Flipped Learning Versus Traditional Lectures in End-of-Life Nursing Education: A Comparative Study in Taiwan

Background End-of-life (EOL) nursing education faces a critical knowledge-practice gap and systemic moral distress due to institutional and procedural ambiguities surrounding Do Not Resuscitate (DNR) orders and Life-Sustaining Treatment (LST) withdrawal. Purpose This study aims to evaluate and compare the practical effectiveness of flipped and traditional teaching in EOL care education and to explore the relationship between knowledge and moral dilemmas in EOL care. Methods A two-group pre- and post-test experimental design was employed to evaluate the educational efficacy of a flipped learning model vs traditional didactic lectures among 109 Taiwanese nurses. Results Baseline data revealed severe deficiencies in nurses’ EOL knowledge and procedural clarity (Mean = 2.72-2.87), with 65.6% experiencing EOL decision implementation-related stress. Post-intervention, traditional lecturing excelled in teaching procedural LST withdrawal protocols ( d = .791), whereas flipped teaching significantly outperformed in contextual DNR clinical judgment ( d = .654) and relational companionship capabilities ( d = .328), while triggering small upward trends in death anxiety and perceived decision dilemmas. Correlation analysis confirmed that EOL knowledge strongly correlates with DNR/LST endorsement, procedural mastery, and ethical reasoning ( r = .450 to .861), but shows no significant correlation with care-related stress or anxiety. Conclusion To optimize EOL nursing readiness and mitigate moral distress, a hybrid pedagogical model is strongly recommended. Educators should leverage structured traditional lectures to rapidly and reliably establish administrative rules and legal protocols, while reserving active, flipped classrooms for nurturing situational clinical reasoning, fostering relational empathy, and navigating existential reflections inherent to dignity-centered palliative care.