Addressing low self-efficacy in palliative care education through Acceptance and Commitment Therapy

Dear Editor,

I am writing in response to a recent publication by Natuhwera et al., ¹ which provides valuable insights into the knowledge and self-efficacy of final-year medical and nursing students in Uganda in providing palliative and end-of-life care. One of the most striking findings was the students’ low self-efficacy across almost all aspects and domains, particularly in their communication patterns about death, their ability to conduct discussions about prognosis, and their interactions with patients’ families. They also reported a lack of confidence in answering sensitive questions such as “how long will I live?” or “will I suffer a lot?” Furthermore, self-doubt also emerged in aspects of patient management, particularly in prescribing pain medication and providing psychological, social, and spiritual support. In fact, in the domain of multidisciplinary teamwork, the lowest scores were seen in the ability to refer patients for complementary therapies or specialized services.

These findings highlight a serious challenge in health professions education, where graduates still feel unprepared for clinical situations that demand emotional sensitivity, communication competency, and integrated clinical skills. In this context, I argue that Acceptance and Commitment Therapy (ACT) offers a highly relevant and appropriate approach to addressing this self-efficacy gap. ACT is a third-generation psychological therapy, emphasizes increasing psychological flexibility through six core processes: acceptance, cognitive defusion, present-moment awareness, self-observation, value clarification, and committed action. This process focuses not only on reducing psychological symptoms but also on increasing an individual’s capacity to act in accordance with their values despite facing difficult thoughts or emotions. ² In palliative care education, this approach is relevant for helping students accept their own anxieties when dealing with terminally ill patients, manage their fear of failure, and continue to act based on professional values, such as empathy, respect for patient dignity, and holistic care. ³

Numerous studies support the effectiveness of ACT in the context of palliative care. A review reported that ACT can be widely applied to patients with progressive illnesses, caregivers, and healthcare professionals, with a positive impact on reducing emotional distress and increasing acceptance of terminal conditions. ⁴ These findings are consistent with prior evidence demonstrating that ACT supports individuals in hospice settings find meaning, increase awareness of the present moment, and reduce avoidance of difficult emotional experiences. ⁵ In a practitioner context, Willi et al. ⁶ reported that ACT’s use of metaphors, mindfulness techniques, and defusion strategies facilitated healthier communication with patients and families. These findings strengthen the argument that integrating ACT into medical and nursing curricula can provide tangible benefits for strengthening student self-efficacy.

Specifically, ACT can address three problematic areas identified in Natuhwera et al.’s study. First, in the domain of communication around death and prognosis, the process of acceptance and defusion can help students disengage from thoughts such as “I can’t talk about death” and train them to be fully present in interactions with patients. With mindfulness, students can be calmer when faced with difficult questions, while remaining focused on the needs of patients and their families. Second, in the domain of patient management, value clarification and committed action can equip students with the internal motivation to take action based on professional values, such as providing adequate pain control and psychosocial-spiritual support, even when they feel anxious or lacking confidence. Third, in multidisciplinary teamwork, the psychological flexibility developed through ACT can encourage students to be more courageous in taking on roles, recognizing their own limitations, and appropriately referring patients to specialized services. ⁷

Empirical evidence on the relationship between self-efficacy and palliative care also strengthens the relevance of ACT. The clinical knowledge and experience are strong predictors of self-efficacy, but theory-based training alone is often insufficient. ⁸ Another study in Mongolia by Kim et al. found that although healthcare workers had greater managerial confidence, they remained low in communication about death. ⁹ Likewise, research conducted in Palestine found that healthcare workers’ self-efficacy in palliative care was low across the board and did not always correlate with knowledge or attitudes, highlighting the need for innovative approaches. ¹⁰ Within this framework, ACT offers a solution by emphasizing psychological flexibility and value clarity, rather than simply accumulating knowledge.

Practical implications of integrating ACT into health education can be realized in the form of experience-based workshops, clinical simulations with death scenarios, and group reflections using ACT metaphor techniques. These interventions can be designed into the final semester curriculum, guided by trained facilitators, and include longitudinal evaluation to assess changes in self-efficacy. A study conducted by Park demonstrated that a multimodal ACT-based intervention was feasible, acceptable, and potentially effective in supporting advance care planning. ⁶ These findings support the need for similar trials among medical and nursing students in developing countries, including Uganda.

In conclusion, the low self-efficacy of medical and nursing students in providing palliative care, as highlighted by Natuhwera et al., this condition constitutes a serious challenge that demands strategic intervention. ACT provides a promising conceptual and practical framework for building students’ capacity for “death work,” enhancing psychological flexibility, and connecting clinical practice with humanistic professional values. Integrating ACT into the curriculum will not only enhance students’ preparedness for dealing with terminally ill patients but also has the potential to shift the paradigm of health education toward a more value-centered and meaningful approach. I encourage the academic and practitioner communities to further explore the implementation of ACT in palliative care education through structured trials and longitudinal research that can strengthen the empirical evidence in this area.

Dony Darma Sagita and Sari Wardani Simarmata Early Childhood Teacher Education Study Program, Universitas Terbuka, Tangerang Selatan, Indonesia Imam Syafii Islamic Education Program, Universitas Terbuka, Tangerang Selatan, Indonesia Ahmad Syaikhu Education Technology Program, Universitas Terbuka, Tangerang Selatan, Indonesia Juliana Simangunsong General Courses Study Program, Universitas Terbuka, Tangerang Selatan, Indonesia