Caring for Dying Patients: Attitude of Nursing Students and Effects of Education

INTRODUCTION

Despite great advances in expertise and medical technology, medicine cannot cure every disease.[1] Death, an extension of birth in all people, is one of the most real things in life.[1] Death is one of the most profound emotional experiences that people encounter.[1] Cultural, ethnic, and religious beliefs help to shape people's attitude toward death and dying.[1] Death often forces people to consider profound questions: The meaning of life, the existence of the soul, and the possibility of an afterlife.[1] Individuals faced with death, their relatives, and their families often rely on ingrained belief systems that help them meet the challenging concepts related to dying and death.[1] Regardless of whether a death occurs in hospital wards or community settings, among the healthcare team members, nurses will spend the largest proportion of time with the dying patient.[234] So, nurses have an important role in caring for this group of patients. This part of nursing care is difficult and may be an emotionally painful, distressing, and sometimes threatening.[5] Nurses’ attitude toward the end-of-life care is thus an important factor in the behavior of nurses who are responsible for caring for terminally ill patients.[2] Several studies have assessed nurses’ attitude toward different aspects of the end-of-life care. In this regards, Razban et al., examined the attitude of two groups of Iranian nurses (oncology and Intensive Care Unit (ICU) nurses) toward palliative care. Razban et al., reported that Iranian nurses have moderately negative to neutral attitudes toward palliative care. Among six categories examined by Razban et al., including truth telling, communication, advance directives, life-prolonging care, patient preferences and withholding and withdrawing treatment, nurses obtained higher score from the category of “patients preferences” and the lowest from the category of “withholding and withdrawing treatment.” Razban et al., also reported significant correlation between Iranian nurses attitude toward palliative care and some demographic characteristics, such as marital status, type of work in the ward, end-of-life care education, level of education, and the experience of caring for a dying family member.[2] In another other study in 2014, Kassa et al., examined nurses’ knowledge, attitude, and practice about palliative care with using Palliative Care Quiz for Nursing (PCQN), Frommelt Attitude Toward Care of the Dying (FATCOD) scale and practice questions.[6] Kassa et al., reported that nurses have favorable attitude and low level of knowledge and practice regarding palliative care. Kassa et al., recommended that education regarding the end-of-life care should be added to nursing education curriculum.[6]

Providing the end-of-life care with high quality is only possible if nurses are educationally prepared.[5] Some parts of these educations are obtained in time of education in nursing schools and colleges. However, there is extensive research documenting deficiencies in undergraduate nursing education related to the end-of-life car.[3] For nursing students’ education, knowledge about their attitude to the end-of-life care and caring for dying patients is necessary.[3] In one study in 2010, Iranmanesh et al., compared the attitude toward caring for dying patients between two groups of students with different religious belief and culture.[7] They examined Iranian and Swedish nursing students’ reporting that Swedish nursing students had more positive attitudes toward caring for dying patients and less fear of death in comparison to Iranian nursing students.[7] In another study, Leombruni et al., examined Italian nursing students’ attitude toward caring for dying patients with using FATCOD-B scale. Leombruni et al., reported that nursing students in Italy need some end-of-life care education.[3] Previous studies mentioned that education about caring for dying patients could be effective in changing nursing students’ attitude. However, studies in this regard are very limited. The aim of the present study was to examine the nursing students’ attitude toward caring for dying patients and the effects of education on their attitude.

MATERIALS AND METHODS

The present study has a quasi-experimental one-group pre-test/post-test design. The study was conducted from September 2013 to November 2013 in Bam School of Nursing and Midwifery in South east of Iran. All final year nursing students were invited to participate. In Iran, the government regulates some nursing education programs. Students can study nursing across all higher education levels from bachelor to doctoral degrees; however, unlike some western countries, Iran does not differentiate by ranking within licensed nursing personnel, and the registered nurse (RN) is the only professionally recognized rank.

The written permission was obtained from the deputy of research, the Ethics Board of the Bam University of Medical Sciences, and all respondents filled in a consent form to participate in the study. In addition, all participants were promised that all data would remain confidential, and be stored safely. Participants answered individually and returned the tests to the researcher. Data were collected using a demographics questionnaire and FATCOD scale. FATCOD scale has 30 items. Two-third of the items relate directly to a person's attitude toward the patient and one-third of the items relate directly to attitude toward the family the members of dying patients. FATCOD items are scored on a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, and 5 = strongly agree). Half of the FATCOD items are worded positively and 15 of them are worded negatively. Scoring is reversed for the negative items. The total score ranges from 30 to 150; higher scores indicate more positive attitudes.[8] The validity and reliability of the Persian version of FATCOD was determined in the previous study by Iranmanesh et al., (alpha coefficient for the questionnaire determined 0.77 and the 3-weeks test-retest coefficient for stability determined 0.70).[7]

Before the study initiation, nursing students were asked to complete the FATCOD scale and a demographics questionnaire. Four weeks after the study, students were retested using the same instrument (FATCOD). Students were taught by a single researcher who has clinical experience in caring for dying patients (MJ). The educations consisted of a 4-hour lecture, film, and a group discussion (in two separated days) in which all aspects of the care for dying patients including concepts of death and dying, beliefs and feelings about the end-of-life care, physiologic and psychological needs of dying patients, the care of the patient's family, and symptoms relief and treatment in dying patients were taught. The workshops took place in conference rooms in the nursing school. The data were analyzed using descriptive statistics and non parametric tests (Wilcoxon and Mann-Whitney Test) in Statistical Package for the Social Sciences (SPSS) software (v18.0; PASW Statistics). The variable was considered to be statistically significant if P < 0.05.

RESULTS

Of the 32 students, 30 participated in this study (response rate of 94%). Of them, 80% were women and 20% were men. The average age of participants was 23.3 (ranging from 21 to 25 years old). Of 30 students, 80% were married and the rest were single. All students reported that they did not receive enough education about caring for dying patients in the 4 years of getting education in nursing school. Also only 20% of the students reported previous experience of dying patients in their clinical courses. With regards to religious beliefs, all students in the present study were Muslim. No significant correlation was found between student's attitude to caring for dying patients and the students’ demographics characteristics (P > 0.05) [Table 1].

Table 1 Relationship between students’ attitude and their previous experience of patients and relative dying

Mean score of FATCOD before education were 3.5 ± 0.43. The highest and lowest mean scores were related to item 21 “It is beneficial for the dying person to verbalize his/her feelings” and item 8 “I would be upset when the dying person I was caring for gave up hope of getting better,” respectively. The mean score of FATCOD after education was 4.7 ± 0.33. The highest and lowest mean scores were related to item 6 “The non-family caregivers should not be the one to talk about death with the dying person” and item 8 “I would be upset when the dying person I was caring for gave up hope of getting better,” respectively. Results showed that the mean score of FATCOD after receiving education increased compared to before receiving education, and this difference was statistically significant P < 0.001. Table 2 shows the mean score of FATCOD items before and after education. Figures 1 and 2 shows ten questions that have demonstrated significant changes after intervention.

Table 2 Nursing students’ responses to frommelt attitude toward care of the dying (FATCOD) items before and after education

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Figure 1

Five question that had less changes after intervention

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Figure 2

Five question that have most changes after intervention

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DISCUSSION

Many nursing students have difficulties in dealing with death and report feeling anxious and unprepared to be with dying patients.[9] The aim of the present study was to examine the effects of education on the attitude of nursing students toward caring for dying patients. Results of the present study showed that Iranian nursing student did not have positive attitudes toward taking care of dying patients. Results also showed that education affects nursing students’ attitude to care for dying patients positively. Iran is a Middle Eastern country with about 77 million residents. Most religions are represented in Iran but the major faith tradition in Iran is Islam.[7] and death is one of the core subjects of Islam.[2] Muslims believe life on this earth and death is only a transition between two different lives.[210] Winning the latter life is the goal of every Muslim. Although there is a tendency that hospitals in Iran provide end-of-life care for patients who need palliative care, throughout Iran, there is no specific hospice care similar to Western countries.[11] Also, research about death and caring for dying patients in Iranian context is very limited. In one study in this regards, Iranmanesh et al., conducted a study among nursing students in Bam and Kerman to measure their attitudes toward death and caring for dying patients.[7] Similar to our findings, they reported that Iranian nursing students did not have positive attitudes toward caring for dying patients. They also reported that Bam student nurses, who had more experience of death due to the Bam earthquake in December 2003, are less afraid of death and also less likely to give care to dying patients in comparison to their counterparts in Kerman.[7] In another study in Italy, Leombruni et al., examined nursing students’ attitudes toward caring for dying patients with using some questionnaire.[3] Mean score of FATCOD scale in Leombruni et al., study was 3.83 that this score is higher than the mean score of FATCOD scale in the present study. Students in Leombruni et al., study obtained more score and low score from item 1 “Giving care to the dying person is a worthwhile experience” and item 3 “I would be uncomfortable talking about impending death with the dying person,” respectively that is different from the findings in the present study. This difference could be related to differences in religious beliefs, cultural, and socio-demographic factors of Iranian nursing students and students in European countries.

Previous studies in Iran suggested that for improving the quality of care at the end-of-life, palliative care education, accompanied by a reflective narrative approach, should be added to the nursing curriculum.[212] However, education on end-of-life care, death, and dying has not been made a part of the undergraduate nursing curriculum for the time being and nurse educators usually include end-of-life issues in other courses, rarely making them an independent course. Results of the present study showed that education about caring for dying patients improved the attitude of nursing students significantly. Similar to our finding, Iranmanesh et al., reported that nursing students that were educated about death and dying had more positive attitudes toward caring for dying patients than non-educated students.[13] In another study in this regards, Kwekkeboom et al., examined the effects of a volunteer palliative care companion program on knowledge and attitude of nursing students to death and caring for dying patients.[14] Consistent with the findings in the present study, results of Kwekkeboom et al., showed that participation in volunteer palliative care companion program increased nursing students knowledge of palliative care, improved attitudes of nursing students toward caring for dying patients, and decreased their concerns about providing nursing care to dying patients.[14] Previous studies about effects of education on the attitude of nurses also showed similar results. In one quasi-experimental study in 2013, El-Nagar and Lawend examined the effect of palliative care education on nurses’ knowledge, attitude, and experience toward caring for chronically ill children.[15] Results of El-Nagar and Lawend study showed that palliative care education increased nurses’ knowledge significantly toward caring for chronically ill children and highly improved nurses’ attitude and practice related to the care of this group of patients.[15] Results of present study also showed that nursing students’ previous history of caring of dying patients and their experience of close relative death does not affect their attitude caring for dying patients. In this regards, previous studies showed similar results to finding of present study. Similar to our finding, Lange et al., that examined nurses’ attitudes toward death and caring for dying patients reported that nurses previous experience with caring for dying patients does not affect their attitudes about death and caring for dying patients.[16] In other study, Iranmanesh et al., reported that nursing students, who had more experience of relative death are less likely to give care to peopleat the end of life.[13]

CONCLUSION

Nursing student may encounter dying patients and their families during their clinical courses. It is essential that they be adequately prepared to care for dying patients. Based on the results of the present study, it was concluded that Iranian nursing students do not have a positive attitude toward caring for dying patients. The results of this study also highlight the importance of education about end-of-life care. The study suggests that educational programs about death and caring for dying patients should be added to undergraduate nursing curricula. Further research is recommended examining nursing students’ knowledge about caring for dying patients and the effect of education on their knowledge.

LIMITATION

This study has some important limitations. As this study was based on a convenience sample and participation was voluntary, there might have been a selection bias that affected the possibility to generalize the results to all students. Since 32 final year students are educating in the Bam School of Nursing and Midwifery, the sample represents a majority (94%) and so the results could be generalized to all of them. Furthermore, the use of self-report questionnaires may have led to an overestimation of some of the findings due to variance, which is common in different methods.