Comparing the Difference in Nurses' Knowledge and Attitudes Toward Near-Death Experiences (N.D.E's) Before and After Receiving N.D.E Education

Renata McAllister

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A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

Comparing the Difference in Nurses' Knowledge and Attitudes Toward Near-Death Experiences (N.D.E's) Before and After Receiving N.D.E Education

A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

Approved by:

Abstract

Near-death experiences (N.D.E's) have been reported in approximately 6.3% to 39.3% of patients who survived death or critical illness. Research indicated that health care professionals, of whom nurses are the largest group, received little education or training on N.D.E's. Nurses' responses to a disclosure could help the patient integrate the experience or contribute to stress and isolation. National nursing standards do not address education or competencies specific to N.D.E's, and few studies have examined educational programs on the topic. This quasi-experimental study examined changes in nurses' knowledge and attitudes before and after a three-part asynchronous training on N.D.E's, measured with the Knowledge and Attitudes About Near-Death Experiences Scale (Kandess). The research questions addressed the relationship between knowledge and attitudes and the changes in each after training. Participants were 41 registered nurses employed in Kaiser Permanente Northern California facilities. They completed a pretest, three asynchronous modules, and a 1-week delayed posttest through a secure online survey platform, along with a demographic questionnaire. The analysis used descriptive statistics, Spearman's rho, a paired-samples t test, and the Wilcoxon signed-rank test. Knowledge and attitudes were positively related at both the pretest and the posttest, and both increased significantly from the pretest to the 1-week delayed posttest. All four alternative hypotheses were supported. The findings may inform nursing continuing education and future research on N.D.E training for health care professionals.

Dedication

To Ruben, my unending source of support and encouragement. You carried the weight of our life so that I could pursue a lifelong goal, and you never once made me feel the cost. You continue to lead with the power of love, and your confidence in me shines a light forward.

It is also dedicated to my children, Saoirse and Lachlan. You teach me every day what the depth of love can do. You are the reason behind every page, and I hope that one day you read this and know that meaningful work is worth pursuing with courage, curiosity, and love.

To my mother and nana, thank you for inspiring in me a lifelong love of learning; without your modeling, this project would never have seemed possible. To my grandma, who instilled in me a deep connection with God and a faith that has anchored me in every season of my life, your spirit and wisdom live in these pages. To my grandpa, a constant source of love shining on me like the sun, thank you for believing in me without ever a hint of wavering.

This accomplishment belongs to all of you as much as it does to me.

This accomplishment belongs to all of you as much as it does to me.

I would first like to express my sincere gratitude to my dissertation committee, Dr. Jerry Green and Dr. Rachel Piferi, for their guidance, patience, prayers, and encouragement throughout the dissertation process. Their thoughtful feedback and steady support shaped this work at every stage. This dissertation would not have been possible without them.

I am deeply grateful to Dr. Jan Holden, whose scholarship in near-death experience research laid much of the groundwork this study builds upon. She was the first person to help me envision this work, and she pointed me toward Dr. Sahar Loseu as a model for my own. She was approachable, kind, and generous with her guidance, and it has been an honor to work toward the same research goals she has advanced throughout her career.

I am also grateful to Dr. Sahar Loseu, who met with me, shared her research and dissertation, and provided the foundation for the structure of this work. She was generous with her time and resources, and her guidance shaped how I approached this study.

I am grateful to Trevor Murray, who modeled scholarship and dedication while creating the space that allowed me to continue my doctoral journey. I also thank Jim D'Alfonso, who leads the Scholars Academy at Kaiser Permanente and champions higher learning for all. I am especially grateful to my Kaiser Permanente mentors, Hannah Kim and Rayne Soriano, who helped me take this study from an idea to a reality within a large health care system. They guided me through the process with patience, skill, and experience. And, of course, to Emily Culver and Rachael McDavid, who offered their editing support and counsel, making clear what seemed muddy.

I offer my sincere appreciation to the nurses who participated in this study. Your time, honesty, and willingness to engage with this research made this possible. I also owe a debt of gratitude to the many nurses, physicians, respiratory therapists, environmental services workers, therapists, and other health care professionals who cared for me during my own health crises and who have mentored and partnered with me professionally. Their compassion and skill are the reason this study exists. They have shown me, both personally and professionally, the profound importance of being seen, heard, and cared for during vulnerable moments.

Table Of Contents

List of Tables

List of Figures

Chapter 1: Introduction to the Study

Introduction

Near-death experiences (N.D.E's) are phenomena that occur during life-threatening situations and are frequently observed within health care settings. In modern health care practice, individuals often survive potentially fatal events due to advancements in medical technology and treatments. Patients are frequently able to disclose their experiences immediately following the events, often in the presence of medical staff. How health care professionals respond to N.D.E disclosures can influence how patients integrate and make meaning of their experiences. Dismissive or hostile responses can cause distress and withdrawal, whereas validation and respectful inquiry can promote trust and assist patients in feeling secure and coping with their experiences. Researchers recommend educating hospital staff about N.D.E's. However, within the nursing profession, training on N.D.E's remains inconsistent and is largely absent from standard curricula. Encounters between patients and nurses can influence patient experience and outcomes, and providing opportunities for nurses to learn about N.D.E's may facilitate ethical, patient-centered care.

This study aimed to assess an asynchronous, three-part N.D.E training program for nursing professionals. This study evaluated outcomes using the Knowledge and Attitudes about Near-Death Experiences Scale (Kandess), administered as a pretest before training and as a delayed posttest approximately 1 week after training.

This study examined pretest-posttest differences in knowledge and attitude scores, guided by Kirkpatrick and Kirkpatrick's evaluation model. The evaluation focused on Level 2 (learning) of the Kirkpatrick model and used the Kandess instrument. Bloom's taxonomy provided a foundational framework for aligning learning objectives with the Kandess assessment. Furthermore, Watson's caring science theory offered a relational, person-centered framework for nurses' responses, whereas the job demands-resources model conceptualized the training program as a resource at work capable of alleviating the emotional burden linked to receiving an N.D.E disclosure. The guiding framework for determining the timing of posttests was Ebbinghaus's forgetting curve. The findings from this study may inform the development of nursing education programs, patient care, communication training, and clinical practice. The following sections summarize the background and biblical foundations of the study, describe the problem and purpose, define key terms, provide the research questions and hypotheses, and explain the significance of the study, leading to Chapter 2, which provides a review of the scholarly literature informing the research.

Background

N.D.E's often occur within clinical care settings, as individuals are surviving life-threatening events at an increasing rate due to improvements in critical care. N.D.E's have been reported across diverse cultures, with studies suggesting that between 6.3% and 39.3% of individuals facing imminent death experience an N.D.E ( Greyson, 2003a, Hashemi et al., Martial et al., Raffaelli et al., Rousseau et al., Shushan, Health care professionals may increasingly encounter disclosures of such experiences from patients after the events. The response to these disclosures can have implications for patient care and influence how individuals ultimately process the experience, either constructively or negatively. However, despite national nursing frameworks guiding nurses to provide ethical, spiritually competent, and patient-centered care, nurse training and preparation specific to N.D.E's are limited and inconsistent, highlighting a gap in education and a subsequent lack of evaluation of N.D.E-specific training (A.A.C.N), American Nurses Association (A.N.A), Accordingly, this study evaluated learning outcomes (knowledge and attitudes) using a validated measure. N.D.E's include a set of commonly reported features and lasting aftereffects. Contemporary research on the topic confirms that common features of N.D.E's include altered time perception, separation from the body, intense feelings of peace, encounters with deceased family members or loved ones, meetings with spiritual guides or figures, a sense of moving through a tunnel, a feeling of approaching a limit or point of no return, and panoramic life reviews. Not all features are required for an N.D.E to be recognized as such, and instruments such as Greyson's N.D.E scale, Martial et al.'s Near-Death Experience Content scale, or Greyson et al.'s veridical N.D.E scale are used to determine the validity of N.D.E's. While identifiable patterns exist, each N.D.E is unique to the individual (Cassol et al., 2018). However, research indicates the presence of consistent patterns in the experiences of many people across different cultures and throughout history (Hashemi et al., Martial et al., After the initial event, lasting changes, referred to as aftereffects, occur and manifest as transformations in values, spirituality, worldview, social orientation, life priorities, attitudes toward death, meaning, and purpose (Long &

Woollacott, 2024; Miquel-Sendra & García-Alandete, 2025). The aftereffects are generally enduring and advantageous. Nevertheless, some individuals report difficulties when integrating the N.D.E into their lives, observing modifications in their relationships and professional environments. This underscores the necessity for informed assistance from health care professionals, including nurses, subsequent to such events.

Reactions of health care personnel, including those of nurses, can influence whether a patient endures distress or progresses toward integrating their experience. Initial responses to the disclosure of an N.D.E may yield either advantageous or adverse effects. Patients often face apprehension about judgment when recounting their N.D.E's, and encountering skepticism may lead to feelings of isolation. Conversely, attentive and supportive listening can facilitate patients' efforts to make meaning of their experiences. Nonetheless, a gap remains in the understanding of N.D.E's and the appropriate strategies to support patients who have undergone such events. Academic researchers have identified a deficiency in the knowledge possessed by health care professionals regarding how to assist N.D.E's following these incidents. Although interpretations of N.D.E's can vary, the clinical priorities are to avoid harm and to ensure patient safety (Cassol et al., Holden et al., Martial et al., Research indicates that dismissiveness can exacerbate distress, and nursing professional codes and education standards require respectful communication that prioritizes patient safety.

National nursing frameworks from the A.A.C.N (2021) and A.N.A (2025) that define set competency expectations underscore the significance of compassionate care, spiritual awareness, a nonjudgmental attitude, active listening, and dignity as integral professional responsibilities. Nursing philosophical theories, such as Watson's (2018) caring science theory and the Caritas Processes, align with national nursing frameworks in their emphasis on providing holistic, spiritually attuned, person-centered care. Nevertheless, nursing education requirements do not explicitly articulate N.D.E-specific content. Formal nursing training on N.D.E's is uncommon; however, such training could serve as a resource to aid nurses' understanding of and attitudes toward N.D.E's and those who experience them.

A review of nursing standards and professional guideline documents from the A.N.A Code of Ethics (2025), the A.A.C.N (2021), and the A.C.E.N (2023) identified no explicit competencies specific to N.D.E education. These organizations and their respective documents, however, emphasize holistic, ethical, and spiritually sensitive patient care. The review does not demonstrate, and the author does not claim, that N.D.E training is absent from all curricula. However, the review indicates that national standards do not explicitly articulate N.D.E education, thereby supporting the aim of this research to evaluate N.D.E training for nurses.

Encounters involving N.D.E disclosures can be emotionally intense and challenging to navigate in conversation for both patients and nurses, and thus increase the emotional demands of nursing work. Within the domain of industrial and organizational psychology, and in accordance with the job demands-resources model, encounters with N.D.E's may be characterized as a job demand. Conversely, training programs that provide language and tools function as job resources, potentially alleviating the stress associated with such encounters and offering education that contextualizes these interactions as part of clinical care. The study evaluated training outcomes within the Kirkpatrick Level 2 (learning) assessment framework and measured changes in knowledge and attitudes with the Kandess.

This study used the original 2016 version of the Kandess to assess nurses' knowledge and attitudes regarding common N.D.E features and aftereffects and the characteristics of experiencers. The Kandess directly evaluated knowledge about and attitudes toward N.D.E's, thereby aligning with Level 2 (learning) of the Kirkpatrick evaluation model. The Kandess is divided into subscales of knowledge (Kandess-K) and attitudes (Kandess-A), permitting separate assessment of each domain and factor. The training program encompassed the common features and aftereffects of N.D.E's, as well as best practices for communication with patients, consistent with the Kandess. Consequently, any variations observed in the pretest to posttest results may be related to the training program. The Kandess was administered as a pretest prior to the self-guided asynchronous training modules and as a posttest 1 week following the training to evaluate learning outcomes, in accordance with Ebbinghaus's (1885/1913) research on the forgetting curve, which demonstrates that the most substantial declines in retention occur during the week after learning. The researcher selected this interval to address potential attrition while still enabling the assessment of lasting learning changes. The interval was selected to address potential attrition while still enabling the assessment of lasting learning changes.

Problem Statement

Research indicates that between 6.3% and 39.3% of individuals returning from clinical death or experiencing a life-threatening event report an N.D.E. Health care interventions such as resuscitation have increased the likelihood of patients surviving life-threatening events within clinical settings. Consequently, patients now have greater opportunities to experience and disclose potential N.D.E's to nursing staff. Common N.D.E features, such as out-of-body experiences (O.B.E's), encounters with spiritual beings, bright light, peace, and a life review, are well documented. The experience can be transformative, often resulting in lasting changes in values, perspectives, and spiritual beliefs. Disclosing these events to nurses offers an opportunity for the nurse to deliver supportive interventions that assist patients in integrating and comprehending their experiences.

Research indicates that when health care professionals respond with negativity, skepticism, or dismissiveness to N.D.E disclosures, patients tend to delay the healthy integration of their experiences, often resulting in feelings of isolation or distress. Individuals who report an N.D.E describe significant unmet needs following such events. Nurses, as part of the care team, can play a crucial role in how patients integrate and interpret N.D.E's. Nursing theories, such as caring science, underscore the importance of holistic care, presence, empathy, and addressing spiritual needs, while the governing bodies of nursing practice such as the Accreditation Commission for Education in Nursing, Association of Colleges of Nursing, American Nurses Association, and Watson's Caring Science nursing philosophy also highlight the value of spiritual care, ethics, and patient advocacy.

A gap exists because of the lack of standardized nursing education on N.D.E's and limited research on how N.D.E training influences nurses' knowledge and attitudes. Furthermore, it remains unclear how nurses' knowledge and attitudes concerning N.D.E's are initially related, or whether this relationship changes after N.D.E-specific training. At the time of this study, an examination of nursing standards within the United States did not reveal N.D.E-specific competencies or curricular expectations. Certain nursing theories and educational frameworks address aspects of death; however, they largely omit the phenomenon of N.D.E's. Given the current incidence of N.D.E reports, this underscores a deficiency in training related to the appropriate management of the physical and emotional needs of patients disclosing N.D.E's

(Holden et al., Pehlivanova et al., Samoilo & Corcoran, Zheng et al.,

2021). This training gap presents an opportunity for the evaluation of educational initiatives concerning N.D.E's for nursing professionals.

Holden et al. (2014) demonstrated that health care professionals' responses to N.D.E disclosures are pivotal in preventing harm to patients. The lack of preparatory training for health care professionals may lead to detrimental effects on patient care, partly due to insufficient essential job resources. The job demands-resources model offers a framework to illustrate that nurses' reactions to patient N.D.E disclosures can be emotionally taxing, representing a job demand. Conversely, job resources such as specialized N.D.E training can enhance nurses' well-being. Zheng et al. (2021) posit that nurses frequently experience increased anxiety concerning death, and resources like training could alleviate this stress. This study proposed using Kirkpatrick's Level 2 framework as a theoretical guide to evaluate learning outcomes from N.D.E-specific training, utilizing the Kandess tool as a pre-and post-assessment. From a Christian perspective, compassionate care is essential. Believers are urged to “bear one another's burdens” and “heal the sick”. The lack of an evaluated N.D.E training program may leave some nurses insufficiently prepared to respond to N.D.E disclosures, potentially impacting patient care and nurse well-being. These elements indicate a gap in the empirical literature assessing N.D.E-specific training for nursing staff. The issue is that nurses do not receive empirically validated N.D.E- specific education; therefore, it remains unclear whether N.D.E training enhances their knowledge and attitudes regarding N.D.E's and how these domains are interconnected prior to and following the training.

Purpose of the Study

This quantitative quasi-experimental study evaluated an educational program by comparing nurses' knowledge and attitudes regarding N.D.E's before and after a self-paced, three-module training, using pretest and 1-week delayed posttest Kandess surveys, and examined the relationship between knowledge and attitudes at each time point.

Research Questions

Research Questions and Hypotheses

R.Q 1: What is the relationship between nurses' knowledge about N.D.E's and attitudes toward N.D.E's before completing the N.D.E training program?

R.Q 2: What is the relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's 1 week after completing the N.D.E training program?

R.Q 3: Do nurses' knowledge about N.D.E's significantly change from pretest to 1-week delayed posttest following an N.D.E training program?

R.Q 4: Do nurses' attitudes toward N.D.E's significantly change from pretest to 1-week delayed posttest following an N.D.E training program?

Hypotheses

Hypothesis 1: There will be a statistically significant relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's before completing the N.D.E training program.

Hypothesis 2: There will be a statistically significant relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's 1 week after completing the N.D.E training program.

Hypothesis 3: Nurses' knowledge scores (Kandess-K) about N.D.E's will significantly change from pretest to 1-week delayed posttest.

Hypothesis 4: Nurses' attitude scores (Kandess-A) toward N.D.E's will significantly change from pretest to 1-week delayed posttest.

Assumptions and Limitations of the Study

This research is based on several foundational assumptions. The Kandess instrument has demonstrated both reliability and construct validity, and it was anticipated to function appropriately within the context of this study. Although participants may sometimes misrepresent responses in self-report research, particularly on sensitive topics, it was assumed that participants answered the Kandess items and demographic questionnaire honestly. Participants were required to have access to a device capable of internet connectivity to view the modules and complete the Microsoft Forms surveys. It was also assumed that the email addresses collected were correctly linked to pre-and posttest data results.

Several limitations may have influenced the outcomes of this study. The quasi- experimental design was selected specifically to evaluate only Kirkpatrick Level 2 outcomes (learning outcomes) and did not encompass assessments of reactions (Level 1), behaviors (Level 3), or results such as patient outcomes (Level 4) (Capili & Anastasi,

2024; Kirkpatrick & Kirkpatrick, 2006). The absence of a control group and the employment of a single-group pretest-posttest design restricted causal inferences (Adams & McGuire, Furthermore, the generalizability of the findings to other regions, roles, or care models may be constrained by the voluntary opt-in recruitment approach and the sampling from a single health system rather than a random sample. Due to the inherent limitations of convenience sampling, the results may be biased toward the sampled population. Research by van de Mortel (2008) indicates that individuals tend to exhibit social desirability bias, which may lead to inaccuracies. As this study relied predominantly on self-reported data, self-report bias constitutes a limitation, as responses may have been affected by the desire to present oneself favorably. Additionally, the pretest-posttest design and the timing of the delayed posttest may have introduced response-shift bias, wherein participants' perceptions of the construct may have changed between assessments. Repeated exposure to the assessment items could have influenced scores independently of learning, and no alternative forms were utilized. Attrition, referring to loss of participants during the course of the study, may have occurred at any stage; however, reminders were issued to minimize this risk. Nonetheless, analyzing only data from participants who completed both assessments mitigated the impact of attrition on internal validity. The administration of the pretest and posttest via Microsoft Forms within the Kaiser Permanente firewall may have resulted in usability disparities, as familiarity with the platform, devices, and browsers varies among participants, a factor not controlled in this study (Dominguez-Figaredo & Gil-Jaurena, 2025). Finally, conducting the posttest approximately 1 week after the pretest may have introduced variability in memory consolidation effects.

Theoretical Foundations of the Study

The study's foundational principles centered on evaluating a three-part, asynchronous online N.D.E training program tailored for nursing professionals. The aim of this investigation was to determine whether participants have acquired knowledge from the modules provided. The Kirkpatrick model, particularly Level 2 (learning), grounded the theoretical framework for this research. The Kirkpatrick model comprises four levels: Level 1 (reaction), which pertains to participant satisfaction; Level 2 (learning), which assesses whether learning has taken place; Level 3 (behavior), which examines behavioral changes resulting from the training; and Level 4 (outcomes), which measures final results such as patient experience scores or other key indicators.

This study evaluated Level 2 learning-related outcomes using pretest-posttest score differences. The Kandess was employed as both a pre-and post-assessment to measure knowledge and attitudes relevant to learning. The learning outcomes, encompassing knowledge and attitudes, were evaluated prior to the training and 1 week subsequent to its conclusion. These outcomes aligned with the affective and cognitive domains delineated in Bloom's taxonomy.

A delayed posttest was employed in lieu of an immediate posttest to mitigate the risk of inflated scores resulting from participants' reliance on recall and working memory rather than long-term, consolidated memory. Ebbinghaus's forgetting curve offered empirical evidence for the 1-week delay before testing. Consequently, the study operationalized Kirkpatrick's Level 2 evaluation through data analysis that tested whether Kandess total and subscale scores differed significantly from pretest to posttest.

Additional supporting theoretical frameworks encompassed Bloom's taxonomy, the job demands-resource model, and caring science theory.

Bloom's taxonomy offers a structured foundation for aligning the module's objectives with the Kandess measures. The Kandess assesses the cognitive (knowledge) and affective (attitudes/values) domains within Bloom's framework, thereby ensuring alignment between assessment methods and learning domains. In Bloom's taxonomy, cognitive outcomes develop from basic levels such as remembering and understanding to more advanced levels such as application and analysis. Similarly, affective outcomes evolve from simpler processes, such as receiving and responding to information, to more complex processes, such as valuing and integrating information.

The cognitive and affective domains, as defined by Bloom, are congruent with the Kandess instrument, which evaluates knowledge and attitudes. The changes in Kandess scores were assessed at the second level of Kirkpatrick's model.

The job demands-resources model offers further support for N.D.E-specific nursing education (Bakker & Demerouti, 2007). This model characterizes job pressures, including emotional stressors, as job demands, while job resources are defined as mechanisms that mitigate or alleviate these demands. Job resources have the potential to enhance employee well-being and performance. Additionally, the job demands-resources model provides context regarding how N.D.E disclosures may be perceived in health care workplaces, as such disclosures can generate additional emotional stress for nurses, thereby escalating job demands. Furthermore, education that delivers targeted information, vocabulary, and resources can serve as a job resource, buffering against stress.

Caring science offers an alternative perspective through which to examine the role of the nurse in patient care, particularly concerning the disclosure of N.D.E's. In accordance with national standards for nursing professionalism and education, caring science provides a theoretical and philosophical framework for operationalizing caring behaviors such as attentive listening, presence, respect, and openness. The mapping of the caring science philosophy to the A.A.C.N Essentials has identified patient care models that foster trusting relationships between patients and nurses. This fundamental expectation of nursing practice aligns with research that indicates patients require during heightened N.D.E disclosure.

Scholarly literature delineates additional instruments for the development and assessment of training programs. While this investigation concentrated on evaluating Kirkpatrick's Level 2 outcomes employing the Kandess instrument, various other evaluation frameworks were available for potential consideration in subsequent studies. The review explored the Context, Input, Process, and Product (C.I.P.P) model, Fink's (2013) taxonomy, and philosophies of caring science within the nursing profession.

From a Christian worldview, Scripture supports the study through teachings on four issues: caring for individuals, N.D.E features and aftereffects, the fruits of the Spirit as they relate to long-term N.D.E aftereffects, and teaching and training. Nursing, as a profession, has its roots in early Christianity, and its original tenets were guided by biblical lessons and themes. Scripture encourages humans to honor the imago Dei (image of God) in everyone and bear one another's burdens, listening before speaking, caring, rejoicing, and weeping with others. Listening before speaking aligns with the need for nurses to hear patients as they disclose N.D.E's, and gentleness in speech is key when nurses receive individuals' stories of N.D.E's. While the Bible does not explicitly discuss N.D.E's, there are accounts similar to contemporary N.D.E descriptions. For example, just as Paul described when he"heard things that cannot be told, which man may not utter", N.D.E's are often reported as ineffable and indescribable. Habermas (2018) examined a common N.D.E feature, O.B.E's. After reviewing veridical accounts of O.B.E's, he argued that N.D.E's are compatible with and supportive of a Christian worldview. Additionally, the alignment between N.D.E aftereffects and fruits of the Spirit provides insight into the long-term aspects of the phenomenon. Research has found long-term, consistent changes in individuals who undergo N.D.E's, such as greater compassion and kindness and a reduction in materialism or competitiveness. These enduring effects, while not an exact match, align with the essence of peace, patience, kindness, self-control, and goodness found among the fruits of the Spirit. Finally, the fourth way in which to view this research in biblical terms is to examine the sentiment toward training. Teaching and equipping others are concepts found throughout Scripture, as Jesus teaches the disciples about the value of training from an early age (Proverbs 22:6; Ephesians 4:11 to 12). Biblical guidance encompasses not only learning and training but also hard work and wisdom as well, all of which can yield fruit (Exodus 35:34 to 35; Proverbs 1:5; Hebrews 12:11). The biblical themes and truths, nursing philosophies, and educational training evaluation theories provided the conceptual framework for this study.

The following presents the study's evaluation approach. Kirkpatrick's Level 2 (learning) was assessed through changes between pretest and delayed posttest utilizing the Kandess scales; Levels 1, 3, and 4 are excluded from this research. Bloom's cognitive and affective domains were employed to ensure alignment of objectives, content, and assessment with the measures of the Kandess. Additionally, the job demands-resources model framed the training as a job resource, offering a rationale for its potential benefits in the workplace. Caring science offered an ethical, patient-centered justification for establishing the tone in patient care and is consistent with national nursing standards. The timing of the delayed posttest corresponded with evidence from the forgetting curve, indicating that knowledge retention should not be evaluated immediately after initial learning. The analysis was two-tailed, examining whether Kandess scores differed significantly from the baseline, with statistical changes interpreted at the second level of Kirkpatrick's evaluation framework.

Definition of Terms

Twenty-eight

The following is a list of definitions of terms that were used in this study.

Asynchronous – Asynchronous refers to a flexible approach concerning the timing of educational activities within this study. Participants had the liberty to access the module materials at their convenience. The learning process did not occur in real time with an instructor; rather, it followed the schedule of the learner. This method is characterized as a self-paced study.

Attitudes (Kandess-A) – Attitudes are defined as the perspectives or dispositions of health professionals regarding N.D.E's, as measured by the Attitudes subscale of the Kandess. In this study, a higher Kandess-A score signifies a more nonjudgmental and supportive attitude toward N.D.E's and near-death experiencers.

Bloom's taxonomy – This study employed Bloom's taxonomy to align the N.D.E training objectives with the Kandess tool, which assessed nurses' knowledge (cognitive) and attitudes (affective) regarding N.D.E's. The taxonomy is a hierarchical framework that categorizes educational objectives based on levels of complexity. It comprises three domains: cognitive, affective, and psychomotor. This research concentrated on the cognitive and affective domains, as it investigated knowledge and attitudes, respectively. The cognitive domain advances in complexity through stages: remembering, understanding, applying, analyzing, evaluating, and creating. The affective domain progresses from receiving, responding, valuing, and organizing to characterizing.

Caring science – Caring science refers to Jean Watson's (2018) humanistic theory of transpersonal caring, which underscores fundamental principles in the nurse-patient relationship, including presence, humility, and spiritual and ethical dedication. This theoretical framework offers a conceptual foundation for the implementation of communication and presence during the disclosure of N.D.E's.

Disclosure – Disclosure is defined as a patient's communication of an N.D.E or a suspected N.D.E to a health care professional. In this research, disclosure pertained to dialogues occurring within inpatient or outpatient environments between patients and health care personnel concerning the patient's N.D.E.

Job demands-resources model – The job demands-resources model describes job demands, such as emotional labor, as factors that can create strain and stress, while job resources, such as organizational support or training, can buffer the effects of these demands. This study treated N.D.E education as a job resource that may ameliorate emotionally taxing disclosure experiences.

Kirkpatrick Level 2 (learning) – Kirkpatrick's second level (Level 2) within

Kirkpatrick's four-tier evaluation framework pertains to any alteration in attitude, knowledge, or skill attributed to the training program.

Kirkpatrick's Level 2 (learning) was assessed by measuring changes in nurses' knowledge about or attitudes toward N.D.E's, utilizing the Knowledge and Attitude subscales of the Kandess instrument administered prior to the training program and 1 week subsequent to the final training module.

Knowledge and Attitudes About Near-Death Experiences Scale (Kandess) –

Kandess refers to a validated instrument designed to assess health care professionals' knowledge and attitudes about N.D.E's through distinct knowledge and attitude subscales

. The Kandess instrument was employed as both a pre-and posttest within this research, with the posttest scheduled to occur 1 week subsequent to the training program in order to evaluate the extent of learning.

Knowledge (Kandess-K) – Knowledge is defined as the factual understanding that health professionals possess regarding N.D.E's, as measured by the Knowledge subscale of the Kandess. A higher Kandess-K score signifies a greater comprehension and awareness of N.D.E characteristics, prevalence, and related clinical issues.

Near-death experience (N.D.E) – N.D.E refers to individually reported experiences that meet the commonly described features of the phenomenon identified in peer-reviewed research. Greyson's (2023b) definition was used for this research:

Near-death experiences are events that occur when people are close to death, typically characterized by transcendent or mystical features, out-of-body experiences, exceptional lucidity, and unusually strong emotions. They generally have profound aftereffects, such as decreasing one's fear of death, enhancing one's spirituality, and radically shifting one's worldview. (pp. 199 to 200)

Near-death experiencer (N.D.E-er) – N.D.E-er is defined as a person who reports having experienced an N.D.E and can provide firsthand knowledge of N.D.E features as described in the scholarly literature.

N.D.E aftereffect – N.D.E aftereffect is defined as a stable change following an N.D.E, such as a change in values, attitudes, worldview, spirituality, or orientations toward death, as documented in research.

N.D.E feature – N.D.E feature is defined as a commonly documented element within N.D.E narratives. N.D.E features may include any of the criteria used to evaluate the validity of N.D.E's, such as bright lights, profound feelings of peace, encounters with spiritual beings, O.B.E's, or life reviews, as cataloged in recent research and analysis. The study referenced N.D.E features to help nurses understand patient language and themes that patients may discuss during disclosure.

Training program – Training program is defined as a structured learning experience designed to create measurable changes in learners' knowledge, attitudes, or skills. The training program for this study consisted of three modules totaling 100 minutes covering N.D.E features, aftereffects, and disclosure responses.

Significance of the Study

This study addressed a training gap in nursing education regarding N.D.E's. Nurses as integral members of the health care team within clinical settings, may encounter disclosures of N.D.E's from patients. Nonetheless, national nursing standards lack specific guidelines pertaining to training or competencies related to N.D.E's. By evaluating a three-part asynchronous training program, including a pretest and a 1-week delayed posttest using a validated measurement tool (Kandess), the study aimed to clarify whether changes in pretest-posttest occurred. In accordance with Kirkpatrick's Level 2 (learning) evaluation framework, the Kandess instrument assessed changes in knowledge and attitudes concerning N.D.E's. Furthermore, the research and educational modules embodied patient-centered responses to N.D.E disclosures by integrating national nursing standards and principles of caring science, such as presence and kindness. Additionally, these modules served as a professional resource that may alleviate emotional strain.

Theoretically, this study aimed to contribute to the existing body of research concerning training evaluation, particularly in the context of nursing and N.D.E's. First, the application of the Kandess instrument within a nursing setting enhanced the current literature by providing evidence on health care professionals' knowledge and attitudes regarding N.D.E's. Second, the study extended the literature by employing Kirkpatrick and Kirkpatrick's (2006) evaluative framework and by reinforcing theory pertaining to the timing of assessment, learning, and retention. These contributions aimed to provide an empirically grounded model that can be replicated and utilized by others in the assessment of learning outcomes.

In practice, the study has the potential to contribute valuable content for nursing professional development and ongoing education. The documented outcomes derived from this research may offer leaders and nurse educators within health systems opportunities to implement an evidence-based model for onboarding, annual training, or continuous professional development. Each module, ranging from 30 to 40 minutes in duration, can be securely stored behind a system firewall, facilitating implementation across the entire health care system. Well-prepared nurses are likely to be better equipped to tailor their responses to patients in accordance with data-driven insights during disclosure experiences, thereby fostering trust and minimizing harm. This study assessed learning at Kirkpatrick Level 2 and did not imply changes in behavior (Level 3) or patient outcomes (Level 4). The study also aimed to inform subsequent longitudinal research evaluating the transfer of knowledge into practice, patient experiences, or outcomes. Researchers may conduct multisite and mixed-methods studies to assess the reproducibility of the training.

Summary

This chapter provided an overview of the research project and its aims. First, the chapter described the phenomenon of N.D.E's and the rationale for conducting a study to evaluate an N.D.E-specific training program for nurses. Within the literature, individuals across cultures report N.D.E's with commonly described features and long-lasting aftereffects. Patients within hospital settings experience N.D.E's, and how health care professionals respond can influence whether patients feel distressed or can integrate and make meaning of their experience. National nursing standards consider ethical and attentive care to be fundamental principles of the profession; however, at the time of this research, there was no explicit delineation of competencies specific to N.D.E's. This study evaluated a three-part asynchronous training for nurses and assessed changes in knowledge and attitudes using the Kandess as a pretest and a 1-week delayed posttest.

This chapter also delineates supporting theoretical models, with particular emphasis on the Kirkpatrick evaluation framework. The Kandess Knowledge and Attitudes subscales assess learning outcomes at Level 2 of Kirkpatrick's model. These subscales correspond with Bloom's (1956) taxonomy of cognitive and affective domains. Additionally, the chapter encompasses the study's purpose, research questions, hypotheses, key terms, assumptions, limitations, and significance. Chapter 2 will scrutinize the pertinent literature that underpins this research.

The literature review will explore the common characteristics and aftereffects of N.D.E's, traits of individuals who report these experiences, disclosures of N.D.E's along with clinician responses, nursing standards and education, the Kandess instrument, the development and evaluation of training programs, and relevant theoretical frameworks.

Chapter 2: Literature Review

This chapter reviews scholarly literature to establish an evidence-based rationale for assessing a nurse training program focused on N.D.E's. It covers the definition of N.D.E's, their frequency across different times and places, common features, and short-and long-term effects, as well as characteristics of those who experience them. The chapter emphasizes the importance of supporting patients who disclose these experiences and highlights the nurse's role as a caregiver in such situations. It explores nursing education, training, and the profession through national philosophies and frameworks, positioning nurses as key advocates in helping patients post-N.D.E.

This chapter also addresses the lack of specialized training for nurses regarding N.D.E's. Since N.D.E's have been documented and studied as a phenomenon with immediate and lasting impacts, there is a need to deepen the understanding of the care required for these patients and the ways nurses can respond respectfully and empathetically, according to N.D.E researchers and nursing standards. However, many nursing education programs do not include instruction on handling disclosures of N.D.E's.

The study proposed a three-part training program for nurses focusing on core knowledge about N.D.E's and how to support patients during disclosure while minimizing harm. The program's effectiveness was evaluated using Kirkpatrick's Level 2 (learning) model and the Kandess, which tracks changes in knowledge (understanding) and attitudes (perspectives). To avoid score inflation due to immediate recall and to reflect true learning retention, the posttest was administered 1 week after the final module, in line with Ebbinghaus's (1885/1913) forgetting curve. The training aimed to serve as a resource that could help reduce the emotional strain on nurses during intense experiences. This chapter prepares the reader to understand the research methodology, purpose, design, and measurement approaches detailed in Chapter 3. The subsequent section explains the search strategies used to gather relevant research and literature for this study.

Description of Search Strategy

The literature review prioritized recent, peer-reviewed scholarly articles and incorporated foundational or seminal works to ground concepts. The search period spanned from 1975 through 2025 to include original sources. Sources were organized and stored using RefWorks, which was accessed through Liberty University.

Databases and Platforms

Searches were conducted using two primary sources: the Liberty University Jerry

Falwell Library and Google Scholar. Through the Liberty University Jerry Falwell

Library, the following databases and publisher portals were searched: A.P.A

Sike-info/Sike-articles, ProQuest, ebsco, PubMed, medline, Sage Journals,

cinahl, Journal of the American Medical Association, Nursing Education in Video,

Taylor & Francis Online, and Wiley Online Library. Google Scholar was used to locate additional papers not found through Liberty University's systems. Biblical references were identified through BibleGateway and E.S.V Literal Word search in support of the

Biblical Foundations section.

Search Terms and Strings

37

Search alerts for new publications were created using the terms “near-death experience,” “caring science,” “Caritas,” “Jean Watson,” “Industrial/Organizational Psychology,” “Industrial Psychology,” “organizational psychology,” “job demands-resource,” “J D-R,” and “N.D.E.” Search terms used to obtain credible sources from the last 7 years included “near-death experience,” “caring science,” “Caritas,” “Jean Watson,” “Industrial/Organizational Psychology,” “Industrial Psychology,” “organizational psychology,” “job demands-resource,” “J D-R,” “nurs* education,” “nurs* curriculum,” “health care + N.D.E,” “I.A.N.D.S,” “N.D.E training,” “N.D.E education,” “Kirkpatrick model,” “Kirkpatrick levels,” “training evaluation,” and “organizational learning.” Older sources were incorporated to allow the inclusion of theoretical and foundational information. Biblical research was conducted online through BibleGateway and esv dot literalword dot com using the search terms “death,” “compassion,” “soul,” “heal,” and “care.”

Search Filters

Search filters were applied when possible. With the exception of books that act as authoritative sources or defined measures, such as those by Burke (2015),,, Kirkpatrick and Kirkpatrick (2006),,, Moody and Perry (2023), Phillips and Phillips (2016), Stufflebeam and Zhang (2017) and Watson (2018), peer-reviewed articles were the focus of the search. Articles were filtered for those focusing on human populations and written in English.

Other Sources and Personal Communication

In addition to reviewing scholarly journals and databases, the researcher engaged in personal communication with her grandmother, a lifelong student of the Bible, to garner insight into various passages throughout Scripture that would inform the research and biblical interpretation of N.D.E's, nursing and caregiving, and overall faith. Over several months, ongoing discussions guided by divine inspiration were conducted on topics pertinent to this research, such as duty, care, miracles, and light, which contributed to providing coherence and significance to the research. Finally, websites of national nursing organizations were examined to gather information about their standards and frameworks. The websites of the A.N.A, A.C.E.N, A.A.C.N, and the National Council of State Boards of Nursing, Inc. (N.C.S.B.N) were reviewed for official documents related to nursing education and standard practices for registered nurses (R.N's).

Screening Process

Titles and abstracts of the selected articles were reviewed first, and then the full texts were read for relevant information. Reference lists were used, and sources were organized in RefWorks. Search alerts were set up in Google Scholar to notify the researcher if new information was published on the topics of N.D.E's, training evaluation, industrial-organizational psychology, Kirkpatrick framework, and job demand-resources. The literature review focuses on studies published between 2018 and 2025. Foundational or seminal works in N.D.E research and industrial-organizational psychology were also included. Priority was given to studies with larger sample sizes and papers that used validated tools. The following section reviews the literature identified from the search methods listed previously.

Review of Literature

Recent interest in N.D.E's began approximately five decades ago, with the research conducted by Moody (1975) representing the inaugural comprehensive investigation into N.D.E's. Contemporary scholarship continues to investigate methodologies to understand and delineate the complex array of factors constituting N.D.E's. At present, there is no singular, universally acknowledged definition of N.D.E's; however, an expanding body of scholarly literature endeavors to describe, classify, and conceptualize N.D.E's. An analysis of existing research has facilitated the identification of common themes among the reported characteristics.

Variations in the definitions of N.D.E's among researchers may be attributed to the complex phenomenology and the broad spectrum of subjective experiences associated with these events., who coined the term “near-death experiences,” characterized the phenomenon as a collection of features consistently reported by individuals facing impending death. Ring (1982) believed the phenomenon to have five core elements, which are reflected in his Weighted Core Experience Index: peace, separation from the body, a region of darkness, brilliant light, and moving through light to another realm. Later, Greyson (1983) developed the N.D.E Scale, which contains 16 items representing recurring features, including O.B.E's, tunnels, light, and meetings with spiritual or other beings. Craffert (2019) asserted that Greyson's N.D.E Scale can be employed to define the concept and can determine when an N.D.E has occurred.

Researchers such as van concurred, defining N.D.E's as a series of events that take place during a death-like situation:

A near-death experience (N.D.E) can be defined as the reported memory of a range of impressions during a special state of consciousness, including several unique elements such as an out-of-body experience, pleasant feelings, seeing a tunnel, a light, deceased relatives, or a life review, and a conscious return into the body. Many circumstances are described during which N.D.E's are reported, such as cardiac arrest (clinical death), shock after loss of blood (childbirth), coma caused by traumatic brain injury or stroke, near-drowning (children) or asphyxia; also in serious diseases not immediately life-threatening, during isolation, depression or meditation, or without any obvious reason. (p. 126)

Other scholars, such as Mays and Mays (2024), favor definitions that focus more heavily on consciousness itself, describing N.D.E's as instances in which a person's consciousness separates from their physical body, whereas Lindsay et al. (2023) explained them as anomalous experiences of consciousness that occur when a person faces imminent death. One researcher,, has conducted similar research on recalled death experiences. These experiences are broader than the general definition of N.D.E, as they encompass any conscious recollection of events during biological death. Parnia et al. (2022) further specified that a recalled death experience should comprise six elements:

(1) a relation with death, (2) a sense of transcendence, (3) ineffability, (4) positive transformative effects (related to meaning and purpose to life), and a (5) severity of illness that leads to loss of consciousness, together with (6) absence of features of other coma related experiences (such as conventional dreams, delirium, and delusions, in the I.C.U or elsewhere). (p. 7)

For this study, Greyson's (2023b) unifying definition was used. Greyson (2023b) interviewed 100 N.D.E researchers and 100 N.D.E-ers to develop a conceptual model that could be widely accepted by scholars and researchers. The definition emphasizes both physical and nonphysical aspects, integrating the natural and supernatural realms.

Near-death experiences are events that occur when people are close to death, typically characterized by transcendent or mystical features, out-of-body experiences, exceptional lucidity, and unusually strong emotions. They generally have profound aftereffects, such as decreasing one's fear of death, enhancing one's spirituality, and radically shifting one's worldview.

This research does not provide an analysis of the meaning and nature of N.D.E's, their causes, or whether they are purely physical and natural or supernatural in origin. Instead, the focus of this study is on the perspectives of individuals who have experienced N.D.E's and those regarded as trusted confidants to whom these experiences are disclosed. For nurses who serve as confidants, this study aimed to identify whether there is a change in knowledge regarding identifiable features and aftereffects of N.D.E's and attitudes toward the phenomenon and those who experience it after education on the topic (Charland-

Verville et al., Greyson, Martial et al., Therefore, this study used a structured, evidence-based training program and a validated instrument, the Kandess, to measure specific knowledge and attitudes toward N.D.E's ( Loseu & Holden, Pace et al., 2016). The present study was founded on the premise that these phenomena occur continually and ubiquitously.

Prevalence of N.D.E's

Several studies have investigated the incidence of N.D.E's, both in the general population and within specific groups, revealing that between 6.3% and 39.3% of individuals who have survived near-death events reported experiencing N.D.E's. For instance, Kovoor et al. (2024) examined patients who had suffered cardiac arrest and found that up to 39.3% of these individuals reported N.D.E's. Similarly, Parnia et al. (2023) observed that 21.4% of cardiac arrest survivors within a hospital environment reported N.D.E-like phenomena, which they referred to as recalled experiences of death. Earlier, Parnia et al. (2001) found that 6.3% of cardiac patients met the criteria for N.D.E., through crowdsourcing methods, identified that approximately 10% of individuals who have survived death report an N.D.E. Raffaelli et al. (2023) reported that N.D.E's occur in 11.4% of migraine patients with R.E.M sleep intrusions, whereas Rousseau et al. (2023) found that 15% of patients experiencing prolonged illness in an intensive care unit (I.C.U) reported N.D.E's., in their research aiming to validate N.D.E Scale, reported that between 4% and 8% of the general population and between 10% and 23% of cardiac arrest survivors report N.D.E's. In the present study, the prevalence data concerning reports of N.D.E's provided a contextual foundation for examining nurses' knowledge and attitudes toward N.D.E's following specialized nurse training on the subject, acknowledging that nurses constitute the largest segment of the health care workforce. Nurses may encounter individuals from diverse backgrounds and cultures, and it is essential for them to recognize that such phenomena have historically occurred worldwide.

N.D.E's Throughout Culture, Geography, and Time

Cultures, ranging from American modern society to Middle Eastern and African civilizations, have documented their accounts of what may now be classified as an N.D.E. This phenomenon is widespread and transcends cultural, geographical, and religious boundaries. Through meticulous examination of individual reports from 1980 to 2022, researchers have identified common themes within the narratives of experiencers, maintaining culture and language as constant variables. Nevertheless, despite the identification of distinct themes across numerous N.D.E accounts, there is no standardized experience; no two N.D.E's are identical.

When N.D.E-ers describe their experiences, it becomes evident that there are filters through which the experiencer recalls the event; individual and societal influences are apparent. While certain universal features are often present during an N.D.E, there is variation in their specific structure, order, and meaning for the individual. Reports occur in many populations, even from those who were blind from birth. Ring and Cooper (1997) documented in their research the remarkable accounts of accurate visual reports provided by blind individuals, who described in detail their resuscitation. N.D.E's are not only reported by adults; there are also childhood N.D.E accounts. While children often describe their N.D.E's in simpler terms, there are consistent themes found within adult and childhood N.D.E's, including O.B.E's, visits to different realms, a sense of peacefulness, and time distortion. These characteristics are part of a suite of consistent features reliably found within N.D.E's. Because N.D.E's are common across cultures and among people, nurses may encounter N.D.E disclosures from diverse patient populations and must be prepared to respond ethically and empathetically. Gaining an understanding of the most commonly reported features of N.D.E's and the characteristics of individuals in whom they occur is also pertinent to nursing.

Common Features and Characteristics of N.D.E's

Although no two N.D.E's are exactly identical, certain features frequently reported by individuals who have undergone such experiences are consistently documented in the scholarly literature. Cassol et al. (2018) observed that an individual's N.D.E may encompass some or all of the established core characteristics, as this phenomenon lacks uniformity. One feature of N.D.E's that is consistently corroborated across various studies is the sense of ineffability. Accordingly, experiencers often begin their narratives with the preface that words cannot adequately capture their experiences, asserting that what transpired transcends the capabilities of the English language and cannot be adequately expressed through human words. Nonetheless, these individuals rely solely on their communicative abilities and personal experiences to articulate these extraordinary events.

The following description approximates an N.D.E. Initially, the individual perceives an unusual phenomenon; they may find themselves observing from an elevated vantage point, focusing on what appears to be a physical body, and gradually recognizing that it is their own body. This realization can be disorienting, as they later acknowledge experiencing an out-of-body state. They are capable of observing and subsequently describing with accuracy what transpires to themselves, their environment, and the individuals in their vicinity. While they may still be endeavoring to comprehend the occurrence fully, they begin to traverse space and time in a manner often described as omnipresent; some individuals report arriving instantaneously to witness their loved ones engaged in everyday activities such as laundry, driving, or other current activities, while contemplating them. The event's lack of temporal constraints may create the impression that all happenings occur simultaneously; however, an element of deliberation and slowness is retained. At a certain stage, the individual might observe a light, possibly situated at the end of a tunnel or within a cave, and feel an inexplicable attraction toward it. This light surpasses earthly illumination; it is luminous, radiant, and extraordinarily bright, yet does not cause harm to the eyes. Numerous experiencers interpret this light as embodying unconditional love and serenity, often enveloping themselves within it; the experience is frequently associated with a benevolent spirit, such as Jesus Christ or deceased relatives.

Approximately 25% of individuals who experience N.D.E's undergo a comprehensive life review. During this phase, individuals may perceive, within the framework of unconditional love, their life, actions, influence on the world, and relationships with others, thereby attributing meaning and purpose to their experiences. They are capable of viewing their existence from the perspectives of others, thereby gaining insight through the viewpoints of those with whom they have interacted. This process is often accompanied by an overwhelming sense of love, deeply rooted in the pursuit of understanding. Moody and Perry (2023) suggest that this transformative and loving energy has the capacity to fundamentally reshape an individual once they have fully emerged from an N.D.E.

The individual may encounter a boundary or limit during an N.D.E, manifesting in various forms such as a partition, a cliff, or a distant locale. This signifies a point of no return; the individual comprehends, through implication, that they cannot proceed beyond this threshold and return to their physical form. The experiencer is either advised to return or has the option to do so. In either case, they are required to reenter their physical bodies, a process described as “hard work”.

The gold-standard measurement instrument for N.D.E's is N.D.E Scale, developed through a systematic review of N.D.E reports. Cassol et al. (2018) conducted thematic analyses of N.D.E's, confirming the overall characteristics of such experiences, including light phenomena, encounters with beings, hyperlucidity, out-of-body experiences, and an altered perception of time, among others. Subsequently, Martial et al. (2020) expanded upon instrument by incorporating additional core elements to develop the Near-Death Experience Content Scale, and most recently, Greyson et al. (2025) developed a veridical N.D.E scale. This literature review examines 16-item tool across the cognitive, affective, paranormal, and transcendental categories in the context of research published since 2020. Researchers classify an experience as an N.D.E when it includes at least 4 of the 16 features. Table 1 delineates these components and features.

Table 1 summary: Components and features of near-death experiences as documented in research between 2020 and 2025. The experience is categorized into five main components. Affective components include bright or white light and overwhelming emotions of love and peace. Paranormal components encompass out-of-body experiences, heightened senses, boundaries or edges, hyperreality, and the absence of pain. Transcendental components include meeting beings and loved ones, tunnels or passageways, a sense of oneness, other realms, ineffability, and a desire to remain in the realm. Finally, cognitive components involve life reviews and altered perceptions of time and space.

Cognitive: Time, Flashes of Insight, Life Reviews

This section first examines the cognitive component, which encompasses time distortion, flashes of insight, and panoramic life reviews. Mays and Mays (2024) emphasized that N.D.E-ers depict their experiences as occurring outside of time, with no clearly defined beginning or end. Moreover, Greyson's (2023b) attempt to construct a framework identified as a sense of transcending both time and space, often including altered perceptions of the passage of time and space as the most frequently reported features of N.D.E's. His research further details life reviews, panoramic memories, and visions of the future, reported by approximately 8% of experiencers, with 31% noting exceptional lucidity. Sameera et al. (2025) found that among kidney patients undergoing dialysis, 58.62% experienced time distortion, 41.37% perceived sudden insight or understanding, and 48.27% recalled past events as part of their N.D.E's. Through text mining techniques, Charland-Verville et al. (2020) discovered that the concept of time was mentioned in 45% of the accounts examined. Hashemi et al. (2023) observed that reports of life reviews and variations in perceptions of time are common, whereas Parnia et al. (2023) described experiences involving movements through time and space.

Affective: Emotions, Bright Light

The affective component of N.D.E's describes the emotional content inherent in such experiences, encompassing sensations of profound peace and love, frequently augmented by the presence of a luminous light. Greyson's (2023b) research indicates that individuals who have experienced N.D.E's report experiencing potent and intense positive emotions, such as unconditional love, approximately 34% of the time, and perceiving a luminous, living light approximately 23% of the time. In his work, experiencers described a “love bath that you keep with you upon return, never to be forgotten”. Sameera et al. (2025) found that 51.72% of N.D.E's experienced brilliant light, 44.82% experienced harmony and oneness, 31.03% felt joy, and 37.93% felt peace. Hashemi et al. (2023) documented feelings of love, peace, bliss, and pleasantness, as well as seeing a bright light, as common features of N.D.E's. Charland-Verville et al. (2020) found through their analysis that the word “white” was mentioned 35% of the time and most commonly paired with “life”; “love” was mentioned 30% of the time, most frequently clustered with the word “felt”; and “light” was the most commonly used word, appearing in 67% of accounts, mostly paired with “see” in their text analysis of accounts. Parnia et al. (2023) found that individuals undergoing events with N.D.E-like features often reported encounters with light.

Paranormal: Senses, Extra Sensory Perceptions, Physical Separation from the Body

The paranormal component of N.D.E's describes the individuals' sensory perceptions, including sensations of physical separation from the body and extrasensory perception. Greyson (2023b) reported that 7% of those who have experienced N.D.E's report no pain, 39% describe out-of-body experiences, and 10% report a sensation of hyperreality. The sensation of hyperreality, or the experience of feeling “real than real,” was the second most common feature of N.D.E's in Greyson's (2023b) development of an N.D.E framework (p. 181). Mays and Mays (2024) support these findings, noting that experiencers often describe feeling highly lucid and experiencing intense sensory enhancement. Sameera et al. (2025) discovered that 41.37% of experiencers reported heightened vividness of senses during the N.D.E, 48.27% reported extrasensory perception (though unverified), and 48.27% reported separation from their bodies. Charland-Verville et al. (2020) observed that sensations were mentioned in 28%

of accounts, while noted that heightened senses are a common feature of N.D.E's. Mays and Mays (2024) confirmed that during these experiences, individuals' consciousness appears to detach from their physical bodies.

Transcendental: Unearthly Realms, Mystical, Deceased and Religious Figures, Limit

The transcendental component of N.D.E's encompasses phenomena such as visiting other realms, witnessing or encountering deceased or mystical beings, and experiencing perceptual boundaries. Greyson (2023b) reported that 23% of individuals who experienced N.D.E's encountered other beings; 4% expressed a desire to remain in other realms; 16% experienced a sense of unity; 5% reported engagement with a tunnel or passage; and 7% described experiencing ineffability. Mays and Mays (2024) confirmed the occurrence of ineffable experiences, emphasizing that no language can fully capture such phenomena.

Sameera et al. (2025) found that 41.37% of N.D.E's described entering other worlds; 31.03% encountered mystical beings; 34.48% reported reaching a boundary; and 34.48% sensed the presence of deceased loved ones or religious figures. Shushan (2024) verified historical accounts that documented tunnels, encounters with deceased beings, and perceptual boundaries. Charland-Verville et al. (2020) identified the term “tunnel” in 35% of reports. Parnia et al. (2023) identified a recurring motif of boundaries or peripheries among cardiac patients.

Hashemi et al. (2023) observed that encounters with beings and entities, as well as sensations of unity or oneness, were prevalent elements. Sterz et al. (2023) reported that experiencers encountered departed relatives and were drawn into a vividly colored tunnel. Zingmark and Granberg-Axell (2022) found that experiencers perceived themselves as existing in an alternate dimension. devoid of their physical bodies. Royse (2021) documented encounters with angels, feelings of profound peace, and an overwhelming sense of unconditional love.

Sequence of Common Features in N.D.E's

The sequence in which the common N.D.E features listed in Table 1 occur has also been the focus of study. Charland-Verville et al. (2020) observed that N.D.E's frequently present groups of features that manifest in a specific order. For instance, out-of-body experiences tend to occur prior to the individual progressing through a tunnel, and encounters or reunions with entities seem to take place subsequent to passing through such a tunnel. Parnia et al. (2023) found that cardiac patients recall O.B.E's immediately following cardiac arrest, implying that these phenomena occur early in the sequence of N.D.E's. Hashemi et al. (2023) reported that, in their research, life reviews and boundary perceptions generally follow tunnel or light experiences; however, Shushan (2024) suggested that life reviews and boundary perceptions are not universally experienced. Martial et al. (2020) discovered that although features tend to occur in a sequence, there is not invariably a linear progression that can be anticipated. Patients may undergo some or all of these common phenomena, and therefore, the descriptions and information pertaining to them constitute a segment of the N.D.E training content within the present study. Moreover, they underscore the items evaluated by the Kandess.

Distressing N.D.E's

While the majority of N.D.E-ers report positive qualities such as peace and joy, a minority of cases involve individuals experiencing distressing N.D.E's ( Cassol et al., Greyson, Such distressing N.D.E's may encompass phenomena such as fear, feelings of emptiness, or encounters with beings that are not of light, which can be perceived as threatening or frightening. Although extensive research has concentrated on the positive aspects and implications of N.D.E's, scholarly investigations have also addressed the occurrence and nature of distressing experiences, noting differences in emotional content and themes compared to positive N.D.E's. Notably, two studies have approached N.D.E's differently: Cassol et al. (2019) conducted a systematic review of distressing N.D.E's, while Greyson (2023a) reviewed the existing literature concerning unpleasant N.D.E's and their implications.

The proportion of N.D.E's reporting distressing N.D.E's varies depending on the methodology employed in studies and the population examined. The prevalence ranges from 10% to 22%, contingent upon the population, definitions, and measurement techniques used. Cassol et al. (2019) reported that 14% of their participants described elements characteristic of distressing N.D.E's. While males and females report distressing N.D.E's at similar rates, survivors of suicide exhibit a higher incidence of distressing N.D.E's compared to pleasurable N.D.E's. These findings are corroborated by Kondziella et al. (2019) and Greyson (2023a), whose analyses indicated that between 10% and 22% of N.D.E's contained distressing elements. Distressing N.D.E's are not an anomaly but constitute a distinct category within N.D.E's.

Greyson and Evans Bush, in their seminal research on distressing N.D.E's, identified three categories of these N.D.E's: inverse, void, and hellish (Bush & Greyson, 2014; Greyson & Evans Bush, 1992). The inverse N.D.E occurs when the individual has a negative reaction to what might otherwise be perceived as a typical N.D.E, which others could interpret as positive. Nevertheless, for the individual experiencing it, the event is undesirable, adverse, or frightening. The void N.D.E is characterized by emptiness, an experience of being drawn into a void, or a sense of vastness and isolation. The hellish N.D.E encompasses torment, torture, vivid imagery, or threats and may include encounters with entities. Cassol et al. (2019) expanded upon the findings of Greyson and Evans Bush (1992), demonstrating that hellish N.D.E's frequently exhibit a structure akin to positive experiences, such as O.B.E's and distortions of time, although feelings of fear and dread often accompany them. More recent research corroborates that such experiences generally lack a sense of peace, are often characterized by an underlying tone of confusion and hostility, and may involve a perception of chaos and fear. Martial et al. (2020) suggested that although the work of Bush and Greyson (2014) and Greyson and Evans Bush (1992) is significant, it remains incomplete, and further classifications should be established beyond the categories of void, hellish, and inverse.

While further research may provide additional clarity on distressing N.D.E's,

Greyson (2023a) and Charland-Verville et al. (2020) stated that because of stigma or fear of judgment or of retriggering traumatic feelings, people can be reluctant to disclose distressing N.D.E's. This lack of education and gap in knowledge make it difficult to gather more data and provide support for individuals experiencing distressing N.D.E's. Even so, the data reveal identifiable themes in distressing N.D.E's similar to those found in positive

N.D.E's. A subset of patients may report fear, void, or even hellish themes and may be more vulnerable after the experience. To support patients through these experiences, this study focused on training that includes listening and nonjudgment.

Overall, the positive N.D.E's documented in research, despite some variation, share common features. Reported phenomena include separation from the body, heightened awareness during unconsciousness, encounters with bright light, interactions with beings, a sense of peace, alterations in the perception of time and space, a comprehensive review of one's life, a perception of a boundary or point of no return, as well as encounters with deceased relatives or spiritual entities. Table 1 presents the core features most frequently described in recent literature.

Aftereffects of N.D.E's

After an N.D.E, individuals frequently encounter both short-term and long-term effects, commonly referred to as aftereffects. These aftereffects have been extensively examined alongside the typical characteristics of N.D.E's and can be systematically categorized into domains that encompass frequently reported phenomena. The systematic review by Miquel-Sendra and García- corroborated evidence that both positive and distressing N.D.E's significantly affect individuals' lives. Long and Woollacott (2024) conducted the most comprehensive investigation of aftereffects to date, analyzing 834 N.D.E's and 42 accounts of life-threatening events without associated N.D.E's. Their findings indicate that, in comparison to individuals who did not experience an N.D.E, those who did exhibit notable and persistent shifts in values, including a diminished or absent fear of death, a belief in God and an afterlife, heightened compassion, increased perceived meaning in life, and enhanced spirituality. These results align with Greyson's longitudinal study, which assessed participants using the Life Changes Inventory at two intervals separated by 20 years, in order to determine the persistence of aftereffects over time. Greyson's research revealed that, overall, attitudes remained relatively stable, with observed increases in appreciation of life, empathy, and pursuit of meaning, alongside decreases in materialism, achievement orientation, and religiosity.

Moreover, the study demonstrated that not only did personal changes endure, but memories of the N.D.E remained vivid, often as clear as the initial experience. Importantly, feelings of peace and the recollections of encounters with light do not diminish with the passage of time., in their investigation into recalled experiences of death, found that positive transformations engendered by N.D.E's are enduring. Numerous researchers have echoed this sentiment over the past 50 years. Although earlier frameworks classified various domains of aftereffects, this paper will primarily adopt the most recent findings provided by Long and Woollacott (2024) as the guiding framework.

Reduction in Fear of Death

Miquel-Sendra and García- demonstrated in their review that individuals experiencing positive N.D.E's exhibited a diminished fear of death. Long and Woollacott (2024) reported a statistically significant increase, from 13% to 77%, in the proportion of individuals who did not fear death following an N.D.E. Greyson (2022) observed that an increased appreciation of death was a consistent phenomenon over time.

Parnia et al. (2022) documented a loss of fear of death subsequent to recalled death experiences. Bianco et al. (2024) corroborated this finding through their research on death anxiety post-N.D.E, revealing a negative correlation between fear of death and scores on the N.D.E Scale. Their results indicated that individuals who experienced N.D.E's perceived death more as a transformation rather than an extinction.

Spiritual and Religious Changes

Research indicates that increased spirituality is prevalent among individuals who experience positive N.D.E's, as evidenced in the review conducted by Miquel-Sendra and García-. In the study by Long and Woollacott (2024), participants exhibited a significant increase in belief in God, rising from 37% to 72%, and in their belief in the afterlife, increasing from 25% to 84%. The narrative accounts revealed that participants perceived their encounters with divinity as authentic and personal, with some describing a feeling of “true home”. Lindsay and Tassell-Matamua (2021) observed in their mixed-method analysis that following an N.D.E, 83% of individuals demonstrated a statistically significant strengthening of their belief in the afterlife, a correlation seemingly related to the intensity of their N.D.E's. Parnia et al. (2022) reported that N.D.E's indicated enhanced morals and ethics and a sense of serving a higher purpose after their experiences., utilizing the Life Changes Inventory, documented increases in spirituality scores following an N.D.E that persisted over two decades. Conversely, one study challenged these assertions; identified that some N.D.E's did not report changes in their spirituality despite experiencing shifts in their values.

Increases in Empathy and Compassion

Miquel-Sendra and García- identified increases in compassion and altruism among N.D.E's with positive experiences. Long and Woollacott (2024) observed that compassion levels tripled following N.D.E's, whereas Greyson (2022) reported that heightened concern for others persisted for over two decades in experiencers. In the study by Parnia et al. (2022), participants who survived death reported having greater compassion, empathy, and mindfulness toward others, as well as increased ease in acting from a position of love. Bianco et al. (2024) demonstrated that N.D.E's exhibited greater empathy and acceptance of others, while Brook (2021) documented increased acts of compassion, such as volunteerism. Jahromi (2021) discovered that, for some individuals, following an N.D.E, interpersonal interactions became more fluid, facilitating love and assistance with greater empathy.

Reduction in Materialism

Miquel-Sendra and García- observed a shift in values, noted a reduction in materialism and an increase in service among people with positive N.D.E's. Participants in Long and Woollacott's (2024) research described a reduction in interest in worldly status symbols, such as wealth, property, possessions, and materialism, and instead chose to focus on the beauty of people and experiences in their lives. Greyson (2022) found the same, noting that higher N.D.E Scale scores were associated with lower achievement concern over time. Bianco et al. (2024) found N.D.E's were less committed to social status or material advances, while Seifu et al. (2024) found a shift from prestige and extrinsic goals toward intrinsic aims after an N.D.E. Jahromi (2021) also observed this change, noting in his qualitative study a shift from materialism toward service. In Parnia et al.'s work, they discussed the reevaluation of priorities for many participants, describing a movement away from worldly interests. The respondents viewed life's struggles as important and saw the blessing within suffering.

Increases in Meaning and Purpose

In their review, Miquel-Sendra and García- found that individuals with positive N.D.E's reported greater appreciation for life, more purpose, and greater meaning. Long and Woollacott (2024) showed that individuals' belief in a meaningful life nearly tripled from 27% to 78% after an N.D.E. Greyson (2022) confirmed this finding with his research showing that over time, experiencers' pursuit of meaning and purpose remained consistent after an N.D.E. Parnia et al. (2022) noted that a central outcome following a recalled death experience is an increased interest in a life with more meaning and purpose. Seifu et al. (2024) observed a renewed sense of direction and meaning of life in participants. King (2023) noted that even in individuals who had attempted suicide, there was a desire to live life and enjoy their existence with an increased sense of self-worth.

Other Observations

Alvarez and D'León identified a negative correlation between high posttraumatic stress disorder scores and post-N.D.E optimism; specifically, following an N.D.E, increased optimism is associated with reduced P.T.S.D. Additionally, they observed physiological changes and spiritual sensitivity, consistent with findings by Miquel-Sendra and García-, who also reported healing abilities and visionary experiences among N.D.E-ers. Greyson (2023b) reported that enduring N.D.E features, such as life reviews and the sensation of being immersed in unconditional love, may enhance the quality of life for individuals who experience them. Nevertheless, not all aftereffects are regarded as positive.

Jahromi (2021) observed that some experiencers feel sadness and upset upon returning to Earth after being in such a pleasurable and peaceful place. Sometimes, this sadness and longing to return to the feeling and experience of the N.D.E can increase the risk of suicidal ideation, as King (2023) observed. Conversely, King (2023) found that a renewed sense of purpose can occur after failed suicide attempts, reducing ideation, noting that the research on suicide is sparse as it relates to N.D.E's. revealed that some N.D.E's find integrating back into their lives difficult, often because their existing relationships and careers do not align with their new identities and values.

Distressing N.D.E Aftereffects

When individuals experience distressing N.D.E's, they, too, have aftereffects, but these aftereffects frequently possess a different quality. Miquel-Sendra and García- discovered through their review that symptoms such as anxiety, depression, anger, and confusion can manifest following distressing N.D.E's. Greyson (2022) observed that individuals who had distressing N.D.E's scored lower on the Life Changes Inventory, indicating smaller improvements and fewer positive long-term outcomes compared to those who had pleasant N.D.E's. Both distressing and positive N.D.E's are characterized by vivid imagery, clarity, significant detail, and heightened sensory experiences. Such vivid recall may complicate the integration of the experience, leading to intrusive thoughts and memories, P.T.S.D, anxiety, and depression. Moreover, these challenging aftereffects may result in social distancing, estrangement, or conflict.

. Individuals may interpret the event as a warning necessitating life changes; conversely, some may dismiss the experience altogether to minimize its impact, while others may grapple with finding meaning, potentially leading to an existential crisis. Due to these factors, or out of fear of judgment and stigma, many experiencers opt not to disclose their experiences, suppressing and avoiding making sense of them completely, limiting their capacity to fully integrate the experience. Nonetheless, Long and Woollacott (2024) found that distressing N.D.E's can, in certain cases, inspire personal growth, with some survivors describing them as transformative or pivotal moments in their lives. Enduring effects, such as shifts in personal values, can influence how individuals interpret their lives and the support and care they require beyond hospital discharge. These documented aftereffects align with the domains and features of the Kandess framework, which underpin the content addressed in the N.D.E training for nurses in this study.

Mental Illness, Spiritual Emergencies, and N.D.E's

Evidence indicates that N.D.E's are generally beneficial, are associated with positive transformations, and are neither hallucinations nor linked to underlying psychopathological conditions. This aligns with the Knowledge and Attitudes subscales of the Kandess, used in this study to evaluate nurses' understanding of N.D.E's and N.D.E-ers, as well as their perceptions regarding disclosure experiences within clinical settings. Ongoing research continues to support the view that N.D.E's constitute a measurable, structured set of transformative features that are typically lucid, thereby differentiating them from mental illness, dreams, or hallucinations. N.D.E's are unique in their presentation, often occurring during medical emergencies as isolated events in individuals without prior mental health conditions, and leaving the experiencer with the capacity to recall in great detail the hyperreal situations and value shifts that remain stable for decades. Greyson (2003b) found that the prevalence of N.D.E's was similar among psychiatric and non-psychiatric patients, confirming that N.D.E's do not occur more frequently in individuals with mental illness. Nevertheless, the experience can induce spiritual distress in some individuals, a phenomenon recognized in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (fifth edition), which includes a specific code for “Religious or Spiritual Problems”. This differentiation between spiritual and mental distress can assist health care professionals and patients in understanding and integrating the experience. Health care professionals often disregard, misunderstand, and misdiagnose N.D.E's, partly due to insufficient education or knowledge regarding the phenomenon.

Table 2 summary: Common aftereffects from near-death experiences and their supporting sources. Positive psychological and spiritual shifts are widely documented, including increased empathy, compassion, and a greater sense of meaning and purpose in life, as well as a reduction in competitiveness, materialism, and fear of death. Other reported effects include lasting clarity and vivid recall of the event for decades, spiritual and religious changes, and changes in abilities or sensitivity. Some individuals experience challenges, such as difficulty integrating into daily life or a longing for another realm, while distressing near-death experiences are associated with anxiety, depression, and PTSD.

Support Needs for N.D.E-ers

Following their return to their physical form and the regaining of consciousness, which is often accompanied by shock and intense emotions, an individual may opt to share their experience. This choice can challenge N.D.E-ers, as they are faced with fear of rejection, misdiagnosis, or possible derision from other people. Fear due to listeners' inattentiveness, skepticism, and labeling tends to encourage N.D.E's to keep their experiences private. Even with these challenges, about 33% of N.D.E disclosures happen within a day of the event. Although extensive research on N.D.E's has been conducted since 1975, there remains a lack of education for health care. professionals on the characteristics and subsequent effects of N.D.E's, as well as on available resources to assist patients in integrating their experiences healthfully.

Because many N.D.E's consider the event one of the most spiritually meaningful of their lives, it is worth considering the individual's needs for support after their N.D.E. Samoilo and Corcoran (2020) argued that every health care professional should be trained in evidence-based research that highlights common features and aftereffects of N.D.E's, the impact on patients and their loved ones, and the patients' need for genuine listening, resources, and education. Globally, R.N's constitute the largest group of health care workers. Compared to other areas, nursing experienced the largest increase in job additions among health care workers between June and August 2025. Nationally, the number of nurses in health care grew between 2012 and 2022, both in hospitals and physicians' offices, offering more opportunities for nurses to engage with patients. As the largest professional group dedicated to patient support, nurses possess a significant opportunity to cultivate an environment where patients feel at ease sharing their narratives. Researchers emphasize the importance of providing psychological safety, as patients often request that health care professionals listen attentively and without judgment. In their investigation identifying deficiencies in care concerning N.D.E disclosures, Samoilo and Corcoran (2020) proposed that establishing a standard operating procedure for patient care following N.D.E's could assist in bridging this care gap.

Pehlivanova et al. (2025) endorse this proposal who examined the support needs of patients after N.D.E's and confirmed the necessity for developing interventions aimed at enhancing the quality of care for individuals experiencing N.D.E's. They proposed that validation, community and professional support, the capacity to share and disclose their experiences, as well as connections with support groups and organizations, are vital components of a personalized approach to facilitating patients' integration and comprehension of their experiences. Zingmark and Granberg-Axell (2022) concurred with Samoilo and Corcoran (2020) that health care institutions should provide education for health care professionals to improve their understanding of N.D.E's and their capacity to respond appropriately to patients and their families following such events. Loseu and Holden (2017) indicated that increased knowledge among health care providers regarding N.D.E's may reduce the likelihood of rejection, minimization, or pathologization of these experiences. When initial responders to patients have access to appropriate resources, the risk of harm can be minimized, and the integration process can be facilitated more effectively.

In a comprehensive investigation examining patient disclosures of N.D.E's, Holden et al. (2014) determined that negative disclosure experiences may adversely affect N.D.E experiencers; specifically, 19% of patients' disclosures were classified as negative or detrimental. Considering the ethical standards that many health care professionals are required to uphold, this underscores the necessity for health care providers to acquire adequate knowledge to respond appropriately. Furthermore,, Samoilo and Corcoran (2020), and identified that N.D.E's often exhibit reluctance to share their experiences due to fears of rejection and minimization, or because of health care providers' minimizing attitude toward their experiences. Holden et al. (2014) found the initial disclosure attempt particularly significant because it influenced whether patients would share their experiences again. Holden et al. (2014) proposed that training health care professionals in responsive validation could enhance the integration of N.D.E's into patient care. These findings, together with the research conducted by Loseu and Holden (2017) involving mental health care professionals, establish a foundation for evaluating nurse-specific N.D.E training within the scope of the present study.

Loseu and Holden (2017) expanded upon previous research examining health care professionals, specifically measuring counselors' knowledge and attitudes regarding N.D.E's following online training. Utilizing the Kandess, they developed an online training intervention aimed at evaluating counselors' understanding and perspectives on N.D.E's, and observed significant positive enhancements in both subscales. They concluded that a three-part intervention comprising asynchronous modules, including a documentary video illustrating real-world examples, a PowerPoint presentation on features, aftereffects, and prevalence, as well as a narrated PowerPoint on how to avoid harm during disclosures, was effective in equipping counselors with the requisite information to improve Kandess scores. The modules designed by Loseu and Holden (2017) served as the basis for developing an N.D.E training program for nurses in this research.

Practical Training With Bloom's Taxonomy

A learning framework, known as Bloom's taxonomy and developed by Bloom

(1956) with revisions by Anderson and Krathwohl (2000), offers a standardized methodology and terminology for establishing an educational protocol that delineates clear and systematic objectives for learners. Bloom's taxonomy has been extensively employed in the formulation of curricula across diverse disciplines, including information technology, social studies, project management, science, and health care. Jia and Balinas (2024), in their investigation of psychiatric nursing education, acknowledged that the framework supplies a well-defined and precise structure for formulating educational aims. Bloom aimed to establish a shared vocabulary, harmonize educational objectives, activities, and assessment methods, and provide a comprehensive landscape of educational opportunities. The taxonomy delineates three categories of educational objectives: cognitive, affective, and psychomotor. Bloom's taxonomy uses verbs to articulate observable actions indicative of respective levels of understanding or competence. As demonstrated in Table 3, the cognitive domain signifies a hierarchy of cognitive outcomes, such as recall and recognition of information; the affective domain encompasses attitudes, interests, and values; and the psychomotor domain pertains to physical senses and actions. This study primarily focused on two domains of Bloom's taxonomy: cognitive and affective, as assessed through the outcomes of knowledge and attitudes in the Kandess.

Table 3 summary: Revised Bloom's Taxonomy, adapted into two domains. The Cognitive domain consists of six hierarchical levels: Remember, which involves retrieving knowledge; Understand, which focuses on determining meaning; Apply, which involves carrying out procedures; Analyze, which is breaking material into constituent parts; Evaluate, which is making judgments; and Create, which is forming a novel whole. The Affective domain includes five levels: Receive, focusing on willingness and attention; Reflect, paying attention to concepts; Form values, developing emotional responses; Organize value system, integrating values; and Personalize value system, where values are incorporated into life and behavior. Each level is associated with specific additional verbs, such as recognize and recall for Remember, or behave and perform for Personalize value system.

Krathwohl, 2002, Theory into Practice, 41(4), p. 215; “Teaching Strategies in Psychiatric Nursing Based on Bloom's Taxonomy of Educational Objectives,” by Z. Jia and J. M. Balinas, 2024, Cureus 16(4), Article e57759; and “Development of Clinical Competence in Nursing in Simulation: The Perspective of Bloom's Taxonomy,” by Juliana da Silva Garcia Nascimento, Tainá Vilhar Siqueira, Jordana Luiza Gouvêa de Oliveira, Mateus Goulart Alves, Daniela da Silva Garcia Regino, and Maria Celia Barcellos Dalri, 2021,

Revista Brasileira de Enfermagem 74(1), p. 5.

Cognitive Domain

The cognitive domain within Bloom's taxonomy comprises six hierarchical levels of skills, progressing from lower-order skills such as basic recall to higher-order skills that entail greater complexity and necessitate advanced learning, evaluation, or creation. The revised hierarchical levels of the cognitive domain, as articulated by Anderson and Krathwohl (2000), include remembering, applying, analyzing, evaluating, and creating (see Table 3; Krathwohl, 2002). Anderson and Krathwohl (2000) further expanded Bloom's original cognitive domain by incorporating four categories of knowledge: factual, conceptual, procedural, and metacognitive. These enumerations of verbs and types of knowledge serve as valuable measurement tools for developing programs that target specific skills or behaviors. Additionally, the progression from lower-order thinking skills such as remembering and recalling to higher-order skills such as evaluating and creating represents a systematic, progressive process that fosters deeper learning and cognitive development (Dabney & Eid, 2024). Stanny (2016) expressed concerns regarding reliance solely on verb lists for organizing learning objectives, emphasizing that Bloom's taxonomy may function as a heuristic device, yet contextual factors and expected outcomes must also be carefully considered. Su and Osisek (2011) proposed that effective knowledge transfer occurs when educational designs encompass both the content and the related cognitive processes. Nonetheless, cognitive learning constitutes only one facet of the comprehensive model.

Affective Domain

The affective domain, as initially articulated by Bloom (1956), encompasses elements related to attitudes, values, and interests. Subsequently, researchers Anderson and Krathwohl (2000) revised the domain, further developing it and employing it as a framework for categorizing an individual's motivation for learning. They characterized the domain as comprising emotional (affective) responses and attitudes that should be cultivated alongside cognitive skills.

As illustrated in Table 3, this domain consists of five processes, arranged hierarchically from least to most complex: receiving, reflecting, forming values, organizing the value system, and personalizing the value system. Jia and Balinas (2024) delineated the domain as focusing on a learner's emotional development and the integration of values, progressing from acceptance to personalization within their own value system. Learners advancing in this domain do so through willpower and motivation to learn. Given that a positive emotional response to learning can foster greater engagement among students, the emotional component can also enhance cognitive processing (Ugur et al., 2015). Similar to the cognitive domain, when educators incorporate considerations of the affective domain into curriculum planning, they can target specific affective outcomes aligned with their instructional objectives.

Critiques and Additional Models

While Bloom's taxonomy maintains widespread application, academia has articulated critiques of the model. One particular critique questions the assumption that cognitive learning progresses in a strictly hierarchical or linear manner. For instance, learners may engage in higher-order and more complex thinking based on their previous familiarity with a subject. In their research, Marta et al. (2024) highlighted a potential concern with the hierarchical structure, noting the risk of emphasizing higher-order processes at the expense of foundational knowledge and skill acquisition. Dabney and Eid (2024), in their comparative analysis of educational frameworks, advocated for the consideration of integrating a nonhierarchical model.

Researchers have examined and applied frameworks beyond Bloom's taxonomy to scaffold learning and outline objectives. Biggs and Collis (1981) formulated the structure of observed learning outcomes, which highlights a deeper quality of learning beyond mere cognitive processes. Their focus was on the complexity of learning, characterized by five levels: prestructural, unistructural, multistructural, relational, and extended abstract. Emphasizing observable learning outcomes rather than internal cognitive activities, they sought to capture the external manifestations of learning. Conversely, Fink's taxonomy of significant learning incorporates a human dimension and caring category alongside foundational knowledge, application, integration, and learning how to learn, rendering it particularly relevant for education in caring professions such as nursing. Researchers Dabney and Eid (2024) posited that employing Fink's taxonomy may cultivate empathy and flexibility as key competencies among nurses, thereby equipping them to address contemporary health care challenges. Although Fink's taxonomy has not seen widespread adoption within health care settings, it remains a valuable alternative method for measuring learning. Researchers such as Burwash et al.

(2016) recommended utilizing both Bloom's and Fink's models to establish a comprehensive and holistic framework.

Bloom's taxonomy can guide educators in developing learning experiences that promote students' cognitive and affective growth, while also ensuring alignment and standardization of curricula and assessments with specified learning objectives. In the current investigation, Bloom's cognitive and affective domains served as the foundational framework for the N.D.E training objectives, which corresponded with the knowledge and attitude constructs evaluated by the Kandess. Su and Osisek (2011) emphasized the utility of the taxonomy for designing lesson plans and curricula aimed at enhancing instructional methodologies, whereas Nascimento et al. (2021), through their integrative literature review, demonstrated that employing Bloom's taxonomy in the design of training programs contributed to the development of clinical competence in nursing. Furthermore, Kaiser Permanente, the organization involved in this research, utilizes Bloom's taxonomy to delineate measurable learning outcomes for nursing courses within its health education departments, in accordance with the regulations established by the California Board of Nursing. Consequently, this study adopted Bloom's taxonomy to establish educational objectives for nursing training.

Nursing Education and Training

Nursing education in the United States offers a comprehensive curriculum that emphasizes clinical proficiency alongside ethical and compassionate care. Students are expected to internalize and exemplify these qualities throughout their professional careers. Prominent frameworks such as the A.A.C.N (2021) Essentials, the A.C.E.N (2023) standards, and the A.N.A (2025) Code of Ethics establish the expectation that nurses communicate empathetically, uphold human dignity, and respect each patient's values and beliefs. These standards underscore the significance of these competencies and skills.

The A.A.C.N (2021) Essentials is a competency-based framework that establishes what nurses must know and what skills they must demonstrate upon their graduation. Within 10 domains, including person-centered care, communication, professionalism, and leadership, nursing graduates must demonstrate their ability to provide clinical care with spiritual and interpersonal sensitivity. The A.C.E.N (2023) reflects similar values through its five standards: mission, faculty, students, curriculum, and outcomes. Its 2023 guidance highlights that curricula must offer academic and clinical experiences that promote ethical conduct, cultural awareness, and compassionate responses to human suffering, ensuring graduates can provide safe and effective care in psychosocially complex situations. Although A.C.E.N does not prescribe specific course content such as N.D.E education, it establishes the expectation that nurses be prepared to address the psychological, emotional, and spiritual dimensions of care, which would naturally encompass empathetic engagement with N.D.E-ers.

The A.N.A (2025) Code of Ethics delineates ten provisions that establish the standards by which nurses uphold the dignity, worth, and humanity of all individuals. Through adherence to these ethical standards, nurses are expected to advocate for patients' rights, exemplify and foster psychological safety, respect cultural diversity, and honor various faith traditions, whilst also safeguarding patients from physical and emotional harm. These directives serve as a professional ethical framework for responding to N.D.E disclosures with respect and impartiality. For instance, Provisions 1 and 3 underscore compassion, trust, and advocacy; Provisions 5 and 6 mandate moral integrity and the cultivation of ethical environments; and Provisions 8 advocates for collaboration that promotes human flourishing.

Although these provisions are not explicitly address N.D.E's, they position nurses as healers who must listen attentively and respond to patients' experiences with humility and presence. To attain licensure, nurses are required to pass the National Council Licensure Examination (nexlex), which assesses their capacity to deliver holistic care across four fundamental categories: safe and effective care, health promotion, psychosocial integrity, and physiological integrity. The psychosocial integrity category of the examination assesses nurses' capacity to support emotional well-being, incorporate cultural and spiritual beliefs, and employ therapeutic communication to facilitate healing. This comprehensive expectation inherently includes the skills necessary to respond compassionately to N.D.E disclosures, as such moments often involve profound psychological and spiritual significance.

Although the A.A.C.N (2021),,, and nexlex standards do not specifically require training on N.D.E's, they emphasize the importance of moral and relational competencies for appropriately addressing such disclosures. National frameworks advocate for compassionate and spiritually sensitive care; however, N.D.E education is generally absent from nursing curricula. Mandalise (2013) examined nursing philosophy and professional responsibilities regarding the care of individuals who have experienced an N.D.E and observed that, despite recurring requests for education on the subject, the inclusion of such material remains an exception, leaving nurses without the essential skills to care for N.D.E's. This study sought to address this educational deficiency by evaluating a nursing training program focused on N.D.E's that align with patient-reported needs, thereby supporting the competencies outlined in national nursing frameworks and caring philosophies.

One nursing philosophy, Jean Watson's (2018) theory of human caring, or caring science, offers a model for the behavioral expressions of these competencies. Caring science underscores the interconnectedness of all living beings and acknowledges compassion, trust, and authentic presence as fundamental elements of nursing practice. These philosophical foundations are directly aligned with the domains outlined by the A.A.C.N (2021), namely Person-Centered Care, Professionalism, and Communication, which specify expectations for nurses to exhibit empathy, ethical awareness, and respect for the spiritual dimension of patients' experiences. Nurses enact caring science through the Ten Caritas Processes described in Table 4, which specify how nurses can foster trust, healing, and sacred caregiving in clinical practice. For instance, the process of embrace encourages nurses to practice loving-kindness toward themselves and others; forgive entails deep listening and acceptance of patients' emotional expressions; and open invites the nurse to remain receptive to “the spiritual mysteries of existence” and the potential for miracles. These Caritas Processes correspond with the skills and behaviors identified by researchers as essential for supporting individuals amid N.D.E disclosures, notably empathy, openness, and active listening.

Table 4 summary: The Ten Caritas Processes, which outline a framework for caring. These processes include Embrace, focusing on loving-kindness and compassion; Inspire, enabling faith and hope; Trust, engaging in spiritual practices; Nurture, sustaining loving relationships; Forgive, listening deeply to all emotions; Deepen, using creativity and caring to find solutions; Balance, adopting a coaching mindset in relationships; Co-create, providing a healing environment; Minister, sustaining dignity through sacred acts of caring; and Open, remaining open to spiritual mysteries and miracles.

Note. Table created by the author, summarizing information from Watson's (2018) discussion of the Caritas Processes.

Through a participatory cross-impact analysis, Horton-Deutsch et al. (2025) described the alignment between caring science and the A.A.C.N (2021) Essentials. They confirmed that caring science reinforces each of the A.A.C.N's 10 domains and serves as a unifying, humanistic thread across nursing education. When health care systems embed caring science, they can foster compassion and dignity and move toward a more caring culture. Evidence suggests that integrating principles of caring science with national nursing curricula standards and expectations for nursing professional practice can create ethical environments in which patients' needs are met, even when disclosing transformative events such as N.D.E's. Caring science can extend the A.A.C.N (2021) and A.N.A (2025) models and frameworks from ideals into behavioral competencies. Ideals such as presence, dignity, and nonjudgment can translate into behaviors readily practiced in everyday nursing. In this study, the Caritas Processes of deep listening and openness to the mystery closely aligned with the Kandess Attitudes subscale.

Professional standards expect registered nurses in the United States to pursue continuing education throughout their careers to enhance professional development and clinical competence. The A.N.A's Code of Ethics (2025), specifically in Provision 5, emphasizes that maintaining competence and engaging in ongoing professional development constitute ethical imperatives. Likewise, the A.A.C.N (2021) articulates that nursing education is a lifelong endeavor; it extends beyond licensure to support nurses in sustaining clinical excellence.

Guidelines issued by nursing organizations in the United States establish a foundation for evaluating a structured N.D.E training program as a form of continuing education for licensed nurses. Utilizing principles of caring science, evidence from prior intervention studies such as Loseu and Holden (2017), a validated instrument such as the Kandess, and Kirkpatrick's Level 2 (learning) evaluation framework, nursing training on N.D.E's can be systematically assessed. The training itself can facilitate instructional learning, as evidenced by the Kandess, and additionally function as a valuable job resource for individuals engaged in a demanding professional career.

Job Demands-Resource Model

The nursing profession is inherently demanding, necessitating nurses to provide care for others while working extended hours and engaging in intense interactions with patients and their families. The emotional impact of the role can be understood through the framework of the job demands-resources model, developed by Bakker and Demerouti (2007) and applied to nursing students. This model is a conceptual structure that suggests occupational roles include both demands, which are components requiring effort such as mental or physical exertion, and resources, which are elements of the job that facilitate the achievement of objectives, promote personal development, or alleviate physical or psychological stress. The job demands-resources model has been instrumental in measuring and managing employee well-being and burnout by analyzing the inputs of demands and resources as well as the outputs of well-being, commitment, performance, and engagement. Job demands and resources can influence workers positively and negatively and contribute either to exhaustion and mental distancing or conversely to health and well-being. Kato et al. (2021) investigated work engagement among nurses and discovered that job resources were positively correlated with engagement, whereas job demands, such as workload, were negatively correlated with engagement. Similarly, Schaufeli (2017) proposed that when emotional or psychological stress exceeds the balance with well-being and workers are lacking essential resources, cynicism and diminished efficacy may ensue. It is important to recognize that not all health care roles encounter identical demands; in fact, research by Gynning et al. (2024) indicates that nurses experience the highest levels of emotional demands among health care professionals.

Job resources can mitigate the toll of job demands, which, in nursing, can include a range of emotional labor due to the need to deal with death and dying and interactions with patients and families. Hoare and Vandenberghe (2024) found that job demands, specifically role overload, strongly contribute to exhaustion and turnover, while Fehr and Koob (2025) found that work overload is associated negatively with affective organizational commitment. In their integrative review, Broetje et al. (2020) observed that among the job resources that aid in addressing demands on nurses are professional resources, including professional development, access to information, and opportunities for learning. Consequently, a training program for nurses on the subject of N.D.E's would serve as a resource within the job demands-resources framework. Given that N.D.E disclosures can generate emotional demands, training that offers practical guidance would function as a job resource, potentially mitigating strain among nurses.

. To assess the efficacy of such training, an empirical model complemented by a validated measurement instrument may be employed.

Kirkpatrick Framework for Evaluating Training

To evaluate the effectiveness of the training program within this research, an appropriate assessment instrument was chosen that corresponds with the training's objectives. The purpose of this study was to examine the variations in nurses' knowledge and attitudes preceding and following an online educational intervention. Although alternative tools such as the C.I.P.P model are available for measuring training effectiveness, the Kirkpatrick four-level model, established in 1959, has been extensively utilized across various industries to appraise training outcomes and serve as a foundation for other assessment methodologies, including the Phillips return on investment model and Kaufman's five-level framework. The Kirkpatrick model has consistently and broadly been employed to evaluate the efficacy of programs in the fields of medicine, nursing, and education. Scholars propose that this framework can streamline the otherwise complex process of training evaluation and that its appeal lies in the limited number of variables and the simplicity of measurement for evaluators, managers, and organizational leaders.

Kirkpatrick's model delineates four hierarchical levels of assessment or evaluation, as outlined in Table 5: (1) response or reaction, (2) learning outcomes, (3) behavior changes, and (4) results or outcomes (Heydari et al., Kirkpatrick & Kirkpatrick, Kirkpatrick and Kirkpatrick (2006) proposed that evaluation may be conducted across all four levels, which they characterize as measures of “the effectiveness of a training program” (p. 3). Level 1 emphasizes the perceptions and responses of the learner or participant regarding the training, encompassing its content, structural design, materials, instructional methods, and overall quality. Kirkpatrick and Kirkpatrick (2006) proposed that although positive reactions may not necessarily ensure learning, negative reactions from participants can result in a diminished motivation to learn. The second level pertains to learning, encompassing three potential areas of focus: a change in attitudes, an increase in knowledge, and/or improved skills. The researchers emphasized that the objectives of the training must be explicitly defined, and that learning is considered to have occurred if there is an improvement in skills, an increase in knowledge, or a change in attitudes. Heydari et al. (2019) noted that this level is frequently assessed using pre-and posttest measures. The third level relates to whether behavioral modifications have transpired as a consequence of the training or whether the learning has been applied in professional practice. Kirkpatrick and Kirkpatrick (2006) advised against evaluating behavioral change solely based on the first two levels, asserting that specific conditions, such as environmental factors and rewards, exist beyond mere desire and knowledge necessary for change.

Table 5 summary: Kirkpatrick's Levels of Evaluation, which categorize training effectiveness into four stages. Level 1, Reaction, measures participant satisfaction and motivation. Level 2, Learning, tracks changes in knowledge, skill, or attitude. Level 3, Behavior, focuses on behavioral changes resulting from training. Finally, Level 4, Results, evaluates organizational outcomes such as profit, quality, cost, production, accidents, and turnover.

Level 4 (outcomes) focuses on the ultimate effects or outcomes of the training, which may comprise performance metrics, overall quality enhancements, or more challenging-to-measure objectives like motivation, leadership, or change management. The model does not inherently follow a hierarchical or linear structure, and subsequent levels necessitate additional observation time. Researchers often utilize longitudinal studies or alternative data collection methods to comprehensively evaluate the effectiveness of training, as attributing behavior (level 3) or outcomes (level 4) to the training process presents challenges owing to confounding factors such as environmental influences.

Table 5

Kirkpatrick's (2006) discussion of the levels of evaluation.

When employing the Kirkpatrick methodology, researchers occasionally restrict their assessment to specific levels, frequently focusing on the lower levels. Steele et al. (2016) discovered, in their analysis of 380 ethics training courses, that the majority were appraised at the reaction level. de Miranda et al. (2025) aimed to evaluate the effectiveness of utilizing the Kirkpatrick framework in nursing education. They observed that, among the 13 studies examined, either the first three levels or all four levels were included. They proposed that the model is efficacious when appropriately selected instruments are employed for each level. Gifford et al. (2023) assessed ongoing professional development in medicine and found that, among 93 studies, the second level of Kirkpatrick's model was most frequently assessed. The researchers identified the absence of a hierarchical or sequential order within the framework, highlighting that the tool was often applied in practice.

In the health care sector, the Kirkpatrick framework is employed to assess the effectiveness of various types of nursing education and training, encompassing areas from clinical care to mental health training. De Miranda et al. (2025) evaluated 13 nursing training programs and found that the programs used Kirkpatrick's model effectively. Level 1 (reaction) was predominantly assessed using Likert scales; Level 2 (evaluation) typically involved learning tests and self-assessment questionnaires; and Level 3 (estimation) was gauged through closed-ended questionnaires concerning participants' perceptions of knowledge transfer. Rasouli et al. (2023) investigated the efficacy of virtual nurse training courses utilizing the three tiers of the Kirkpatrick model, concluding that virtual training represents an effective educational modality capable of complementing traditional training methods.

Peng et al. (2025) conducted a comprehensive review of international research, concluding that the Kirkpatrick framework serves as a valuable instrument for evaluating continuing education in nursing, especially in establishing the relationship between nurse satisfaction and behavioral modification. They advised the integration of the Kirkpatrick and C.I.P.P models in future assessment efforts. Scholars such as Gifford et al. (2023) and Muqorobin et al. (2022) have also proposed combining the C.I.P.P and Kirkpatrick models. Muqorobin et al. (2022) analyzed 18 studies and determined that the C.I.P.P model is most effective for program design and implementation, whereas Kirkpatrick's model is most appropriate for training programs. The current study used the

Kirkpatrick Level 2 (learning) framework and administered the Kandess before and after training to assess changes in nurses' knowledge and attitudes regarding N.D.E's

.

Measurement of Knowledge and Attitude About N.D.E's

Pace (2013) developed a scale to evaluate knowledge and attitudes about N.D.E's for her dissertation and later published it with colleagues. Prior to the Kandess instrument, Near-Death Phenomenon Knowledge and Attitude Questionnaire served as the sole available scale assessing knowledge and attitudes concerning the phenomenon. Foster et al. (2009) identified tool as outdated, prompting to design the Kandess as a contemporary alternative. Additionally, developed a scale to evaluate knowledge and attitudes about N.D.E's for her dissertation, which was subsequently published with colleagues.

The Kandess tool was developed through consultation with a panel of experts, a review of relevant N.D.E literature, pilot testing, and factor analysis. The tool contains two subscales, Attitudes and Knowledge, derived from N.D.E literature and a focus group of experts containing one psychiatrist, two nurses, and several professional counselors across the United States. The final instrument employs a Likert-type scale and comprises 23 items to assess attitudes and an additional 23 items to evaluate knowledge. Participants, including students and counselors, were involved in both the pilot and primary validation studies to demonstrate the tool's ability to produce consistent results across different samples. Through exploratory factor analysis, Pace et al. (2016) identified four factors of N.D.E attitudes: (1) real or spiritually beneficial experiences, (2) believe and encourage talk, (3) mental health implications, and (4) recognizable phenomenon. Additionally, three domains of knowledge were delineated: (1) N.D.E content, (2) N.D.E aftereffects, and (3) experiencer characteristics. Prior to reliability testing, there were four domains; however, the fourth domain proved unreliable and was removed from the final tool.

With that adjustment, the study's results showed a strong Cronbach's alpha of.816-.909 and a test-retest r of.65-.79; the Kandess demonstrated reliability and validity. The findings validated the Kandess as a tool for measuring health professionals' knowledge and attitudes about N.D.E's, a conclusion later supported by Loseu and Holden (2017).

As Kirkpatrick and Kirkpatrick (2006) discussed, evaluating the Level 2 (learning) domain of training necessitates examining the cognitive and affective domains of learning. The Kandess assesses both attitudes and knowledge. The Attitudes subscale of the Kandess comprises four factors, measured by 23 items focused on an individual's attitudes toward N.D.E's, and three knowledge domains, assessed by 23 items that measure basic understanding of N.D.E's.

Kandess-A

The Attitudes subscale, Kandess-A, assesses the perspectives of health professionals regarding N.D.E's. It considers whether these professionals regard N.D.E's as genuine, spiritually significant, and sincere, or alternatively, perceive them as fabricated, immaterial, or susceptible to medicalization. Additionally, the scale evaluates the likelihood of a health care provider dismissing or accepting a patient's account of their N.D.E. Scores derived from this subscale reflect both the respondent's belief in N.D.E's and their openness to patient disclosures, with higher scores signifying greater acceptance.

The first factor,'Real, Spiritually Beneficial Experience,' comprises eight items and assesses whether the participant believes N.D.E's are authentic and of spiritual significance, or if they are inclined to dismiss them as hallucinations or dreams. The items are Likert-scale statements evaluating whether the participant perceives the patient's experience as a dream, hallucination, imagination, objectively real, benevolent, or supportive. Furthermore, these items determine whether the participant recognizes the experience as an N.D.E and whether they believe their patient. High scores in this category indicate that the health care professional regards the N.D.E as legitimate and beneficial.

The second factor, 'Believe and Encourage Talk,' comprises six items assessing the respondent's willingness to allow the experiencer to share their story and whether they are inclined to listen in a manner that fosters discussion or disclosure. Together, the statements assess whether the health care professional would avoid engaging in conversation with the patient, provide the patient with an opportunity to express themselves, abstain from speaking, inquire about the experience, and determine whether they believe patients to be generally truthful while disclosing the event. These items align with research encouraging listening and dialogue with patients who disclose their experiences to support integration and reduce harm. Higher scores in this factor indicate that the professional encourages and creates safe opportunities for disclosure.

The third factor, 'Mental Health Implications', comprises five items designed to assess attitudes toward N.D.E's as either pathological or normal. The statements emphasize whether health care professionals would regard the experience as indicative of mental illness, question the patient's mental state, suspect deception, doubt the patient's sanity, or perceive the experience as threatening. High scores in this section indicate that the professional does not perceive N.D.E's as indicators of dishonesty or mental disorder.

Finally, the fourth factor, 'Recognizable Phenomenon,' evaluates whether the participant acknowledges the phenomenon as being well documented. This section comprises four statements that measure the participant's likelihood to be surprised by the patient's experience, recognize it as an ordinary phenomenon, and understand its significance. Higher scores on this factor suggest that the participant perceives N.D.E's as sufficiently familiar, thereby reducing the likelihood of surprise or dismissal. Enhancing attitudes, such as cultivating an understanding of the N.D.E phenomenon as legitimate, supports nonharmful interactions with patients, as proposed by Holden et al. (2014) and Samoilo and Corcoran (2020) as a supportive approach. This study aimed to investigate changes in attitude resulting from a training intervention adapted from Loseu and Holden's research, which aligns with the Kandess-A factors.

Kandes-K

The Knowledge subscale of the Kandess comprises three domains: N.D.E

Content, Aftereffects, and Experiencer Characteristics. This subscale evaluates the factual dimension of knowledge acquisition and corresponds to Kirkpatrick's Level 2 (learning) domain. It specifically measures nurses' understanding of the empirical evidence related to N.D.E's, rather than their personal perceptions of them.

The first domain, 'N.D.E Content', encompasses items related to the characteristics of an N.D.E, including the standard features outlined in Table 1. The statements within this domain inquire whether the participant concurs that during an N.D.E, individuals frequently encounter an ineffable quality, traverse a tunnel, are exposed to a bright light, see deceased relatives or friends, leave their bodies, review their life, experience time distortion, perceive unconditional love, and decide to return to their bodies. Additionally, it assesses whether participants report veridical perceptions following the N.D.E. High scores in this domain indicate that the participant's knowledge corresponds with research-based information on N.D.E's, whereas lower scores may signify misunderstandings or incomplete comprehension.

The second domain, 'Aftereffects', assesses comprehension of the enduring emotional, spiritual, and behavioral impacts of N.D.E's. This section, comprising nine assertions, evaluates participants' concurrence that N.D.E's frequently report diminished fear of death, frustration in elucidating the experience, reduced materialistic tendencies, alterations in interpersonal conflicts, increased sensitivities, physical aftereffects, a transformed worldview, enhanced intuitive abilities, and a renewed sense of purpose. Higher scores within this domain indicate an understanding of the influence of N.D.E's on personal lives, whereas lower scores may highlight gaps in such comprehension.

The final domain, 'Experiencer Characteristics,' assesses participants' understanding of who experiences N.D.E's and the specific circumstances under which these occurrences take place. Participants indicate their level of agreement that N.D.E's occur across age groups, racial and ethnic backgrounds, religious affiliations, and worldviews, and that both men and women report them. When individuals possess an accurate understanding of the features and subsequent effects of N.D.E's, as well as the characteristics of those who experience them, they are less prone to misclassification of the phenomenon. This increased understanding diminishes the likelihood of missing opportunities for caring interactions or meaningful moments between patients and caregivers. Higher scores reflect an acknowledgment that N.D.E's occur across diverse cultural and demographic populations, whereas lower scores suggest a more limited comprehension of their universality.

Current Practice and Use of the Kandess Instrument

The Kandess (Kandess-A and Kandess-K) measures both knowledge and attitude changes resulting from training relevant to Kirkpatrick and Kirkpatrick's (2006) Level 2 (learning) domain. The modules developed for this research were designed to expand upon earlier work by Loseu and Holden (2017) by employing a three-part online intervention that encompasses education on harm reduction during N.D.E disclosure, evidence-based facts, and real-world examples. The research design utilized the Kandess tool both pre-and post-training; however, the determination of the appropriate timing for assessment was a carefully considered aspect of the process.

Posttest Timing in Educational Training

Researchers have sought to distinguish between when genuine learning has transpired and instances where taught material remains confined to short-term or working memory. For the purpose of this investigation, learning shall be defined as knowledge that has been retained and consolidated into long-term memory, thereby enabling retrieval without recent exposure to the material. Immediate assessments may lead researchers to make inaccurate inferences about learning and may inflate outcomes because participants rely on working memory rather than consolidated long-term memory. The decision regarding the timing of learning assessments constitutes a methodological choice that can significantly influence the validity of a study.

More than a century ago, Ebbinghaus (1885/1913) pioneered research into how information decays over time within memory. In his study, Ebbinghaus first memorized lists of meaningless syllables and then tested how easy they were to relearn after waiting for intervals ranging from 20 minutes to 31 days, as shown in Table 6.

Table 6 summary: Savings percentages decrease as the retention interval increases. The highest savings of 58.2 percent occur at a 20 minute interval, while the lowest savings of 21.1 percent are seen at a 31 day interval. Other intervals show a steady decline, such as 44.2 percent at 1 hour and 27.8 percent at 2 days.

Ebbinghaus (1885/1913) measured retention indirectly by examining the relearning effort required when the material had been previously learned; he called the reduction in relearning effort savings. His study formulated the concept known as the forgetting curve, which is represented as a curvilinear function characterized by an initial steep decline followed by a gradual plateau, illustrating retention over time (see Figure 1; Ebbinghaus, 1885/1913; Murre & Dros, 2015; Rivera-Lares et al., 2023). According to this model, the rate of information loss is non-linear, with rapid decreases observed on the first day, followed by a more protracted and gradual decline. As detailed in Table 6, the average retention diminished from 58.2% at 20 minutes to 33.7% on the first day, 25.4% at six days, and 21.1% at 31 days. More recent studies have successfully replicated the curve using identical intervals, thereby validating the robustness of the Ebbinghaus forgetting curve model.

Figure 1 summary: A line chart showing retention savings over various retention periods, ranging from 20 minutes to 31 days. Retention savings decrease steadily as the retention period increases, with the steepest decline occurring between 20 minutes and 9 hours. The takeaway is that the ability to relearn information diminishes over time, illustrating the forgetting curve.

Table 6

Note. Savings indicates the percentage reduction in relearning time in subsequent periods relative to the original learning; higher values indicate greater retention. Values shown mirror the graph in Figure 1.

In their experiment, Murre and Dros (2015) replicated Ebbinghaus's research, and the results closely matched the original findings, showing that the most significant information loss occurs within the first 24 hours. Although the two experiments took place more than 100 years apart, Murre and Dros (2015) note the shared characteristics of the studies. One key finding is that forgetting did not follow a smooth curve but increased after the first day. Ebbinghaus thought this could be due to measurement error, yet Murre and Dros (2015) observed the same pattern, now attributed to sleep's effect on memory. Petzka et al. (2023) found that sleep enhances retention in both item and associative memories, emphasizing that the first night of sleep after learning has lasting benefits. However, the forgetting curve shows that, despite the increase in retention after sleep, there is a sharp decline in retained information during the first 24 hours, after which the curve stabilizes and forgetting slows over time. Researchers agree that memory consolidation begins during the first night's sleep, as new information shifts from short-term to long-term memory.

Radvansky et al. (2022) proposed that memory can be segmented into distinct phases associated with neurological consolidation: working memory (the initial minute after the acquisition of new information), early long-term memory (up to 12 hours), transitional long-term memory (the following week), and enduring memory (beyond the week). Their analysis of existing memory research led them to assert that the transitional long-term memory phase, which occurs within the first week post-learning, is particularly crucial for the consolidation process. Manoli et al. (2018) investigated verbal memory recall, assessing performance after 30 minutes and following a one-week interval. Their results indicated that a substantial amount of forgetting transpired during the 7-day period immediately succeeding the learning phase, as compared to the initial 30-minute period. These findings corroborate those of,, and Murre and Dros (2015), demonstrating that the rate of memory loss diminishes and stabilizes beyond the 6-day mark.

The timing of a posttest can significantly influence conclusions regarding learning outcomes. Accordingly, in this study, a posttest was administered approximately 1 week after the educational training in order to assess learning after the initial retention period. This methodology aligns with the evidence provided by both historical and contemporary scholars engaged in the study of retention, forgetting, recall, and memory.

Biblical Foundations of the Study

This section reviews four biblical areas related to the study: caring for individuals who report N.D.E's; Scripture relevant to N.D.E features and aftereffects; New Testament descriptions of the fruit of the Spirit in relation to N.D.E aftereffects; and Scripture concerning teaching and training. The first biblical topic to investigate concerns nursing, patient care, and how an individual, through acts of compassionate care, can witness some of the most remarkable moments of joy and sorrow. Nursing can be considered a sacred calling, providing the opportunity for the carer to effuse empathy, honor the dignity and sacredness of each individual, and reflect the image of God. Shelly and Miller (2006) defined Christian nursing as “a ministry of compassionate care for the whole person” (p. 14). Each patient, during every individual encounter, can be held with respect, humility, and deep care by nurses, just as Jesus did as he cared for lepers, washed feet, and used mud compresses. Nurses promise to maintain ethical behavior, a commitment foundational to their sacred vocation. Galatians 6:2 says, “Carry each other's burdens,” which can be balm to the soul for a person who has just undergone a transformative event like an N.D.E. Furthermore, Christians learn about the meaning of being present, even across social groups, as they navigate others' belief systems in their vocation. Jesus shows, throughout the New Testament, his unwavering presence in the face of both suffering and joy. Supporting patients who have had intense spiritual and emotional experiences is essential, and nurses play a key role as healers if they choose to be empathically present and open during the vulnerable post-N.D.E time, rejoicing with those who rejoice and weeping with those who weep.

Christ urges his followers to, “Heal the sick, raise the dead, cleanse lepers, cast out demons. Freely you have received; freely give,” and this call to action for nurses can allude to the Watson (2018) Caritas Process of “opening to the mystery” of their healing and transformative presence as they sit with patients. Watson's caring science theory echoes this sentiment by inviting nurses to engage in transpersonal relationships, open to mystery, and view each patient encounter as a sacred moment. When nurses provide psychological safety for their patients, with deep, nonjudgmental listening, they are abiding by the guidance given in Proverbs 18:13: “If one gives an answer before he hears it, it is a folly and a shame.” Nurses can attune to their patients' physical needs.

However, when grounded spiritually, they can help the person holistically. In service of loving God with “all their heart and soul,” they have an opportunity to see another child of God and minister to them with hope and the conviction that their healing work is “all to the glory of God” (1 Corinthians 10:31; Colossians 3:23, Mark 12:30).

While the Bible does not directly address N.D.E's, some stories from Scripture reflect the common features of N.D.E's listed in Table 1. First, most N.D.E's find it challenging to describe their experiences in human language; as Paul tells of his spiritual experience, he notes that he “heard things that cannot be told, which man may not utter”. Although many experiencers have this ineffable understanding, they attempt to provide descriptions to those who will listen.

Habermas (2018) studied one feature of N.D.E's, O.B.E's, and posited that N.D.E's are supportive of theological Christianity after analyzing multiple accounts of veridical O.B.E's from persons who described what happened during the time they were clinically deceased. He argued that these accounts provide empirical evidence supporting the idea that the soul continues after death. The Bible contains many stories that depict elements of N.D.E's., a Christian pastor, found numerous parallels between the 1,000 N.D.E accounts he examined and biblical reports. He believes that N.D.E's can serve as a confirmation of Christian beliefs when viewed through the lens of the Bible.

The concepts that souls are separate from the body, that consciousness survives beyond a living body, and that they return to God, are supported in 2 Corinthians 5:8 when Paul declares, “We would rather be away from the body and at home with the Lord,” and in Ecclesiastes 12:7, which says, “And the dust returns to the earth as it was, and the spirit returns to God who gave it”. Many N.D.E-ers report moving through time and space without their physical bodies, meeting an all-knowing, pervasive light filled with loving force. In John 8:12, Jesus is depicted as the divine light: “I am the light of the world. Whoever follows me will not walk in darkness but will have the light of life” other Scriptures describe Jesus as the “peace of God, which surpasses all understanding” (Philippians 4:7) or “fullness of joy” (Psalm 16:11) in the presence of God, aligning with the sense of overwhelming peace that many N.D.E-ers report as a part of their own experience, along with a life review with evaluation and assessment of the deeds throughout one's life. Christians understand through Scripture that there is a judgment period after one dies, as shared in Hebrews 9:27, “And just as it is appointed for man to die once, and after that comes judgment,” and Romans 14:10, “Why do you pass judgment on your brother?

Or you, why do you despise your brother? For we will all stand before the judgment seat of God.” The Bible, in Matthew 25:31 to 46, says the final judgment depends on how individuals treated the least of the least, which aligns with what N.D.E-ers report: they are given opportunities to understand, from others' perspectives, how their interactions impacted them.

Another N.D.E feature that is potentially conveyed in text is how God can use altered states to provide information and inspire insight. An N.D.E could be considered an altered state, as could having visions. In Scripture, when Stephen is close to dying, he sees Jesus next to the Almighty, a reality unknown in the waking earthly realm, beyond what human eyes can see unless God allows it. Again, through the Lord's wisdom, realities were revealed when Elisha's servant's eyes were opened and he saw chariots of fire, affirming that elements exist beyond the human realm. Not only that, accounts from individuals blind from birth who can see during their N.D.E's mirror Isaiah's vision that shows"the eyes of the blind shall be opened". In the New Testament, Paul is"caught up to the third heaven," potentially describing something akin to the O.B.E's reported by N.D.E-ers (2

Corinthians 12:2 to 4).

Many individuals who have had an N.D.E tell of their encounters with spirits, angels, and departed loved ones in other realms. According to John 14:2, there are many rooms in the Father's house, perhaps indicating the existence of other realms. Moreover, the description of assembled angels and souls departed in Hebrews 12:22 to 23 aligns with accounts of spiritual beings from N.D.E-ers.

A sense of yearning to be in the realm of the N.D.E often lasts in those who survive death. Scripture points to the Christian's proper place being in Heaven, with God, which N.D.E-ers perceive as a feeling of home. It can be challenging to transition back into a human body when returning from a place of peace; many hope to return, reflecting Paul's longing to be with Christ: “My desire is to depart and be with Christ, for that is far better”. However, when they return, experiencers often share their extraordinary understanding that all things in the universe are interconnected and all beings are a part of one creation, a concept echoed in John 17:21, which says, “That they may all be one, just as you, Father, are in me, and I in you, that they also may be in us, so that the world may believe that you have sent me”. Because of this understanding and the transformational nature of N.D.E's, experiencers often return with lasting aftereffects.

Examining how the aftereffects of N.D.E's align with the fruits of the Spirit and other Scripture passages helps frame the wholeness of the experience. As described in this literature review, N.D.E researchers have found long-term and consistent changes in the lives of N.D.E-ers, such as increased peace, compassion, kindness, and empathy and reduced fear of death, materialism, and competitiveness. Paul's description of the"works of the flesh" as immorality, envy, or strife stands in distinct contrast to the natural results one can expect when living in alignment with the Spirit; the outward fruit is evidence of the inner transformation resulting from God's work. This transformation is evident in the lives of N.D.E-ers who return changed. The fruits of the Spirit, according to Jesus, can be used to measure a person's sincerity in their faith. In Galatians 5:22 to 23, it is written,"But the fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control; against such things there is no law." Although not directly aligned, the fruits of the Spirit and N.D.E aftereffects have discernible parallels.

The aftereffect of reduction in the fear of death may align with the fruit of peace, written about extensively throughout the Bible, such as in Psalm 23:4, which says, “Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me”. As reported, N.D.E-ers often have a profound sense of peace while in the unearthly realm and return to know that there is no fear to be had. However, peacefulness does not only exist in the heavenly realm for N.D.E-ers.

Many N.D.E-ers return to waking life transformed, having intimately known the feeling of peace and experienced unconditional love, which they then express through compassion for others. This may be described as the fruits of love, kindness, patience, goodness, gentleness, and self-control. Love can be seen in their actions as they follow Jesus' words to “love one another,” doing so in a deeper sense than pre-N.D.E. Additionally, the reduction in materialism or increase in self-control and goodness is often apparent, as individuals shift toward more service-oriented or spiritual pursuits as opposed to the competitive, self-indulgent nature humans struggle with, perhaps aligning with what is written in Matthew 6:19 to 20, “Do not lay up for yourselves treasures on earth … but lay up for yourselves treasures in heaven.”

N.D.E-ers often return with an increased sense of meaning or purpose, understanding that there is a plan. The natural unfolding of this new realization is an expression of the fruits of joy and goodness as N.D.E-ers fulfill what is written in Psalm 139:13 to 16: “You knitted me together in my mother's womb. … In your book were written, every one of them, the days that were formed for me, when as yet there was none of them”. Survivors often return with a deep resolve and meaning, knowing that “for those who love God all things work together for good, for those who are called according to his purpose”.

Even during and after distressing N.D.E's, there is possible fruit to bear, eventually. Although those who have distressing N.D.E's often return with confusion and discomfort, there may be opportunities to find comfort from Scripture. Some N.D.E-ers describe frightening accounts of being alone, completely separated from God, and judged as unworthy, and sensing torture and burning around them. The Bible describes eternal destruction, separation from God, unrelenting torment, unquenchable fire, and eternal punishment, depicting what N.D.E-ers report. Some individuals describe their experiences as complete darkness and isolation as described in Jude 1:13, which addresses those for whom “utter darkness has been reserved forever.” The lived experience of this darkness and hellish features can provide survivors of distressing N.D.E's an opportunity to process the event, mourn it, and transform. Matthew 5:4 says, “Blessed are those who mourn, for they shall be comforted,” offering support to persons who have experienced suffering. The Bible discusses anguish and lament throughout its books, reminding the reader that God's grace can be enough during times of sorrow. For example, 2 Corinthians 12:9 says, “My grace is sufficient for you, for my power is made perfect in weakness.” Allowing God's grace to guide the N.D.E's' integration of their experience can leave the door open for individuals to perceive their distressing N.D.E as a warning signal, create meaning and purpose from the spiritual experience, and find ways to “renounce ungodliness” and change their course. When viewed through the lens of grace, transformation can allow the fruit of the Spirit to grow and blossom. Change can occur in many ways, and for individuals preparing to care for people with N.D.E's, a personal transformation can occur as they learn and grow through training and preparation.

To evaluate whether knowledge and attitudes have changed, a training was conducted for this research study. The Bible supports the foundational element of this study, training. Scripture presents preparation, teaching, and equipping others as ways to build technical skill and character, instill purpose, and serve others. In Proverbs 22:6, it is written, “Train up a child in the way he should go; even when he is old he will not depart from it”, showing that training in and of itself can create lifelong behavioral changes. Training is a key tenet of the Bible, as can be seen in Ephesians 4:11 to 12, which says, “And he gave the apostles, the prophets, the evangelists, the shepherds and teachers, to equip the saints for the work of ministry, for building up the body of Christ,” whereby the training itself is to prepare people for the roles that they will eventually assume. Scripture states that a goal of training is to prepare oneself “for godliness” because it “holds promise for the present life and also for the life to come.” First Timothy 4:7 to 8 also states that “bodily training is of some value.” Again, Proverbs 1:5 shows that wisdom and learning are valued: “Let the wise hear and increase in learning, and the one who understands obtain guidance,” underscoring that even those deemed wise are called to keep building their skills and growing. Proverbs 9:9 emphasizes continuous growth, stating, “Give instruction to a wise man, and he will be still wiser; teach a righteous man, and he will increase in learning.” Hebrews 12:11 explains that while discipline, or teachings, may be difficult, they can yield fruit: “For the moment of all discipline seems painful rather than pleasant, but later it yields the peaceful fruit of righteousness to those who have been trained by it.” Education and training can sharpen a person, as Ecclesiastes 10:10 explains: “If the iron is blunt, and one does not sharpen the edge, he must use more strength, but wisdom helps one to succeed.” These passages recognize learning, skill development, and the pursuit of wisdom as valuable. The Bible consistently features skill development and wisdom, and God celebrates the pursuit of growth. Scripture contains the nursing values of presence, dignity, attentive listening, and empathy, which align closely with patients' needs during N.D.E disclosure.

. Biblical truths and nursing philosophy and ethics, which emphasize caring, grounded this study.

In summary, the literature affirms that N.D.E's constitute a recurrent and identifiable phenomenon characterized by common features and enduring aftereffects that influence individuals across diverse cultures and contexts. These experiences are frequently transformative and may leave patients in a vulnerable state; consequently, the responses of health care professionals play a crucial role in their integration into the patients' lives. Research demonstrates that early disclosure can be detrimental if health care professionals pathologize or dismiss the experience, whereas it can be beneficial when empathy and validation are demonstrated. Standards established by national nursing organizations such as the American Nurses Association (A.N.A), the American Association of Colleges of Nursing (A.A.C.N), and the Accreditation Commission for Education in Nursing (A.C.E.N), as well as philosophies such as caring science, concur that it is essential for nurses to deliver compassionate, patient-centered care. These principles are consistent with Scriptural guidance to honor each individual created in the image of God, to listen before speaking, and to bear one another's burdens. Nevertheless, a notable gap exists in the training provided to nurses regarding how best to support patients following an N.D.E.

To bridge the educational gap, the current study evaluated a three-part training program aligned with the cognitive and affective domains of Bloom's taxonomy. This program functions as a job resource within the framework of job demands-resources model, and evaluated according to Kirkpatrick's Level 2 utilizing the validated Kandess instrument. The study administered the post-assessment approximately 1 week after instruction, consistent with Ebbinghaus's curve, to facilitate memory consolidation and reduce reliance on short-term memory. The theoretical and ethical underpinnings derived from both scholarly literature and Scripture underpin the study and its methodology. Building upon this evidence, Chapter 3 delineates the methodology for this quasi-experimental investigation, encompassing procedures, measurement techniques, data analysis, and potential limitations.

Chapter 3: Research Method

This chapter describes the research methods used to evaluate nurses' knowledge and attitudes toward N.D.E's before and after participation in an asynchronous online educational program. This quantitative, quasi-experimental study aimed to compare nurses' knowledge and attitudes regarding N.D.E's before and after the educational intervention, as well as to explore the relationship between knowledge and attitudes using the Kandess instrument. The chapter comprises the following sections: Research Questions and Hypotheses, Research Design, Participants, Study Procedures, Instruments, Operational Definitions of Variables, Data Analysis, Limitations, and Assumptions. The study aligned with Kirkpatrick Level 2 (learning) for evaluating outcomes. The learning objectives of the module were informed by Bloom's revised taxonomy. The scheduling of a 1-week delayed posttest aligned with the forgetting curve research, targeting retention beyond short-term working memory.

Research Questions

Research Questions and Hypotheses

R.Q 1: What is the relationship between nurses' knowledge about N.D.E's and attitudes toward N.D.E's before completing the N.D.E training program?

R.Q 2: What is the relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's 1 week after completing the N.D.E training program?

R.Q 3: Do nurses' knowledge about N.D.E's significantly change from pretest to 1-week delayed posttest following an N.D.E training program?

R.Q 4: Do nurses' attitudes toward N.D.E's significantly change from pretest to 1-week delayed posttest following an N.D.E training program?

Hypotheses

Hypothesis 1: There will be a statistically significant relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's before completing the N.D.E training program.

Hypothesis 2: There will be a statistically significant relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's 1 week after completing the N.D.E training program.

Hypothesis 3: Nurses' knowledge scores (Kandess-K) about N.D.E's will significantly change from pretest to 1-week delayed posttest.

Hypothesis 4: Nurses' attitude scores (Kandess-A) toward N.D.E's will significantly change from pretest to 1-week delayed posttest.

Research Design

This quantitative quasi-experimental study employed a pretest and delayed posttest design to assess an online asynchronous educational training consisting of three modules with a total duration of 100 minutes. The modules included a narrated PowerPoint presentation on N.D.E features, aftereffects, and characteristics; a narrated PowerPoint presentation on research concerning potential harm during N.D.E disclosures; and a video presenting real-world examples of N.D.E disclosures in medical settings. The Kandess was utilized to measure variations in knowledge and attitudes before and after the training intervention. Kirkpatrick's Level 2 framework served as the guiding theoretical model. Outcomes Kandess-K and

Kandess-A were evaluated at two time points: pretraining and 1 week after training.

The study's design was modeled after the research conducted by Loseu and Holden

, which investigated counselor knowledge and attitudes through an online training program comprising two PowerPoint presentations and one video. The current training program was adapted from this prior research, which reported improvements in knowledge and positive attitude shifts among participating counselors.

The three self-paced modules, totaling 100 minutes, could be completed within two weeks and taken in any order, although suggestions for completing the first, second, and third were provided. Mirroring the modules presented by Loseu and Holden (2017), the initial module provided foundational information regarding the nature of N.D.E's, their prevalence, and the identification of common features that distinguish them from other phenomena. It elaborated on the typical aftereffects experienced by individuals who have undergone N.D.E's and offered communication strategies suitable for disclosure scenarios.

The second module emphasized the importance of preventing harm when patients disclose their N.D.E's. It discussed the potential negative consequences of invalidating and pathologizing these phenomena and differentiated between supportive and non-supportive approaches to engaging with patients who disclose their N.D.E's. The third module featured a video depicting patients and health care providers describing their experiences within the health care system, illustrating how health professionals' reactions can influence patient outcomes. It also reviewed the common features of N.D.E's and addressed prevalent misconceptions. The final, third module provided recommendations. aligned with supporting individuals who have experienced an N.D.E. Collectively, these three modules offered three perspectives for approaching and supporting patients.

Participants

Participants were licensed registered nurses employed by Kaiser Permanente in Northern California. Inclusion criteria comprised individuals aged 18 or older, holding an active registered nurse license, employed by the organization, and willing to provide consent to participate in the research and complete the modules. Exclusion criteria included individuals under 18, non-nursing personnel, employees not affiliated with Kaiser Permanente, and nurses on leave. Recruitment was conducted via email from nursing staff mailing lists, through word of mouth, and via organization-wide intranet flyers. Communication methods are detailed in Appendix B. An a priori power analysis for a paired-samples t-test (two-tailed, alpha = 0.05 ) with an effect size of d = .5 indicated that a minimum of 34 participants was required to attain 80% statistical power (see Appendix E). To account for potential attrition, incomplete surveys, or unmatched records, the targeted sample size ranged between 45 and 55 participants. The final matched sample of 41 participants exceeded the minimum required for power.

Study Procedures

Participants were recruited for this voluntary research study through internal Kaiser Permanente emails, online and printed flyers, and verbal recommendations via on-site channels, as detailed in Appendix B. Recruitment communications included descriptions of the study and instructions for participation. All recruitment materials clearly stated that participation was entirely voluntary.

Participants were supplied with a hyperlink to the electronic informed consent form, as detailed in Appendix C. The consent documentation included information about the study, such as its purpose, participants' responsibilities, potential risks and benefits, the voluntary nature of participation, confidentiality assurances, the right to withdraw at any time, and the possibility of earning continuing education hours. Participants were expected to review the document and provide their consent accordingly.

Consent was obtained electronically. Email addresses were collected to track module and survey completion, and responses were kept confidential (not anonymous).

Participants used their email addresses to access the training, pretest, and posttest. They received links to surveys and modules, reminders to complete the posttest, and information about continuing education units (C.E.U's) for interested individuals. Email addresses were securely stored and used only for logistical purposes and C.E.U processing communication.

As Figure 2 illustrates, after providing consent, participants completed a Microsoft Forms pretest hosted behind Kaiser Permanente's firewall. The pretest included a researcher-developed demographic questionnaire, items on familiarity with caring science, and the Kandess. Subsequent to the pre-survey, participants encountered a pop-up message containing a link to the initial module and also received three additional links to the three asynchronous modules via email. These modules were stored on Microsoft Forms behind the firewall of Kaiser Permanente. Following the completion of the first module, participants were provided with the link to the second module; after completing the second module, they received the link to the third module.

Figure 2 summary: A flowchart depicting the study process, starting with recruitment and informed consent, followed by a pretest and the completion of three educational modules. After the modules, participants receive a series of email reminders over three weeks to complete a posttest via Microsoft Forms, concluding with a thank-you page. The diagram outlines the sequential steps and follow-up mechanism used to ensure participant completion of the pretest, training, and posttest.

Upon completion of the third module, participants were invited to attest to their completion of the modules and to provide their information if interested in receiving C.E.U's. This process enabled individuals to request contact hours for nursing continuing education. The information provided was managed separately from survey responses.

Participants received a reminder with a link to complete the post-survey 1 week after they completed the final module. They returned to the posttest, and upon completion, a pop-up message in Microsoft Forms expressed gratitude for their participation and provided the contact information of the researcher. For participants who failed to complete the posttest, reminders were issued twice more: once in the second week and once in the third week following the completion of the final module.

Figure 2

Flow of Participation in Research Study

Note. The figure illustrates the design flow that participants in the study engaged in.

Informed consent, pretest, modules, C.E.U request and attestation, one-week delay, posttest, and completion.

C.E.U's

Interested nurses could earn two contact hours after completing all three modules. Approval from the California provider of nursing C.E.U's is available in Appendix G. Participants would submit their attestation once they finished the three modules of the training program. Contact hours were granted regardless of research participation; nurses could complete the modules and receive C.E.U's without having finished every survey item, as participation was voluntary. The C.E.U provider, an individual within Kaiser Permanente separate from the researcher of this paper, gathered contact information from those completing the modules and issued C.E.U certificates.

Data Security

All data were stored on a password-protected Kaiser Permanente drive and server behind Kaiser Permanente's firewall. The data will be retained for three years as per Institutional Review Board policy, after which it will be permanently deleted. Data, including email addresses, were kept confidential (not anonymous). Links to the Microsoft Forms, surveys, and modules, as well as reminders and, if requested, C.E.U information, were sent to the email addresses provided by participants. Data were stored in a separate linkage file on an encrypted, access-restricted K.P drive, separate from survey responses. Analysis used study I.D's only. The dataset will be destroyed after three years, per Institutional Review Board policy.

Instrumentation and Measurement

This quantitative study used two instruments: (a) the Kandess and (b) a concise demographic questionnaire developed by the researcher. The Kandess was used to assess variations or consistency in participants' knowledge of and attitudes toward N.D.E's. The demographic questionnaire was used to collect descriptive data on participants' characteristics.

The Kandess

As demonstrated in Appendix A, the Kandess is a tool that assesses factual knowledge and personal attitudes regarding N.D.E's among health care professionals. For this investigation, the Kandess served as the primary instrument for quantitatively evaluating pre-and post-training knowledge and attitudes, as well as detecting any changes thereof. The instrument comprised two subscales, namely Kandess-A and Kandess-K, each consisting of 23 items. Participants rated each statement on a Likert-type scale, where higher scores denote greater understanding of N.D.E's and more supportive attitudes toward N.D.E's and N.D.E's. This validated instrument was selected to examine the influence of online training on health care professionals, building upon prior research conducted by Loseu and Holden (2017). Pace et al. (2016) employed exploratory factor analysis to identify four factors within the attitude subscale: Real or Spiritually Beneficial Experience, Believe and Encourage Talk, Mental Health Implications, and Recognizable Phenomenon. Additionally, three knowledge domains were delineated: N.D.E Content, N.D.E Aftereffects, and Experiencer Characteristics. Reliability assessments revealed Cronbach's alpha values ranging from.816 to.909, and test-retest reliability coefficients between r = 0.65 and r = 0.79. The factor analysis and expert review corroborated the construct validity of the instrument. These findings affirm that the Kandess exhibits robust psychometric properties and is thus suitable for evaluating Kirkpatrick and Kirkpatrick's (2006) Level 2 (learning) outcomes. Authorization for the use of the Kandess was granted by the author (refer to Appendix A). The Kandess was administered as a pre-and post-intervention survey via Microsoft Forms, hosted on a secure server behind Kaiser Permanente's firewall.

Demographics

The demographic variables are either nominal or ordinal and were collected using a researcher-designed demographic questionnaire (see Appendix D). Items inquired about age range, gender, years of nursing experience, highest educational degree, clinical work setting, prior experience with caring science, and previous N.D.E education. These data were used for descriptive statistics and did not serve as the primary variables in the study.

Operationalization of Variables

Educational Training is operationally defined as an independent variable representing participation in each of the three asynchronous online educational modules. The content of these modules encapsulated commonly reported features and aftereffects, with an emphasis on neutral, patient-safe communication and behaviors such as avoiding pathologizing language, listening humbly, and maintaining full presence. Additionally, the modules offered real-world scenarios and examples illustrating health care providers' experiences with N.D.E's and N.D.E-ers. This variable was evaluated through an examination of the differences and relationships between dependent variables of knowledge and attitudes at both pretest and posttest, utilizing the 46-item Kandess.

Kandess-K (Knowledge about N.D.E's) is operationally defined as a continuous interval-level dependent variable based on the total composite score from the 23-item

Kandess-K evaluating knowledge of the features and aftereffects of N.D.E's, and demographic commonalities among N.D.E-ers. Each item was rated on a

5-point Likert scale (1 = completely false to 5 = completely true), with higher scores indicating greater knowledge of N.D.E's.

Kandess-A (Attitudes toward N.D.E's) is operationally defined as a continuous interval-level dependent variable based on the composite score from the 23-item Kandess-A that evaluates attitudes and perceptions of N.D.E's and experiencers. Each item was rated on a 7-point Likert scale (1 = completely disagree to 7 = completely agree), with higher scores reflecting more positive attitudes.

Data Analysis

The data analysis for this research determined statistically significant changes in nurses' knowledge or attitudes about N.D.E's after participation in a three-part asynchronous training program. The data were analyzed using I.B.M S.P.S.S Statistics

(Version 31). Descriptive and inferential statistics were used to answer the research questions.

Descriptive Statistics and Demographic Variables

A brief demographic questionnaire was developed to gather background information from participants. The demographic data was utilized solely for descriptive purposes and was not incorporated into inferential analyses. The demographic variables are either nominal or ordinal and were collected through a researcher-designed demographic questionnaire (see Appendix D). This questionnaire gathered details such as age, gender, years of licensure as a nurse, primary clinical setting, highest nursing degree, knowledge and experience in caring science, application of caring science principles, and whether the nurse has received education on N.D.E's prior to the training program.

Frequencies and percentages for items including gender, degree level, and clinical setting were calculated. Additionally, means and standard deviations were computed for continuous variables such as years of experience.

Research Questions 1 and 2: Relationships Between Knowledge and Attitudes

The initial two research questions inquired about the relationship between nurses' knowledge concerning N.D.E's and their attitudes toward N.D.E's before and 1 week subsequent to completing the N.D.E training program. Shapiro-Wilk tests indicated that Kandess-A scores violated the normality assumption at both time points, whereas Kandess-K scores were normally distributed. The assumptions for Pearson's correlation were not met, and the relationships between the variables were evaluated using ranked scores. Spearman's rho was used for both R.Q 1 and R.Q 2, testing whether knowledge and attitude scores were associated at pretest and posttest.

Research Questions 3 and 4: Pretest-Posttest Changes in Knowledge and Attitudes

To examine R.Q 3 and R.Q 4, a paired-samples t test was used for knowledge scores, and a Wilcoxon signed-rank test was used for attitude scores because the attitude change scores violated normality. Prior to conducting these tests, normality assumptions were verified through the Shapiro-Wilk test, analysis of skewness and kurtosis, and visual inspection of histograms and Q-Q plots. Furthermore, extreme outliers were scrutinized. Kandess-A scores were not normally distributed for R.Q 4, and the nonparametric Wilcoxon signed-rank test was used. All tests were two-tailed, with statistical significance determined at p less than 0.05. Additionally, Cohen's d and 95% confidence intervals were calculated for R.Q 3, and the effect size for the Wilcoxon signed-rank test was calculated as r = |z| divided by the square root of N.

Delimitations, Assumptions, and Limitations

This research was delimited to licensed R.N's, 18 years and older, within Kaiser Permanente in Northern California who volunteered to complete an online training module about N.D.E's. The study excluded all other health care professionals (such as physicians, advanced practice providers, mental health practitioners, spiritual care providers, and respiratory therapists), individuals under 18 years of age, other Kaiser Permanente regions, and different health care systems. The educational program was self-paced and administered online via Kaiser Permanente's secure platform; alternative formats, including hybrid or face-to-face sessions, were not considered. The study's outcomes focused solely on knowledge and attitudes related to N.D.E's, assessed through the Kandess instrument. No qualitative or behavioral data were collected, nor were patient outcomes or long-term results examined. The investigation evaluated only Level 2 (learning) of Kirkpatrick's model and excluded Levels 1, 3, and 4. The delimitations pertained specifically to nurse learning and attitude changes following N.D.E training.

The assumptions in this research were premises assumed to be true for the study's execution. It was presumed that the Kandess instrument is a valid and reliable measure of knowledge and attitudes among the participating nurses, consistent with prior research and psychometric evaluations conducted by Pace et al. (2016). Furthermore, it was assumed that all participants would respond to the Kandess items with honesty and to the best of their ability, and that they possessed sufficient proficiency in English to comprehend and complete the modules and the Kandess. An additional assumption was that participants would complete the three training modules prior to the administration of the posttest. In accordance with Ebbinghaus's (1885/1913) forgetting curve, a 1-week delay was used for the posttest. It was also assumed that participants would have access to appropriate devices and reliable internet connectivity to facilitate the completion of the modules and surveys via Microsoft Forms. The study used email addresses to link pretest and posttest surveys accurately to the corresponding study identification in accordance with the data management plan.

Potential limitations or weaknesses inherent in this study design may have impacted the generalizability and interpretation of the findings. First, the study employed a voluntary convenience sample of eligible licensed R.N's who opted to participate following recruitment via email and internal postings. Andrade (2020) indicates that convenience sampling involves selecting from a population accessible to researchers, and the results are thus only generalizable to that specific population.

Consequently, the findings of this research are confined to nurses within the Kaiser Permanente Northern California system. Second, this study employed a single pretest-posttest design without a control group, which cannot establish causality. Changes in Kandess scores were presented as evidence of learning rather than definitive proof that the training caused improvement. Third, the instrument utilized was a self-report tool, which Edlund and Nichols (2024) describe as a data collection method in the social sciences aimed at understanding individuals' knowledge, thought processes, and behaviors. Nonetheless, this method yields results that are unverifiable and susceptible to social desirability response bias. Fourth, response-shift bias may have occurred as participants progressed through the modules between pretest and posttest. Fifth, the study did not collect long-term data due to its design and the data-collection timeline within the dissertation. No long-term data were collected, potentially limiting understanding of long-term behavioral changes (Level 3) or patient outcomes (Level 4) following the educational intervention, as delineated by Kirkpatrick and Kirkpatrick's model. The design primarily aimed to examine learning (Level 2) and not other levels. Sixth, there was a risk of attrition between pretest and posttest, which could reduce the study's statistical power due to reduced sample size. However, Adams and McGuire (2022) assert that when data is limited to matched pretests and posttests, internal validity may remain intact.

Seventh, variations in memory consolidation may have influenced results owing to the self-guided nature of module completion and the 1-week interval between module completion and posttest; reminders were issued during the first, second, and third weeks post-completion to mitigate this effect, though some variability may have persisted. Eighth, minor discrepancies may have arisen from the utilization of the Microsoft Forms platform. Dominguez-Figaredo and Gil-Jaurena (2025) have observed that familiarity with digital tools can positively affect perceptions of assessment procedures. Since individual experiences with the platform may have differed, perceptions may have consequently varied. Despite these limitations, the design provided preliminary data for evaluating N.D.E training in future research.

This chapter described the design and methodology of a quantitative quasi-experimental research study intended to evaluate nurses' knowledge and attitudes concerning N.D.E's prior to and following an online, asynchronous educational intervention. Guided by the Kirkpatrick and Kirkpatrick (2006) Level 2 framework for assessing participant learning, the study was structured around four research questions. These questions examined changes in the dependent variables, knowledge and attitudes, following the targeted training, as well as the relationship between these constructs across the two time points.

Furthermore, a brief questionnaire was utilized to gather descriptive statistical data. The study aimed to recruit exclusively licensed nurses employed within the Kaiser Permanente Northern California health system, employing convenience sampling.

An a priori analysis in G*Power 3.1.9.7 established a required sample of 34 participants for a two-tailed test with an alpha level of.05 and 80% statistical power. Consequently, a minimum of 34 nurses was necessary to attain 80% power, and a recruitment target of 45 to 55 nurses was maintained to compensate for attrition. The final matched sample of 41 nurses exceeded the minimum required sample size. Nurses were recruited via convenience sampling through channels within the Kaiser Permanente system, including emails, online intranet posts, and word of mouth. This study extended prior research conducted by Loseu and Holden (2017) and employed an online asynchronous format. All consent procedures and modules occurred within a secure platform housed within Kaiser Permanente's firewall. Participation was kept confidential, though not anonymous. Participants were asked to complete three modules, followed by a posttest 1 week after completing the final module to evaluate retention of knowledge. Data analysis involved paired t-tests to compare pre-and post-training scores and Spearman's rho correlation to examine the relationship between knowledge and attitudes, using the Kandess. The analysis used Wilcoxon signed-rank tests for nonparametric data when scores did not meet the normality assumption.

The limitations of this study encompassed its scope within the context of the Kirkpatrick framework, the absence of a control group, limited generalizability, social desirability and response-shift biases, attrition, familiarity with the utilized digital platforms, and memory consolidation. These procedures established a framework for assessing the learning outcomes of N.D.E training for nurses. Chapter 4 will present the findings of this study alongside the analysis outlined in Chapter 3, including pre-and post-assessment scores, comparisons between them, correlations between knowledge and attitudes, and descriptive data.

Chapter 4: Results

This quantitative quasi-experimental study evaluated an educational program by comparing nurses' knowledge and attitudes regarding N.D.E's before and after a self-paced, three-module training, using pretest and 1-week delayed posttest Kandess surveys, and examined the relationship between knowledge and attitudes at each time point. The study focused on four research questions: (R.Q 1) What is the relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's before completing the N.D.E training program? (R.Q 2) What was the relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's after completing the N.D.E training program? (R.Q 3) Do nurses' knowledge about N.D.E's change significantly from pretest to 1-week delayed posttest following an N.D.E training program? And (R.Q 4) Do nurses' attitudes toward N.D.E's change significantly from pretest to 1-week delayed posttest following an N.D.E training program? This quantitative quasi-experimental study used a pretest-delayed posttest design with an online educational training comprising three modules. The training defined N.D.E's, discussed the potential harm of disclosure, and provided real-world examples of N.D.E disclosures. The Kandess was used to measure changes in knowledge and attitudes before and after the training intervention. Kirkpatrick's Level 2 framework served as the guiding theoretical model. This chapter presents descriptive results, including demographics, followed by findings organized by research question.

Descriptive Results

A total of 41 nurses employed at Kaiser Permanente completed both the pretest and 1-week delayed posttest, providing matched samples for 41 participants. This sample met the minimum required size of 34, as determined by an a priori power analysis in G*Power 3.1.9.7 for a two-tailed paired-samples t test with alpha = 0.05 and power = 0.80 (see Appendix E). Participants ranged in age from 37 to 67 years old, with a mean of 51.78 and a standard deviation of 7.45. Demographics are presented in Table 7.

Table 7 summary: Demographic characteristics of 41 registered nurse participants. The group is predominantly female at 85.4 percent and highly experienced, with 68.3 percent having been licensed for more than 20 years. In terms of education, the most common highest degree is a Master's at 41.5 percent, followed by a Bachelor's at 31.7 percent. The most frequent clinical settings are the Intensive care unit at 24.4 percent, Perioperative/PACU at 19.5 percent, and Other at 29.3 percent. Regarding professional experience with near-death experiences, 92.7 percent had no prior NDE education, though 56.1 percent reported that a patient has disclosed an NDE to them.

Descriptive statistics were computed for all participants (N = 41) on both subscales of the Kandess at pretest and posttest (see Appendix J). The Kandess-K, scored on a 1 to 5 scale, showed a pretest mean of 3.47 (S.D = 0.25), with scores ranging from 3.09 to 4.04. At posttest, the mean increased to 4.18 (S.D = 0.50), with scores ranging from 2.87 to 4.96. Pretest scores showed a slight positive skew (skewness = 0.26)

with a platykuric distribution (kurtosis = -0.74). Posttest scores reflected a modest negative skew (skewness = -0.56) and a near-mesokurtic distribution (kurtosis = -0.22), indicating a shift toward higher knowledge scores following the intervention. The

Kandess-A subscale, scored on a 1 to 7 scale, demonstrated a pretest mean of 6.20 (S.D =

0.65), with scores ranging from 3.96 to 7.00. At posttest, the mean was 6.48 (S.D = 0.64), with scores ranging from 3.87 to 7.00. Pretest scores showed a negative skew (skewness = -1.27) with a leptokurtic distribution (kurtosis = 2.17). Scores were concentrated in the upper range of the scale. Posttest scores showed negative skew (skewness = -2.61) and a leptokurtic distribution (kurtosis = 7.92).

Study Findings

The findings of this quantitative quasi-experimental study present the results of analyses conducted to evaluate changes in nurses' knowledge and attitudes regarding N.D.E's and to examine the relationships between these variables before and after the N.D.E training. The study addressed each research question using statistical procedures selected after assessing normality, thereby allowing interpretation of both parametric and nonparametric results. The following sections detail the relationships between knowledge and attitudes at pretest and posttest, as well as the changes in each construct one week after completing the training.

Relationship Between Knowledge and Attitudes Before Training

The study examined the relationship between nurses' knowledge and attitudes regarding N.D.E's prior to the online training. The alternative hypothesis predicted a statistically significant relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's prior to completing the training program. Normality was assessed for both pretest variables using the Shapiro-Wilk test, examination of skewness and kurtosis, and visual inspection of histograms and Q-Q plots. Kandess-K pretest scores were normally distributed, W (41) = 0.952 , p = 0.083. Kandess-A pretest scores violated the normality assumption, W (41) = 0.904 , p = 0.002. Because Pearson's product-moment correlation requires normality of both variables, Spearman's rho correlation was used as a nonparametric alternative. As displayed in Figure 3, Spearman's rho correlation indicated a statistically significant, large positive association between pretest Kandess-K and pretest Kandess-A scores, rho (39) = 0.539 , p less than 0.001. The squared Spearman rank-order correlation coefficient of determination indicated that nurses' knowledge and attitude rank scores shared approximately 29% of their variance prior to the training. The alternative hypothesis (H.1) was supported at alpha = 0.05 .

Figure 3 summary: A scatter plot showing the relationship between KANDES-A attitude scores and KANDES-K knowledge scores before training for 41 participants. A positive linear regression line is plotted with an R-squared value of 0.275, indicating a weak to moderate positive correlation where higher attitude scores generally correspond with higher knowledge scores.

Figure 3

Relationship Between Knowledge and Attitudes After Training

The study examined the relationship between nurses' knowledge and attitudes regarding N.D.E's 1 week after the online training. The alternative hypothesis predicted a statistically significant relationship between nurses' knowledge about N.D.E's and their attitudes toward N.D.E's 1 week after completing the training program. Normality was assessed for both posttest variables using the Shapiro-Wilk test, examination of skewness and kurtosis, and visual inspection of histograms and Q-Q plots.

Kandess-K posttest scores were normally distributed, W 41 equals point 961, p equals point 170.

Kandess-A posttest scores violated the normality assumption, W 41 equals point seven zero eight, p less than point zero zero one.

Because Pearson's product-moment correlation requires normality of both variables,

Spearman's rho correlation was used as a nonparametric alternative. A

Spearman's rho correlation indicated a statistically significant, large positive relationship between posttest Kandess-K and posttest Kandess-A scores, rho 39 equals point 501, p less than point 001

(see Figure 4). The squared Spearman rank-order correlation coefficient of determination indicated that nurses' knowledge and attitude rank scores shared approximately 25% of their variance after the training. The alternative hypothesis (H.2) was supported at alpha equals point zero five.

Figure 4 summary: A scatter plot showing the relationship between KANDES-A attitude scores (x-axis) and KANDES-K knowledge scores (y-axis) for 41 participants. A positive linear trend line is plotted with an R-squared value of 0.369, showing that as attitude scores increase, knowledge scores generally increase as well. The takeaway is that there is a positive correlation between participants' attitudes and knowledge regarding near-death experiences.

Figure 4

Comparing Knowledge About N.D.E's Before and 1 Week After Training

The study examined changes in nurses' knowledge regarding N.D.E's from pretest to the 1-week delayed posttest. The alternative hypothesis predicted that nurses' knowledge scores would significantly change from pretest to 1-week delayed posttest. Normality of the Kandess-K change scores (posttest minus pretest) was assessed using the Shapiro-Wilk test, examination of skewness and kurtosis, and visual inspection of histograms and Q-Q plots. The Kandess-K change scores were normally distributed, W (41) = 0.974 , p = 0.470; therefore, a paired-samples t test was used. All tests were two-tailed at alpha = 0.05 . Cohen's d was calculated to describe the magnitude of the paired difference, and a 95% confidence interval for the mean difference was reported.

Kandess-K total scores increased significantly from pretest (M = 3.473, S.D = 0.252) to posttest (M = 4.176, S.D = 0.495), t (40) = -8.614, p less than 0.001, d = 1.345, 95% C.I [-0.868,

-0.538] as seen in Figure 5. The negative t value and confidence interval reflect the pretest-minus-posttest subtraction in S.P.S.S; scores increased. The effect size (d = 1.345)

was large. The alternative hypothesis (H.3) was supported at alpha equals point zero five.

Figure 5 summary: A boxplot comparing the mean KANDES-K total knowledge scores before and after training on a scale from 1 to 5. The scores after training are notably higher and show a wider distribution than the scores before training. The takeaway is that the training led to an overall increase in knowledge scores.

Comparing Attitudes Toward N.D.E's Before and 1 Week After Training

The study examined changes in nurses' attitudes toward N.D.E's from pretest to the 1-week delayed posttest. The alternative hypothesis predicted that nurses' attitude scores would significantly change from pretest to 1-week delayed posttest. Normality of the Kandess-A change scores (posttest minus pretest) was assessed using the Shapiro-Wilk test, examination of skewness and kurtosis, and visual inspection of histograms and Q-Q plots. The Kandess-A total change scores violated the normality assumption, W (41) = 0.746 , p less than 0.001, confirmed by skewness and kurtosis values (see Appendix J). Therefore, a Wilcoxon signed-rank test was used as a nonparametric alternative. All tests were two-tailed at alpha equals point zero five. Effect size was calculated as r equals absolute value of z divided by the square root of N. Kandess-A total scores increased significantly from pretest ( M equals 6.199, S.D equals 0.654) to posttest ( M equals 6.476, S.D equals 0.639), z equals minus 4.128, p is less than point zero zero one, r equals point 644, shown in Figure 6. The effect size ( r equals point 644) was large. The alternative hypothesis (H.4) was supported at alpha equals point zero five.

Figure 6 summary: A boxplot comparing KANDES-A total scores before and after an intervention. The post-intervention scores show a higher median and a higher overall distribution compared to the pre-intervention scores, though both groups exhibit several low-scoring outliers. The takeaway is that total KANDES-A scores generally increased following the intervention.

Figure 6

Note. Kandess-A = Knowledge and Attitudes about Near Death Experiences–Attitudes subscale. Scores are mean scores for the Kandess-A pre-and posttests on a scale from 1 to 7. Open circles indicate moderate outliers; stars indicate extreme outliers.

This chapter presented the results of a quantitative quasi-experimental study that examined changes in nurses' knowledge of and attitudes toward near-death experiences after a three-part asynchronous online training program. Data from a matched sample of 41 registered nurses were analyzed using parametric and nonparametric procedures. Knowledge and attitude scores were both significantly higher at the 1-week delayed posttest than at pretest. Nurses showed greater knowledge of N.D.E's and more supportive attitudes after completing the program. Knowledge and attitude scores were also positively associated at both time points, which suggests a relationship between cognitive and affective learning outcomes.

These results provide a basis to discuss N.D.E education and its association with measurable improvements in nurses' knowledge and attitudes. They give a foundation for interpreting the training program, considering its implications for nursing practice and education, and identifying areas for further study. Chapter 5 interprets these results, examines their implications, discusses the study's limitations, and offers recommendations for future research.

Chapter 5: Discussion

This quantitative quasi-experimental study evaluated a self-paced, three-module educational program by comparing nurses' knowledge and attitudes regarding N.D.E's before and after the training. The study used a pretest and a 1-week delayed posttest, Kandess surveys, and examined the relationship between knowledge and attitudes at each time point. The findings showed statistically significantly higher knowledge and attitude scores at posttest than at pretest. This chapter summarizes the study's findings, discusses the results in relation to existing literature and caring science, considers the implications for nursing education, nursing practice, and nursing theory, acknowledges the study's limitations, and presents recommendations for future research.

Summary of Findings

This section summarizes the main findings for each of the four research questions, as presented in Chapter 4. This section presents the findings without interpretation; the subsequent section provides the interpretation. All pertinent statistical results are documented in Chapter 4.

The first research question concerned the link between nurses' knowledge about N.D.E's and their attitudes toward them before any training had taken place. The findings indicated that prior to the training, nurses possessing greater knowledge of N.D.E's, or higher Kandess-K scores, generally held more favorable attitudes, or higher Kandess-A scores. The association was strong, and approximately 29% of the variance in nurses' ranked knowledge and attitude scores was shared prior to the training.

The second research question focused on the link between nurses' knowledge and attitudes 1 week after the educational training. The results showed that the same connection between knowledge and attitude was present. Just as before the education, nurses with greater knowledge of N.D.E's tended to have more supportive attitudes toward them after the educational training. The estimated shared rank-order variance between nurses' knowledge and attitude scores decreased slightly from approximately 29% at pretest to approximately 25% at 1-week delayed posttest.

The third research question assessed whether nurses' knowledge about N.D.E's changed following the N.D.E educational training. Knowledge scores were higher 1 week after training than before training, rising from an average of 3.47 to 4.18 on the 5-point scale. The fourth research question addressed attitudes toward N.D.E's and N.D.E-ers. Nurses reported more supportive attitudes after the training than before it, with scores rising from an average of 6.20 to 6.48 on the 7-point scale.

The findings showed that knowledge and attitudes were positively associated at both times, with higher scores on Kandess subscales at posttest than pretest. The discussion explores these findings and their relation to past research and frameworks.

Discussion of Findings

This study examined nurses' knowledge about and attitudes toward N.D.E's before and after a three-part, self-paced online training program. The study addressed four research questions with the Kandess and Kirkpatrick's Level 2 evaluation framework. The discussion below relates the findings to existing literature, the study's theoretical contributions, and the biblical foundations established in Chapter 2.

R.Q.1: Relationship Between Knowledge and Attitudes at Pretest

Prior to the training, nurses with greater knowledge of N.D.E's also exhibited more supportive attitudes toward them. The connection between knowledge and attitudes was strong. Just under one-third (29%) of the rank-order variance in nurses' knowledge and attitude scores was shared prior to the training. The findings revealed a correlation: Nurses who possessed a deeper understanding of these experiences tended to approach them with openness rather than skepticism.

This pattern aligns with the literature in Chapter 2, which describes how knowledge and attitudes can impact how health care professionals respond to patients who disclose N.D.E's. Holden et al. (2014) documented that some N.D.E's perceived their disclosures to health care professionals as negative, unpleasant, or harmful. Those findings underscore the benefits nurses can gain from learning how to communicate with and educate patients who disclose N.D.E's. Lack of knowledge may therefore be a contributing factor to less supportive attitudes. Similarly, Pehlivanova et al. (2025) found that a positive initial reaction to a disclosure increased the likelihood that experiencers would regard the support they received as helpful. The pretest correlation found here provides evidence of the knowledge-attitude link among this sample of nurses.

Loseu and Holden (2017) investigated the same relationship among licensed professional counselors and discovered that knowledge about and attitudes toward N.D.E's were positively correlated prior to training. The findings align with the present research, indicating that among nurses, as with counselors, increased knowledge of N.D.E's is associated with more supportive attitudes toward N.D.E's prior to any training. This study further distinguished itself by including licensed registered nurses as health professionals, a demographic not examined by Loseu and Holden (2017).

The pretest correlation also aligned with Bloom's (1956) theory of learning, which posits that the cognitive and affective domains are distinct yet interconnected. Nurses with a stronger factual understanding of N.D.E's also held more supportive attitudes toward them and the individuals who experience them, which indicated that the two dimensions of learning did not function independently in this sample. The Kandess assesses knowledge and attitudes simultaneously, and its use contributes to the evidence supporting Kirkpatrick's framework stating that knowledge and attitudes are part of Level 2 learning.

R.Q.2: Relationship Between Knowledge and Attitudes at Posttest

One week after the training, the correlation between nurses' knowledge and attitudes remained largely consistent with the initial observations. Nurses with greater knowledge continued to report more positive attitudes toward N.D.E's, with approximately 25% of the rank-order variance in knowledge and attitude scores shared at the 1-week delayed posttest. Although the correlation was marginally weaker than before nurses participated in the training, it remained.

Knowledge scores went up after the training, but the link between knowledge and attitudes changed only slightly from pretest to posttest. Loseu and Holden (2017) found that the relationship between knowledge and attitude became more pronounced after training within their counselor sample, which contrasts with the findings of the present study. The present study found statistically significant positive associations at both pretest and posttest. This was the one area in which the present results ran counter to the comparison study. The difference may stem from the makeup of the two samples, the different settings, or this study's single-group design, as opposed to the two-group design Loseu and Holden (2017) used. The study did not test whether the pretest and posttest correlations differed; however, it did establish positive pre-and posttest associations. The connection did not grow stronger after training, unlike the connection reported by Loseu and Holden (2017). Determining whether this response to training is common among nurses or specific to this group may require investigation across larger, more varied samples.

R.Q.3: Change in Knowledge Pretest to Posttest

Nurses demonstrated a significantly higher level of knowledge regarding N.D.E's 1 week following the training compared to prior to the training, with average scores rising from 3.47 to 4.18 on the 5-point scale. The self-paced training contained material related to N.D.E patterns, aftereffects, and experiencer characteristics. At the conclusion of the study, nurses exhibited a markedly increased understanding of the nature of these experiences, their short-and long-term effects, and the characteristics of the individuals reporting them, compared to their initial knowledge.

Loseu and Holden (2017) found a similar knowledge increase after comparable training among counselors. In their analysis, knowledge was the main factor that set trained participants apart from untrained ones. This study extended that finding to a new context, a nursing workforce within a large integrated health system, where knowledge again rose after the training.

Zingmark and Granberg-Axell (2022) and Samoilo and Corcoran (2020) have called for health care institutions to offer such training. The increases in scores found in this study may provide support for recommendations that had relied mainly on interview and narrative evidence.

Participants began the study with some understanding of N.D.E's. On average, their knowledge scores before training were about 3.5 on the 5-point scale, above the midpoint, though their scores left room for further learning. This finding corresponds with research by Mandalise (2013) and Foster et al. (2009), who found that N.D.E content was mostly missing from nursing curricula, even for practitioners who wanted to learn it. Loseu and Holden (2017) also reported that most of their participants had no formal education on the subject. In the current study, the large majority of the participants had no prior formal education on N.D.E's, but more than half of the nurses had heard accounts of N.D.E's directly from patients. Their initial familiarity likely came from clinical encounters rather than formal learning, which points to the need for a structured program to build on what they knew.

The timing of the knowledge assessment was another important element of the current study. According to Ebbinghaus (1885/1913), most forgetting occurs within hours and days of learning. Murre and Dros (2015) confirmed this pattern; therefore, the study retested nurses' knowledge 1 week after the final module. Loseu and Holden (2017), on the other hand, retested participants immediately after training.

It is possible that some of their participants' gains came from short-term memory. Waiting a week reduced that risk and made it more likely that the scores reflected lasting retention. Nurses scored higher on the knowledge measure after 1 week, indicating retention beyond the steep early decline of the forgetting curve and supporting an interpretation of retention rather than short-term recall.

R.Q.4: Change in Attitudes Pretest to Posttest

Nurses' attitudes toward N.D.E's were more supportive 1 week after the training than before, with average scores rising from 6.20 to 6.48 on the 7-point scale. The change was statistically significant, though attitudes were positive even before the training. The high baseline limited the room for attitude scores to rise, which restricted the magnitude of the change that could be observed.

Loseu and Holden (2017) found a greater increase in attitude scores among trained counselors than untrained ones in their study, but attitudes improved less than knowledge in their sample, according to their descriptive statistics. They evaluated knowledge and attitudes jointly through descriptive discriminant analysis, and they did not analyze attitude change separately, as this study did. However, the researchers did comment on why there may have been small increases in attitude scores rather than large ones.

They suggested that attitudes may already have been positive before training, leaving little room for further improvement, or that attitude change may take longer or require repeated exposure, unlike gains in knowledge. The current findings align with these ideas. First, nurses' attitude scores approached the top of the possible range before training and showed only limited improvement after training. The high starting point may, however, be only part of the explanation for the small increase in attitude scores.

Loseu and Holden (2017) offered another possibility, which also applies, that a single, self-paced program may not provide the time or repeated exposure that a shift in attitudes appears to require, and the modest movement observed in the study is consistent with the possibility that meaningful attitude change may require more than one training program.

The high attitude scores at the beginning of the study may be attributable to several factors. First, nurses in this study were self-selected, meaning that they chose to take part in this study. The consent and description of the study made it clear that N.D.E's would be a focus of the research. Individuals who were attracted to this study may have already been receptive to the subject matter. Additionally, within the selected health system, there is high regard for ongoing research and professional development. The incentive of two continuing education units for completing the study, in addition to the existing organizational culture, may have created a more receptive sample than might be found in other settings. In the present study, attitude scores, although high at baseline, increased after the training, despite having little room to increase.

Samoilo and Corcoran (2020) recommended the implementation of standardized N.D.E training for health care professionals. Holden et al. (2014) support this recommendation; they found that some experiencers perceived N.D.E disclosures as harmful regardless of the professional's background. This finding highlights the potential benefit of this training program for all health care professionals, even with the high scores seen prior to training. Pehlivanova et al. (2025) found that a supportive first reaction influenced whether experiencers judged their care as helpful. That attitudes improved in this study, even from a strong starting position, suggests that formal training may contribute something beyond the accepting attitudes nurses already possessed and that the instrument was sensitive enough to capture the change.

Another point to consider is the design of this study compared to Loseu and Holden's (2017). This study used a single cohort of nurses without a control group. Because of the design, it is not possible to state that the increase in knowledge and attitudes was only due to the training. Potential external influences may have affected the study between its beginning and end. Influences such as interactions with patients, clinical experiences, discussions with other participants, independent research on the topic, or completion of the pretest may have influenced the results. The Limitations section discusses the constraints created by the study design.

Clarifying the outcomes assessed within Kirkpatrick and Kirkpatrick's framework helps define the study's scope. This investigation examined Level 2 outcomes, which pertain to the learning evidenced by changes in nurses' knowledge and attitudes. It did not evaluate Level 3 outcomes, which pertain to the actual behaviors and responses of nurses in clinical practice. Consequently, the results are consistent with learning occurring; however, they do not demonstrate that nurses' behaviors at the bedside have necessarily changed as a result. Whether the observed improvements in knowledge and attitudes led to different responses from nurses to patients disclosing N.D.E's remains unknown and was beyond the scope of this study.

Theoretical Contributions

This study made contributions to the theoretical literature. It provided empirical evidence supporting Kirkpatrick's Level 2 framework in a nursing context. Increases in knowledge and attitudes were consistent with the learning outcomes associated with Kirkpatrick's second level, thereby extending the application of this framework in nursing education, specifically in N.D.E training, a subject not previously evaluated using this framework. As noted above, this contribution is bounded by the level of the model the study addressed: The evidence speaks to learning, not to the subsequent levels of behavior or results.

The study also supported forgetting curve by demonstrating that the increase in knowledge remained quantifiable 1 week subsequent to training. Since Loseu and Holden (2017) conducted their assessment immediately after the training, their results could not exclude the possibility of short-term recall. The decision to delay testing for 1 week, based on Ebbinghaus's finding that forgetting occurs most rapidly during the initial days after knowledge is acquired, yielded scores consistent with learning, thereby supporting the implementation of delayed assessments in future evaluations of similar programs.

The connection this research found between knowledge and attitudes supports position that the cognitive (knowledge) and affective (attitude) domains are interlinked rather than distinct. Loseu and Holden (2017) identified a comparable association among their sample of counselors. The current study, employing a different design, expands the findings to a new professional cohort of nurses and provides additional support for assessing both dimensions within a single instrument to evaluate learning.

This study extended the work of Loseu and Holden (2017) with counselors to registered nurses within a health care system setting. This extension demonstrates the potential scalable nature of the training program and the use of the Kandess tool. The

Kandess is a validated assessment tool that has seen limited use in the literature thus far, and this investigation is among the first attempts to use it within a registered nurse population. Studies such as those by Samoilo and Corcoran (2020) and Zingmark and

Granberg-Axell (2022) lacked a pre-and posttest intervention in their call for health care education around N.D.E's specific to nurses. Additionally, reported unmet support needs of N.D.E-ers without evaluating a training program. This current research has contributed to the field by providing pre-and posttest data from a validated tool after employing a training program. This design sets this study apart from previous work that was mostly observational.

The findings from this research relate to the job demands-resources framework that informed this study. The literature review in Chapter 2 conceptualized an unexpected near-death disclosure as a job demand, or an emotionally taxing scenario that a nurse must manage in real time. The discussion argued that N.D.E training could serve as a job resource to help nurses meet that demand. The increase in nurses' knowledge supported this framing, as the training provided the type of informational resource the model describes. A nurse who genuinely understands what N.D.E's are, who they happen to, how they impact a person's life in the long and short term, and how to offer resources and support is better suited to respond to disclosures from patients than a professional lacking those foundational pieces of knowledge. The observed knowledge gain in this study aligns with the notion that structured education can function as a workplace resource for demands that nurses cannot anticipate but are likely to face. However, based on the smaller shift in attitude scores, it is possible that the training may have a greater impact on knowledge than attitudes, acting as a better resource for the cognitive job demand of disclosures than emotional or relational demands.

The findings further connect with Watson's (2018) caring science, which Chapter 2 established as a relational framework for how nurses receive and respond to patients.

Health care professionals with attitudes supportive of N.D.E disclosures exhibit a willingness to listen, remain present with the patient as they share their stories, do not dismiss or reject their accounts, and treat the patients with reverence and calm, understanding the nuance of each individual's experience. These qualities outlined in the attitudes portion of the Kandess closely align with Watson's Caritas Processes.

Watson's model focuses on authentic presence, openness to mystery, and the cultivation of a trusting relationship. The overall improvement in nurses' attitudes following training was consistent with a shift toward a caring orientation. Watson also described the development of these qualities as happening over time, which aligns with Loseu and

Holden's (2017) assertion that attitude changes may take consistency and repetition, as well as with the findings in this current research. Based on the attitude scores, it is possible that the training was consistent with Watson's (2018) caring science framework of a caring orientation. It is likely that the fully developed expression of the caring orientation depends on sustained practice beyond the scope of a single program.

Biblical Foundations

The findings connect to the biblical foundations in various ways. At the center of caring for patients with dignity is the doctrine of the imago Dei, teaching that all persons are created in God's image. This belief underpins the respect given to patients sharing N.D.E's. Because every person is made in God's image, they deserve care and compassion, and health care providers should have the ability to understand that the human mind may not be able to make sense of what the soul experiences. Shelly and Miller (2006) described nursing as a calling with compassionate service at its core. Clinical skills are certainly the bedrock of nursing, but the compassionate service that so many nurses provide is a way to embody Christian principles, including humility and kindness. When nurses treat patients who share their stories with presence and sincerity, they exemplify these values.

The findings for the first and second research questions relate to how understanding and temperament work together. Knowledge and attitudes were positively associated at both time points. In Scripture, knowledge and character are intertwined, so growth in one supports growth in the other. This connection reflects the study's finding that nurses with greater knowledge of N.D.E's tended to hold more supportive attitudes toward them.

The third research question relates to the biblical principle of equipping people for meaningful work. Higher knowledge scores at posttest reflect the biblical teaching of empowering people for meaningful work. Ephesians 4:11 to 12 highlights leaders' role in"equipping the saints for the work of ministry, for building up the body of Christ". A training program that raises nurses' knowledge of N.D.E's is one way to equip them for this kind of service.

The findings for the fourth research question relate to the scriptural call to listen before speaking and to respond with gentleness. Proverbs 18:13 cautions to listen before answering: "If one gives an answer before he hears, it is his folly and his shame." The ability to receive a patient's N.D.E disclosure with patience and gentleness rather than in haste, can demonstrate the fruit of the Spirit, such as gentleness, patience, and kindness, reflected in Christian nature (Galatians 5:22 to 23). More supportive attitudes align with a willingness to listen without dismissal and to receive patient stories with humility. Proverbs 1:5 instructs readers to listen, increase their learning, and seek guidance, which this study encouraged; the higher knowledge and attitude scores demonstrated learning.

Finally, although the N.D.E phenomenon is not explicitly named in Scripture, the Bible provides accounts of experiences beyond the physical world, as discussed in Chapter 2. For instance, Paul described being caught up to paradise and hearing"things that cannot be told, which man may not utter". Patients who share their N.D.E's often describe feelings that are equally difficult to express and very personal. The deeply personal nature of an N.D.E disclosure underscores the importance of training nurses to listen with compassion and care, rather than dismissing these profound accounts.

The findings of this research have implications for nursing education, practice, and theoretical frameworks. This study investigated changes in nurses' knowledge and attitudes regarding N.D.E's following a self-directed, three-part educational program. The results demonstrated statistically significant improvements in both knowledge and attitudes upon the completion of the training. These findings contribute to the existing body of research on nurses' educational preparedness to respond to patients who disclose N.D.E's. Due to the study design, which employed a one-group pretest and 1-week delayed posttest without a comparison group, the changes in knowledge and attitudes cannot be attributed solely to the educational training. This section discusses how the findings from this research might inform nursing education, professional practice, theory, the scientific community, industrial-organizational psychology consultation, and faith-based organizations.

Implications for Nursing Education

A central implication of this research relates to nursing education. Prior studies have found that nurses are seldom provided with formal training on N.D.E's or methods to support patients who experience them, despite the likelihood of encountering such situations in their routine nursing practice (Holden et al., Mandalise,

Pehlivanova et al., Research has also shown that limited knowledge of N.D.E's may lead to responses that patients perceive as dismissive or unhelpful (Holden et al.,

Pehlivanova et al., Samoilo & Corcoran, The present study contributes to the existing literature by demonstrating that nursing participants had higher scores on knowledge and attitude assessments following completion of educational modules. This approach is one strategy for addressing the existing preparation gap.

Participants completed the educational modules in a self-paced online format, suggesting that this approach is feasible for delivering specialized educational content to practicing nurses. Nurses must contend with daily schedules and demands that are sometimes unpredictable, making it difficult to allot time for training for patient-facing nurses. However, continuing education is expected of registered nurses.

The implementation of training modules such as the one in this study aligns with the A.A.C.N Essentials' (2021) emphasis on preparing nurses to deliver holistic, person-centered care through lifelong learning and professional development. This study did not evaluate or compare various instructional approaches. However, the results indicate that a self-paced online model may be one way to transfer N.D.E knowledge to working nurses.

Because N.D.E's receive little attention in traditional nursing education, this format may serve as one approach to supplement existing continuing education and professional development programs.

These implications extend across the continuum of nursing education. This study was limited to practicing registered nurses. However, the educational gap identified in the literature extends beyond the practicing workforce to prelicensure programs, graduate education, nurse residency, orientation for newly hired nurses, and continuing education. This recommendation aligns with the A.A.C.N's (2021) patient-centered, evidence-based education.

Implications for Nursing Practice

This study also has implications for nursing practice, particularly in situations where patients choose to disclose an N.D.E. Previous research has shown that many nurses receive little or no education about N.D.E's, even though these conversations often occur in clinical settings. Participants in the present study had higher knowledge scores and more positive attitudes after completing the educational modules. Education about N.D.E's may better prepare nurses to care for and communicate with patients who discuss these experiences.

Knowledge of the characteristics of an N.D.E is only one element of supporting patients who have disclosed their experience. Patients often remember how health care professionals respond when they first talk about these experiences, and dismissive reactions may discourage them from saying more. The findings suggest that education may help nurses approach these conversations with a nonjudgmental attitude, attentive listening, and respect for the patient's perspective. The nurse's role is to recognize that the experience may hold personal meaning for the patient and to respond in a therapeutic, professionally appropriate way, rather than to interpret its meaning.

Watson's caring science also reflects these ideas and describes nursing as more than completing clinical tasks. It includes being present with patients, listening carefully, and recognizing the importance of spiritual experiences for the individual.

Implications for Theory

An important implication of this study is that learning occurred in both the cognitive and affective domains described by Bloom (1956). The findings are also consistent with Kirkpatrick and Kirkpatrick's (2006) Level 2 (Learning). However, the study did not examine whether learning influenced nursing practice or patient outcomes, which correspond to Kirkpatrick's Levels 3 and 4. The findings also relate to the job demands-resources model, in that structured education may serve as a job resource that helps nurses manage emotionally demanding situations such as unexpected N.D.E disclosures. Nursing leaders responsible for education and professional development may wish to consider adopting an approach similar to the one in this study to educate their staff.

Implications for the Scientific Community

This study has implications for how the Kandess is used as a tool. Pace et al. (2016) built and tested the Kandess using counseling students and practicing counselors. They designed the tool for use across health professions and hoped future researchers would test it with other groups. Loseu and Holden (2017) used the scale with another sample of counselors. This study used the Kandess with registered nurses, a group not included in the original testing or other research.

The tool detected a change in nurses' scores after training. This suggests the Kandess can be used outside the group in which it was first used, and it gives other researchers a reason to consider the tool when studying education on N.D.E's. This study, therefore, adds to the existing literature by using the Kandess to examine pre-and posttest data from nurses in a large health care system. Unlike many studies that used qualitative data or counselor samples, this research offers quantitative insights about nursing in particular.

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The findings from this study have implications for I/O psychology consultation. Among other offerings, I/O consultants can support organizations by designing and developing effective training aligned with employees' competencies. This study offers a model for providing N.D.E training to nurses within the health care system and industry.

The results suggest that brief, self-paced training can be associated with measurable gains in employees' knowledge and attitudes, a common goal of workplace learning programs. I/O consultants within health care may also seek additional ways to improve bedside manner and communication with health care professionals, which the findings from this research may also inform. Considering that many N.D.E disclosure interactions can be a high emotional demand for the nurse, the training can also be framed as a job resource under the Job Demands-Resources model. This contributes to employee well-being, retention, and engagement.

Due to the asynchronous nature of the education, it may also be easier to spread across organizations that require alternative work schedules and models.

Implications for Faith-Based Organizations

The findings may also have significant implications for Christian and other faith-based nurses, organizations, and nursing education programs. Shelly and Miller (2006) asserted that nursing constitutes a form of ministry characterized by compassion and holistic care. Providing education that equips nurses to handle N.D.E reports from patients in a nonjudgmental manner is an effective way to support their ministry. The training methodology outlined in this study has the potential to prepare Christian nurses to perform their service-oriented roles while practicing skills such as active listening and healing. There may also be an opportunity to collaborate with spiritual care providers, such as chaplains, in hospital settings. Additionally, faith-based organizations might consider N.D.E training as a strategic approach to empowering nurses to deliver spiritually competent and sensitive care.

Organizations that have implemented the caring science nursing theory may find value in incorporating N.D.E training into their educational framework. Given the significant overlap between the core principles of caring science and best practices for responding to N.D.E disclosures, such as being present, humble, receptive, and compassionate, there is an opportunity for caring science coaches to integrate N.D.E training into their instructional modules.

The implications above share a common thread. A brief, structured course on N.D.E's was associated with higher knowledge and more supportive attitudes, and nurses with both may be better prepared to respond to patients with competence and compassion. These findings reach nursing education, clinical practice, theory, the scientific community, industrial-organizational psychology consultation, and faith-based care. N.D.E education has value across the settings where nurses are trained and supported.

This study presents several limitations acknowledged prior to data collection, as well as additional constraints identified during the research process to consider. These limitations relate to the research design, sampling methods, instrumentation, study procedures, and overall scope of the project.

The primary limitation relates to the research design. This study employed a one-group pretest-posttest design without a control group. In the absence of a comparison group, it is not possible to definitively attribute the observed increases in knowledge and attitudes solely to the educational training. External factors, such as interactions with colleagues, patient encounters, autonomous reading, or increased familiarity with the survey questions, may have also contributed to the increase in scores between the pretest and posttest. Furthermore, this investigation focused exclusively on learning outcomes, aligning with Level 2 of Kirkpatrick's evaluation model. The study did not assess whether nurses changed their clinical practices after training or whether the training affected patient care outcomes.

The second limitation was the sample utilized. A predominantly female cohort of experienced nurses, each with over 20 years of professional practice, was recruited via convenience sampling from Kaiser Permanente Northern California. Consequently, the findings may not be generalizable to nurses at different stages of their careers, male nurses, or individuals employed within other health care systems or practice environments. Participation was voluntary, and nurses were informed that the study focused on N.D.E's prior to deciding whether to participate. It is plausible that nurses with an interest in spirituality or N.D.E's were more inclined to volunteer than those without such interests, potentially influencing the scores.

A third limitation pertains to the measurement instrument. The Kandess is a self-report survey; thus, responses depend on participants' evaluations of their own knowledge and attitudes. Self-report measures are inherently subject to response bias, as participants may answer in ways they perceive as expected following the training. Response-shift bias may also have influenced results as nurses became more familiar with the instrument, thereby affecting scores. Although researchers designed the Kandess for various health professionals, they primarily validated it with master's counseling students and practicing counselors rather than nurses. While the instrument demonstrated satisfactory performance in this study, further research involving nursing populations would enhance confidence in its applicability to registered nurses.

The study's procedures were the fourth limitation. Because the educational program was self-paced, participants completed the training and posttest on slightly different schedules. While reminders were sent and all participants completed the posttest within the designated time frame, the time between finishing the training and completing the posttest varied among participants.

This variability is relevant given that forgetting occurs most rapidly in the days immediately following learning. Participant attrition also occurred between the pretest and posttest. Although the final matched sample exceeded the minimum sample size identified in the power analysis, attrition reduced the number of participants included in the final analysis. Differences in participants' familiarity with the Microsoft Forms platform, used for consent, collection of demographics, and both Kandess administrations, may also have influenced their experience completing the surveys, since prior comfort with a digital tool can affect how participants perceive the assessment process (Dominguez-Figaredo & Gil-Jaurena, 2025).

Fifth, recruitment procedures were a limitation of this study. The majority of recruitment was conducted via email, internal communication channels, and word of mouth within the organization. Recruiting nurses in person across all Kaiser Permanente Northern California medical centers was beyond the scope of this dissertation study.

Instead, the sample consisted of individual participants who independently observed recruitment flyers and announcements. Participants also received two contact hours of continuing education credit upon completion of the study. Individuals seeking hours may have been motivated by the opportunity to earn such credits.

Lastly, all study materials were presented exclusively in English, which may have limited accessibility for individuals preferring other languages.

A sixth limitation pertains to the scope of analysis. This study assessed overall changes in knowledge and attitudes using the total Kandess knowledge and attitude scores. It did not examine changes within individual knowledge domains or attitude factors comprising the instrument. Consequently, it was not feasible to determine whether certain aspects of knowledge or attitudes experienced greater change than others following the educational intervention.

The findings of this study present many possibilities for future researchers. The training program was associated with significant increases in nurses' knowledge and attitudes regarding N.D.E's. The design, sample, and scope of the project raise additional questions that, if addressed, could further reinforce the evidence supporting N.D.E education in nursing. The following recommendations expand upon both the findings and limitations identified in the current study.

Examine Individual Knowledge Domains and Attitude Factors

The present study focused on overall knowledge and attitude scores rather than on the specific domains and factors that constitute the Kandess. The analysis of the total scores addressed the primary research questions and revealed significant improvements in participants' knowledge and attitudes following the educational intervention. Future researchers could focus on how the three knowledge domains and four attitude factors do or do not change. These findings could indicate which training components require improvement and how researchers might improve them.

For instance, future research could investigate whether nurses exhibit greater gains in understanding the content of N.D.E's or in recognizing common aftereffects. Or, whether certain attitudes are more prone to change than others. Such insights could inform the refinement of future educational programs by highlighting topics that justify increased focus.

Utilize Comparison or Control Groups

An additional logical extension of the present study would be to repeat this study, incorporating a comparison or control group. While the one-group pretest-posttest design has proven effective in assessing participant improvement, it does not exclude alternative explanations for such improvements. A randomized controlled study would yield more evidence from a comparison-group design that the observed modifications are attributable to the training program itself. A follow-up study employing a more rigorous design would enhance confidence in the program's effectiveness.

Assess Behavioral and Clinical Outcomes

This study examined learning outcomes aligned with Level 2 of the Kirkpatrick model. However, it did not investigate whether learning translated into behavioral changes in nurses' daily practice. Investigating whether education affects behavior may be a valuable research pursuit. Future research could examine whether nurses who complete N.D.E education modify their approaches toward potential N.D.E's, feel more confident initiating conversations about N.D.E's, communicate differently, or exhibit greater comfort in providing emotional and spiritual support. Although such studies may require additional time, they would also allow researchers to assess whether patients perceive interactions with trained nurses as more supportive and trustworthy, and whether patients' overall experience is enhanced.

Evaluate Long-Term Retention

Knowledge and attitudes were measured 1 week after participants completed the educational program. Although scores at this time point demonstrated short-term learning, the study did not determine whether participants maintained those gains over time. Additional follow-up assessments at 1 month, 3 months, 6 months, or even 1 year after the training would provide data about long-term retention.

Further, qualitative studies may identify learnings that a previously developed tool may not capture. Those findings could also help determine whether periodic refresher education is needed to maintain nurses' knowledge and confidence and whether participants' educational needs change over time.

Replicate the Study Across Diverse Nursing Populations

Given that this investigation was confined to nurses within a single health care system, replicating the study across diverse settings may generate more generalizable results. Including nurses from various regions of the country, other nations, different clinical specialties, and a range of health care organizations would reveal whether increases in knowledge and attitude scores were consistent across different populations. Also, expanding the participant criteria to include nurses with diverse educational backgrounds, levels of experience, and clinical roles could provide more comprehensive insight into the areas in which this form of education may have the greatest impact.

Investigate Outcomes Related to Nurse Well-Being

Although this study primarily concentrated on educational outcomes, future research could also explore how asynchronous N.D.E education impacts nurses themselves. From the perspective of the job demands-resources model, education may serve as a job resource by enhancing confidence and diminishing uncertainty for nurses interacting with patients who disclose N.D.E's. Research that incorporates outcomes such as burnout, emotional exhaustion, compassion satisfaction, work engagement, perceived organizational support, or psychological safety could help determine whether the benefits of this education extend beyond knowledge acquisition and positively affect nurses' wellbeing.

Explore Integration Across the Nursing Education Continuum

Another area that may benefit from examination is nursing education itself. The majority of nurses receive minimal or no formal instruction regarding N.D.E's prior to beginning their clinical practice. Implementing this training within undergraduate and graduate nursing curricula, as well as in externships and residencies, could help determine whether integrating this subject earlier enhances preparedness before nurses assume autonomous patient care responsibilities. Research comparing students exposed to this education during nursing education with practicing nurses who receive it subsequently could yield findings into the optimal timing of its delivery.

Compare Instructional Methods

The educational program utilized in this study was delivered via a self-directed online format; however, this represents only one method of providing such education. Future research could compare online instruction with instructor-led workshops, simulation experiences, standardized patient interactions, panel interviews with N.D.E-ers, or case-based scenario analysis. Various teaching approaches may impact not only knowledge and attitudes but also confidence, communication skills, and long-term retention. Identifying the most effective educational strategies would help educators develop training programs that optimally prepare nurses for clinical practice.

Further Validate the Kandess in Nursing Populations

The Kandess performed effectively within this cohort of registered nurses; however, Pace et al. (2016) initially developed and validated it among counseling students and professionals. Further research involving nursing professionals would increase confidence in the instrument's applicability within nursing research. Additionally, investigating whether the tool's psychometric properties remain stable across various health care professions would further enrich the expanding body of literature on N.D.E education and assessment.

Incorporate Qualitative Methods

Finally, this study employed quantitative methods to assess learning outcomes. While quantitative data can demonstrate whether changes occurred in nurses' knowledge and attitudes, it does not explicate how participants experienced the educational process nor how the training influenced their clinical practice post-completion. Quantitative data may not capture individual experiences nurses have had and wish to share as they consider integrating the new knowledge into their professional practice.

Using qualitative methods could provide a more comprehensive and holistic understanding. Such studies may also identify additional educational needs and best practices that have not yet been recognized. The mixed-method or combination of quantitative and qualitative findings would offer a more complete understanding of how education can prepare nurses to deliver and evidence-based care to patients reporting N.D.E's.

Summary

Nursing education often does not address N.D.E's despite evidence that nurses encounter patients who disclose these experiences during clinical practice. The purpose of this study was to compare nurses' knowledge and attitudes regarding N.D.E's before and after a structured, self-paced training program. The findings revealed statistically significant improvements in both knowledge and attitudes following completion of the self-paced educational program, as well as correlations between the knowledge and attitude subscales. These findings are supportive of existing literature suggesting education may help prepare nurses to respond more effectively to patients who report N.D.E's.

The discussion examined the findings within the context of existing research and theoretical frameworks. The findings align with established theories including Watson's caring science, Kirkpatrick and Kirkpatrick's evaluation model, and Bloom's taxonomy, demonstrating that participants who completed the program not only gained knowledge but also exhibited more supportive attitudes. Due to the study's one-group pre-and 1-week delayed posttest design and use of convenience sampling, the observed learning outcomes cannot be attributed solely to the training.

The study contributes to the expanding body of literature examining continuing education for health care professionals on N.D.E's. Future research can explore and investigate numerous remaining questions. Nurses who completed a brief, self-paced training on N.D.E's showed greater knowledge and more supportive attitudes 1 week later. By showing that a brief, self-paced program was associated with greater knowledge and more supportive attitudes among nurses, this study offers nurse leaders and educators an evidence-informed starting point for preparing nurses to respond competently and compassionately when patients disclose N.D.E's.

Table J1 summary: A single question asking if study participation is voluntary.

Image summary: A screenshot of the G*Power 3.1.9.7 software interface showing a power analysis for a t-test comparing two dependent means. The top panel displays two overlapping probability distributions with critical t-value markers, while the bottom panels list input parameters including an effect size dz of 0.5 and a power of 0.80, resulting in a calculated total sample size of 34. The figure demonstrates the process of determining the required sample size for a specific statistical power and significance level.

Table J1 summary: Normality tests for study variables with 41 participants show that KANDES-K scores are normally distributed, while KANDES-A scores are not. Specifically, KANDES-K Change Scores, as well as KANDES-K Pretest and Posttest Total Scores, are all marked as normal, with p-values ranging from .083 to .470. In contrast, KANDES-A Change Scores, Pretest Total Scores, and Posttest Total Scores are all non-normal, with p-values of .002 or less. The non-normality of KANDES-A is characterized by higher absolute Z scores for skewness and kurtosis, such as a kurtosis Z score of 19.55 for KANDES-A Change Scores.

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: Table J2 summary: Normality tests for 41 participants across two scales. For the KANDES-K scale, measured on a 1 to 5 scale, the mean increased from 3.473 at pretest to 4.176 at posttest. For the KANDES-A scale, measured on a 1 to 7 scale, the mean increased from 6.199 at pretest to 6.476 at posttest. The table also provides standard deviations, minimums, maximums, skew, and kurtosis for each of these four measurements.

Table J3 summary: Spearman Rank-Order Correlations among KANDES-K and KANDES-A total scores for 41 participants. The strongest relationship is found between the KANDES-A pretest and posttest totals, with a correlation of .687. Other significant correlations include the KANDES-A pretest and posttest totals with the KANDES-K posttest total at .356 and .501 respectively, and the KANDES-A pretest total with the KANDES-A posttest total at .539. The correlation between the KANDES-K posttest and KANDES-A posttest is .501.

Table J4 summary: A paired-samples t-test for 41 participants shows a statistically significant increase in KANDES-K Total scores from a pre-test mean of 3.473 to a post-test mean of 4.176. This improvement is supported by a t-value of -8.614, a p-value of less than .001, and a large effect size of 1.345.

Table J5 summary: The KANDES-A Total score increased significantly from a pre-test mean of 6.199 to a post-test mean of 6.476 for the 41 participants. This improvement is statistically significant with a p-value of less than .001, a z-score of -4.128, and a large effect size with an r-value of .644.