying process and after bereavement. Fear or avoidance of death may make it difficult for nurses to manage their emotional responses while providing care for dying patients (). As part of end-of-life care training, death education helps nurses build knowledge about death and improve their ability to respond to death-related care situations (). Existing evidence indicates that death education may ease death anxiety, improve attitudes toward terminal care, and help nurses feel more prepared to manage death-related situations (, ). In 1986, the American Medical Association (AMA) recommended the inclusion of death education in healthcare professional training. Although death- and palliative-care education is increasingly recognized as important for health-professional training, recent Chinese studies continue to show limited exposure to such training and substantial educational needs among medical and nursing students (). The End-of-Life Nursing Education Consortium (ELNEC) provides a well-known structured curriculum for improving end-of-life care competence in nursing students and clinical nurses (). ELNEC-based programs have subsequently been implemented in countries including Germany, Canada, and Singapore (). In Mainland China, traditional reluctance to discuss death has slowed the development of formal death education. However, growing attention to palliative care and care across the life course has encouraged the development of death education programs based on different educational and theoretical models. In China, Community Health Service Centers (CHSCs) deliver much of the frontline primary care work, including routine care, health education, and preventive services (). Community nurses are often involved in caring for patients with advanced illness, advising families, and discussing end-of-life issues (). Their views on death and confidence in handling death-related situations can shape the care they deliver. Yet many community nurses have few opportunities for specialized end-of-life care training, making targeted continuing education necessary. Using the Knowledge-Attitude-Practice framework as its organizing logic, the program focused on three areas: knowledge about death and dying, orientation toward death-related care, and preparation for end-of-life communication and advance care planning ().