Research
Factors influencing attitude toward care of dying patients in first-year nursing students Carina Lundh Hagelin, Christina Melin-Johansson, Ingela Henoch, Ingrid Bergh, Kristina Ek, Kina Hammarlund, Charlotte Prahl, Susann Strang, Lars Westin, Jane Österlind and Maria Browall
Aim: To describe Swedish first-year undergraduate nursing students’ attitudes toward care of dying patients. Possible influences such as age, earlier care experiences, care education, experiences of meeting dying patients and place of birth were investigated. Method: The Frommelt Attitude Toward Care of the Dying Scale (FATCOD) was used in six universities. Descriptive statistics and regression analysis were used. Results: Some 371 students (67.3%) reported overall positive attitude toward caring for dying patients (total mean FATCOD 119.5, SD 10.6) early in their first semester. Older students, students with both earlier care experience and earlier education, those with experience of meeting a dying person, and students born in Sweden reported the highest scores, a more positive attitude. Conclusion: Age, earlier care experience and education, experiences of meeting a dying person and place of birth seems to affect students’ attitudes toward care of the dying and need to be considered among nursing educators. Key words: Death l End-of-life care l Nursing education l Nursing students l Questionnaire This article has been subject to double-blind peer review.
© 2016 MA Healthcare Ltd
D
28
eaths in society occur within all care organisations, and nurses, for example, in acute, community and hospice care, all spend time with patients and their families delivering end-of-life care. Nurses occupy a prominent and significant position in the care of dying patients and see this as their responsibility (Browall et al, 2010). Tait et al (2015) show that the quality of palliative care delivered by nurses can be directly affected by their attitude toward caring for dying patients. Nursing education must instil the necessary skills to prepare undergraduate students to provide high-quality end-of-life care as this is a complex (Lindqvist et al, 2012) and emotionally demanding area (Parry, 2011; Ek et al, 2014; Strang et al, 2014). Emotional skills training and educational programmes for end-of-life care as part of
professional nursing education are desired (Mitchell et al, 2006; Wallace et al, 2009; Charalambous and Kaite, 2013; Gillan et al, 2013). There have been efforts to address the lack of preparedness among nursing students, but, despite these, little is known about how they might be improved (Ramjan et al, 2010).
Background Nursing students are often expected to provide end-of-life care to patients during their clinical practice (Chow et al, 2014). How students experience encounters with dying patients in a clinical situation depends on several factors, such as the students’ own expectations, the support and role of the mentor, the particular skills required and the relationship with the patient and family (Parry, 2011). To face challenging care scenarios involving death and dying, nursing students need appropriate preparation, first on a theoretical level, as well as learning methods for crisis management in clinical training (Ramjan et al, 2010; Aradilla-Herrero et al, 2013; Charalambous and Kaite, 2013), to later be able to emphasise strategies that are both patient- and family-centred. It is therefore important that teaching and education about care of the dying is provided to students before, during and after meeting a dying patient (Huang et al, 2010). Nursing education models for end-of-life care force students to face challenging care scenarios, sometimes with minimal or no supervision and guidance (Wallace et al, 2009, Charalambous and Kaite, 2013). End-of-life care simulation is suggested as a strategy that may help to prepare undergraduate nursing students to provide quality end-of-life care (Gillan et al, 2013; Fabro et al, 2014). Education in palliative care, death and dying can differ in undergraduate nursing education between universities in the same country and also
© 2016 MA Healthcare Ltd
Abstract
International Journal of Palliative Nursing 2016, Vol 22, No 1
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
© 2016 MA Healthcare Ltd
Research
between countries. For example, studies from Turkey (Kav et al, 2013), US, Norway, Sweden (Smith-Stoner et al, 2011), Iran (Iranmanesh et al, 2010) and Taiwan (Huang et al, 2010) all describe that end-of-life care is a concern in undergraduate nursing curricula, although the amount of both theoretical and clinical education is not described in depth and seems to vary in terms of focusing on end-of-life care, e.g palliative care, or integrated in, for example, cancer care. A study from Argentina (Mutto et al, 2010) describes that although palliative care is not integrated in nursing education, students showed positive attitudes toward meeting dying people. However, the students had problems in dealing with death and felt uncomfortable and unprepared to be with patients who were dying (Mutto et al, 2010). This finding is in line with the results presented by Al Qadire (2014) that first-year nursing students have some knowledge about symptom and pain management but less so about psychological, spiritual and philosophical issues and principles about palliative care. Although death was perceived as natural, encountering patients at the end of life had an emotional impact on nursing students, as it, aroused feelings of fear, helplessness and uncertainty (Ek et al, 2014; Strang et al, 2014). This has been described as balancing between duty, demands, own insufficiency, lack of experience and fear about death (Strang et al, 2014). Students are also unsure of how to address patients’ spiritual needs, that is how to assess and provide spiritual care to end-of-life patients (Mitchell et al, 2006). Factors that might influence students’ attitudes toward dying people are age, experience in health care, previously caring for a dying person, age when they first encountered the death of a relative, and concerns about dying (Smith-Stoner et al, 2011; Henoch et al, 2014). Race and religion are not found to correlate to attitude toward death (Dunn et al, 2005). However, Iranmanesh et al (2010) found that Iranian nursing students were more afraid of death than Swedish nursing students, hence personal cultural factors may influence fear of death. Nursing students need focused training to manage their own reactions and emotions (EdoGual et al, 2014) and sensitive guidance when encountering dying patients (Strang et al, 2014). To positively influence the students’ attitudes and promote professional development, theoretical education about death and dying should be individualised and culturally sensitive (Iranmanesh et al, 2010). To be able to meet the different needs and to support nursing students
International Journal of Palliative Nursing 2016, Vol 22, No 1
during training, it is of a great importance to increase knowledge about the factors that affect their attitudes toward care of a dying patient. The authors’ hypothesis is that nursing students’ attitudes toward caring for dying patients can be negatively affected by younger age, cultural background, lack of earlier care experiences or care education, or earlier experiences of meeting dying patients. Hence, the authors investigated the attitudes of nursing students at the beginning of their first semester of training.
❛Some 135 students (36%) had no experience of meeting a dying person.❜
Aim The overall aim was to describe Swedish firstyear undergraduate nursing students’ attitudes to the care of dying patients and to describe factors influencing these attitudes.
Method The present baseline study is the first of several studies in a longitudinal research project following undergraduate nursing students during their education. This study focused on nursing students’ completed Frommelt Attitude Toward Care of the Dying Scale (FATCOD) (Frommelt, 1991), estimating their attitudes toward care of dying patients and their families.
Participants In Sweden, registered nurses (RN) must complete a 3-year bachelor of science programme in nursing before they can be registered as nurses by the National Board of Health and Welfare. The students were recruited from six universities in Sweden, located in rural (r) and urban (u) areas in the country. All nursing students at the six universities were invited to take part in the study at the beginning of the first semester; on three occasions during autumn 2011, and the rest during winter 2012.
Measurement The students completed the Swedish version of the original Frommelt Attitude Toward Care of the Dying Scale (FATCOD) (Frommelt, 1991). In this 30-item questionnaire, answers are given on a 5-point Likert scale (1= Disagree, 2= [no category name], 3= Neither, nor, 4= [no category name], 5= Agree). The FATCOD has been translated from English to Swedish and validated in a Swedish sample of nurses and nursing students (n=213) and was found to reach satisfactory reliability levels (Henoch et al, 2014). The questionnaire comprises an equal number of positively and negatively worded statements. FATCOD scores are calculated by summing all item ratings, after reversing ratings of negatively
29
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
Research
worded items. Due to earlier tests (Henoch et al, 2014), the total FATCOD is used as one total scale. The score range is 30–150, where higher scores indicate a more positive attitude toward care of a dying person. Further, a study-specific demographic form was used to obtain data on the student’s age, gender, previous health care education, previous experience of caring, previous experience of meeting a dying person and place of birth. This form included options for answers as ‘yes’ or ‘no’. For the question of previous experiences from meeting a dying person, answer options were: as a relative; carer; or as a student. Place of birth was answered with: in Sweden, or in another country, with a line to write in which country.
Data collection Students were informed about the study by the head of the department or by the researcher in the group at the specific university. Students were given both verbal and written information and the questionnaire was distributed to those who accepted participation. Questionnaires were completed during class and handed back to the researcher after completion.
Analysis The aim of the analysis was to explore factors that might affect/influence nursing students’ attitudes toward caring for dying patients. Included factors were: gender; age group; university; earlier care education; earlier experience of care; experience of meeting a dying person; and place of birth. FATCOD was calculated if at least 27 items in the questionnaire were answered. Demographic variables and FATCOD scores are presented with descriptive statistics. Included variables were first, analysed in a univariate linear regression model and second, significant independent variables found in the univariate analysis were included in a multiple linear regression model. In regression analysis the following factors were used as references: female; youngest age group (18–35 years); the university with the lowest mean of total FATCOD (university D); answering ‘yes’ in the following factors: earlier care education; earlier experience of care; experience of meeting a dying patient; and born in Sweden. All analysis was conducted using Statistical Package for the Social Sciences (IBM SPSS) version 22, and in all tests, statistical significance was established at a 5% significant level and 95% confidence interval.
30
Ethical considerations The study was approved by the Regional Ethics Committee (Dnr 426-08, T999-11), by the head of the institutions, the head of the nursing programmes, and discussions were held with students’ organisations before the start of the study. Students were given verbal and written information and gave informed consent.
Results In total, 371 students of a possible 551 chose to participate (67.3%) at the beginning of their first semester of their 3-year bachelor of science programme in nursing. Participants were mainly from urban areas: university A (u) 39 of 136 possible (29%); university B (u) 84 of a possible 100 (84%); university C (u) 69 of 89 possible (77%); university D (u) 58 of 85 possible (68%); a minority of the participants were from rural areas (r): university E (r) 53 students of 71 possible (75%); and university F (r) 68 of 70 possible (97%). Most students were female (83.3%), and the mean age was 24.3 years (Standard Deviation (SD) 6.3), with a median age of 22 years (range 18-51 years). Dividing participants into groups by age showed that the largest group of students was between 18–25 years (70.4%). Almost 78% (77.9%) of the students had no earlier care education, while 56.1% reported that they had earlier experiences of care. Participating students had most experiences of meeting a dying patient as a relative (23.5%) or as a carer (22.1%). Some 135 students (36%) had no experience of meeting a dying person. Most participating students were born in Sweden (88.1%) or in represented Nordic countries (89.2%) (Table 1).
Attitudes toward caring for a dying person and their family A total of 368 students answered at least 27 items in the questionnaire with a calculated total mean FATCOD level of 119.5 (SD 10.6); median 119 (min-max 82–147). Three students had left between 5–8 items unanswered with no visible pattern other than they were the last items in the questionnaire. University D had fewer students with earlier care education; earlier care experience; experience of meeting a dying person; and also fewer older students. Analysing reports per item showed the highest mean score for the total sample reported on: item 1: giving care to the dying person is a worthwhile experience (mean 4.6, SD 0.6); item 4: caring for the patient’s family should continue throughout the period of grief and bereavement (mean 4.6, SD 0.7); item 10: there are times when the dying
© 2016 MA Healthcare Ltd
❛Students at the beginning of their nursing education programme, early in semester one, report an overall positive attitude toward caring for dying patients.❜
International Journal of Palliative Nursing 2016, Vol 22, No 1
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
Research
Table 1. Demographic characteristics and earlier experience (n=371) n
(%)
18–25 years
261
(70.4)
26–35 years
76
(20.5)
36–51 years
31
(8.4)
Missing data
3
(0.8)
Male
62
(16.7)
Female
309
(83.3)
Yes
289
(77.9)
No
81
(21.8)
Missing data
1
(0.3)
Yes
208
(56.1)
No
162
(43.7)
Missing
1
(0.3)
Age groups
Gender
❛The present study also shows that where the student is born could affect their attitude toward caring for dying patients.❜
Earlier care education
Earlier care experience
Earlier experience of meeting dying person No
135
(36.4)
Yes, as a: relative
87
(23.5)
carer
82
(22.1)
student
9
(2.4)
relative and carer
40
(10.8)
relative and student
7
(1.9)
carer and student
6
(1.6)
relative, carer and student
5
(1.3)
Yes
327
(88.1)
No
43
(11.6)
Missing data
1
(0.3)
331
(89.2)
Other European country
17
(4.6)
Africa3
1
(0.3)
Asia4
21
(5.9)
1
(0.3)
Born in Sweden
Countries Nordic countries1 2
South America
© 2016 MA Healthcare Ltd
3
1. Sweden, Finland, Iceland are represented. 2. Bosnia and Herzegovina, Bulgaria, Estonia, Italy, Poland, Portugal, Russia, Spain and Turkey are represented. 3. One country in the region is represented—due to anonymity not presented. 4. Countries within central-, south-, east- and west Asia are included.
person welcomes death (mean 4.6, SD 0.7); item 16: families need emotional support to accept the behaviour changes of the dying person
International Journal of Palliative Nursing 2016, Vol 22, No 1
(mean 4.6, SD 0.6); item 18: families should be concerned about helping their dying member make the best of his or her remaining life (mean
31
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
Research
4.6, SD 0.7); and item 27: dying people should be given honest answers about their condition (mean 4.6, SD 0.7). A medium mean score was reported on item 3: I would be uncomfortable talking about impending death with the dying person (mean 2.9, SD 1.3). The lowest mean score for the total sample was made on: item 7: the length of time required to give nursing care to a dying person would frustrate me (mean 1.7, SD 1.0); item 17: as a patient nears death, the nurse should withdraw from his or her involvement with the patient (mean 1.2, SD 0.7); item 19: the dying person should not be allowed to make decisions about his or her physical care (mean 1.5, SD 0.8); and item 28: educating families about death and dying is not a nursing responsibility (mean 1.7, SD 1.0). Comparing the answers given to each question by the students at each university show the largest SD in items describing an inconvenience in meeting and caring for a dying person. This was in item 3, 26 (SD 1.3), and items 2, 5, 8, 11, 13, 14 (SD 1.2). In all but two (items 8 and 13), students at university D showed the highest mean levels (with an SD difference between 0.1 and 0.5), according to statement posed. These students, at university D, were, for example, more afraid to become friends with a dying person (item 14), would feel uncomfortable talking about impending death with the dying person (item 3), and would feel uncomfortable if entering the room of a terminally ill person they found him or her crying (item 26).
Factors that affect the attitude toward care of a dying person Factors that could affect the attitude toward care for a dying person were identified. These factors were as follows: gender; age group; university; earlier education, care experience, or meeting of a dying person; and place of birth of the student, and were initially analysed one at the time in the univariate linear regression model. Results showed that older age groups, universities, all but one (compared to the university with the lowest ratings, as a reference), having an earlier care education, an earlier experience of meeting a dying person, and an earlier care experience and if born in Sweden, all had statistically significant higher ratings, thus a more positive attitude, in the FATCOD scale (Table 2). Analysing significant variables, age groups, university, earlier education, care experience and of meeting a dying person, and place of birth in a multiple regression analysis showed that students born in Sweden reported a statistically significant higher score (ß=5.96, p
Factors influencing attitude toward care of dying patients in first-year nursing students Carina Lundh Hagelin, Christina Melin-Johansson, Ingela Henoch, Ingrid Bergh, Kristina Ek, Kina Hammarlund, Charlotte Prahl, Susann Strang, Lars Westin, Jane Österlind and Maria Browall
Aim: To describe Swedish first-year undergraduate nursing students’ attitudes toward care of dying patients. Possible influences such as age, earlier care experiences, care education, experiences of meeting dying patients and place of birth were investigated. Method: The Frommelt Attitude Toward Care of the Dying Scale (FATCOD) was used in six universities. Descriptive statistics and regression analysis were used. Results: Some 371 students (67.3%) reported overall positive attitude toward caring for dying patients (total mean FATCOD 119.5, SD 10.6) early in their first semester. Older students, students with both earlier care experience and earlier education, those with experience of meeting a dying person, and students born in Sweden reported the highest scores, a more positive attitude. Conclusion: Age, earlier care experience and education, experiences of meeting a dying person and place of birth seems to affect students’ attitudes toward care of the dying and need to be considered among nursing educators. Key words: Death l End-of-life care l Nursing education l Nursing students l Questionnaire This article has been subject to double-blind peer review.
© 2016 MA Healthcare Ltd
D
28
eaths in society occur within all care organisations, and nurses, for example, in acute, community and hospice care, all spend time with patients and their families delivering end-of-life care. Nurses occupy a prominent and significant position in the care of dying patients and see this as their responsibility (Browall et al, 2010). Tait et al (2015) show that the quality of palliative care delivered by nurses can be directly affected by their attitude toward caring for dying patients. Nursing education must instil the necessary skills to prepare undergraduate students to provide high-quality end-of-life care as this is a complex (Lindqvist et al, 2012) and emotionally demanding area (Parry, 2011; Ek et al, 2014; Strang et al, 2014). Emotional skills training and educational programmes for end-of-life care as part of
professional nursing education are desired (Mitchell et al, 2006; Wallace et al, 2009; Charalambous and Kaite, 2013; Gillan et al, 2013). There have been efforts to address the lack of preparedness among nursing students, but, despite these, little is known about how they might be improved (Ramjan et al, 2010).
Background Nursing students are often expected to provide end-of-life care to patients during their clinical practice (Chow et al, 2014). How students experience encounters with dying patients in a clinical situation depends on several factors, such as the students’ own expectations, the support and role of the mentor, the particular skills required and the relationship with the patient and family (Parry, 2011). To face challenging care scenarios involving death and dying, nursing students need appropriate preparation, first on a theoretical level, as well as learning methods for crisis management in clinical training (Ramjan et al, 2010; Aradilla-Herrero et al, 2013; Charalambous and Kaite, 2013), to later be able to emphasise strategies that are both patient- and family-centred. It is therefore important that teaching and education about care of the dying is provided to students before, during and after meeting a dying patient (Huang et al, 2010). Nursing education models for end-of-life care force students to face challenging care scenarios, sometimes with minimal or no supervision and guidance (Wallace et al, 2009, Charalambous and Kaite, 2013). End-of-life care simulation is suggested as a strategy that may help to prepare undergraduate nursing students to provide quality end-of-life care (Gillan et al, 2013; Fabro et al, 2014). Education in palliative care, death and dying can differ in undergraduate nursing education between universities in the same country and also
© 2016 MA Healthcare Ltd
Abstract
International Journal of Palliative Nursing 2016, Vol 22, No 1
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
© 2016 MA Healthcare Ltd
Research
between countries. For example, studies from Turkey (Kav et al, 2013), US, Norway, Sweden (Smith-Stoner et al, 2011), Iran (Iranmanesh et al, 2010) and Taiwan (Huang et al, 2010) all describe that end-of-life care is a concern in undergraduate nursing curricula, although the amount of both theoretical and clinical education is not described in depth and seems to vary in terms of focusing on end-of-life care, e.g palliative care, or integrated in, for example, cancer care. A study from Argentina (Mutto et al, 2010) describes that although palliative care is not integrated in nursing education, students showed positive attitudes toward meeting dying people. However, the students had problems in dealing with death and felt uncomfortable and unprepared to be with patients who were dying (Mutto et al, 2010). This finding is in line with the results presented by Al Qadire (2014) that first-year nursing students have some knowledge about symptom and pain management but less so about psychological, spiritual and philosophical issues and principles about palliative care. Although death was perceived as natural, encountering patients at the end of life had an emotional impact on nursing students, as it, aroused feelings of fear, helplessness and uncertainty (Ek et al, 2014; Strang et al, 2014). This has been described as balancing between duty, demands, own insufficiency, lack of experience and fear about death (Strang et al, 2014). Students are also unsure of how to address patients’ spiritual needs, that is how to assess and provide spiritual care to end-of-life patients (Mitchell et al, 2006). Factors that might influence students’ attitudes toward dying people are age, experience in health care, previously caring for a dying person, age when they first encountered the death of a relative, and concerns about dying (Smith-Stoner et al, 2011; Henoch et al, 2014). Race and religion are not found to correlate to attitude toward death (Dunn et al, 2005). However, Iranmanesh et al (2010) found that Iranian nursing students were more afraid of death than Swedish nursing students, hence personal cultural factors may influence fear of death. Nursing students need focused training to manage their own reactions and emotions (EdoGual et al, 2014) and sensitive guidance when encountering dying patients (Strang et al, 2014). To positively influence the students’ attitudes and promote professional development, theoretical education about death and dying should be individualised and culturally sensitive (Iranmanesh et al, 2010). To be able to meet the different needs and to support nursing students
International Journal of Palliative Nursing 2016, Vol 22, No 1
during training, it is of a great importance to increase knowledge about the factors that affect their attitudes toward care of a dying patient. The authors’ hypothesis is that nursing students’ attitudes toward caring for dying patients can be negatively affected by younger age, cultural background, lack of earlier care experiences or care education, or earlier experiences of meeting dying patients. Hence, the authors investigated the attitudes of nursing students at the beginning of their first semester of training.
❛Some 135 students (36%) had no experience of meeting a dying person.❜
Aim The overall aim was to describe Swedish firstyear undergraduate nursing students’ attitudes to the care of dying patients and to describe factors influencing these attitudes.
Method The present baseline study is the first of several studies in a longitudinal research project following undergraduate nursing students during their education. This study focused on nursing students’ completed Frommelt Attitude Toward Care of the Dying Scale (FATCOD) (Frommelt, 1991), estimating their attitudes toward care of dying patients and their families.
Participants In Sweden, registered nurses (RN) must complete a 3-year bachelor of science programme in nursing before they can be registered as nurses by the National Board of Health and Welfare. The students were recruited from six universities in Sweden, located in rural (r) and urban (u) areas in the country. All nursing students at the six universities were invited to take part in the study at the beginning of the first semester; on three occasions during autumn 2011, and the rest during winter 2012.
Measurement The students completed the Swedish version of the original Frommelt Attitude Toward Care of the Dying Scale (FATCOD) (Frommelt, 1991). In this 30-item questionnaire, answers are given on a 5-point Likert scale (1= Disagree, 2= [no category name], 3= Neither, nor, 4= [no category name], 5= Agree). The FATCOD has been translated from English to Swedish and validated in a Swedish sample of nurses and nursing students (n=213) and was found to reach satisfactory reliability levels (Henoch et al, 2014). The questionnaire comprises an equal number of positively and negatively worded statements. FATCOD scores are calculated by summing all item ratings, after reversing ratings of negatively
29
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
Research
worded items. Due to earlier tests (Henoch et al, 2014), the total FATCOD is used as one total scale. The score range is 30–150, where higher scores indicate a more positive attitude toward care of a dying person. Further, a study-specific demographic form was used to obtain data on the student’s age, gender, previous health care education, previous experience of caring, previous experience of meeting a dying person and place of birth. This form included options for answers as ‘yes’ or ‘no’. For the question of previous experiences from meeting a dying person, answer options were: as a relative; carer; or as a student. Place of birth was answered with: in Sweden, or in another country, with a line to write in which country.
Data collection Students were informed about the study by the head of the department or by the researcher in the group at the specific university. Students were given both verbal and written information and the questionnaire was distributed to those who accepted participation. Questionnaires were completed during class and handed back to the researcher after completion.
Analysis The aim of the analysis was to explore factors that might affect/influence nursing students’ attitudes toward caring for dying patients. Included factors were: gender; age group; university; earlier care education; earlier experience of care; experience of meeting a dying person; and place of birth. FATCOD was calculated if at least 27 items in the questionnaire were answered. Demographic variables and FATCOD scores are presented with descriptive statistics. Included variables were first, analysed in a univariate linear regression model and second, significant independent variables found in the univariate analysis were included in a multiple linear regression model. In regression analysis the following factors were used as references: female; youngest age group (18–35 years); the university with the lowest mean of total FATCOD (university D); answering ‘yes’ in the following factors: earlier care education; earlier experience of care; experience of meeting a dying patient; and born in Sweden. All analysis was conducted using Statistical Package for the Social Sciences (IBM SPSS) version 22, and in all tests, statistical significance was established at a 5% significant level and 95% confidence interval.
30
Ethical considerations The study was approved by the Regional Ethics Committee (Dnr 426-08, T999-11), by the head of the institutions, the head of the nursing programmes, and discussions were held with students’ organisations before the start of the study. Students were given verbal and written information and gave informed consent.
Results In total, 371 students of a possible 551 chose to participate (67.3%) at the beginning of their first semester of their 3-year bachelor of science programme in nursing. Participants were mainly from urban areas: university A (u) 39 of 136 possible (29%); university B (u) 84 of a possible 100 (84%); university C (u) 69 of 89 possible (77%); university D (u) 58 of 85 possible (68%); a minority of the participants were from rural areas (r): university E (r) 53 students of 71 possible (75%); and university F (r) 68 of 70 possible (97%). Most students were female (83.3%), and the mean age was 24.3 years (Standard Deviation (SD) 6.3), with a median age of 22 years (range 18-51 years). Dividing participants into groups by age showed that the largest group of students was between 18–25 years (70.4%). Almost 78% (77.9%) of the students had no earlier care education, while 56.1% reported that they had earlier experiences of care. Participating students had most experiences of meeting a dying patient as a relative (23.5%) or as a carer (22.1%). Some 135 students (36%) had no experience of meeting a dying person. Most participating students were born in Sweden (88.1%) or in represented Nordic countries (89.2%) (Table 1).
Attitudes toward caring for a dying person and their family A total of 368 students answered at least 27 items in the questionnaire with a calculated total mean FATCOD level of 119.5 (SD 10.6); median 119 (min-max 82–147). Three students had left between 5–8 items unanswered with no visible pattern other than they were the last items in the questionnaire. University D had fewer students with earlier care education; earlier care experience; experience of meeting a dying person; and also fewer older students. Analysing reports per item showed the highest mean score for the total sample reported on: item 1: giving care to the dying person is a worthwhile experience (mean 4.6, SD 0.6); item 4: caring for the patient’s family should continue throughout the period of grief and bereavement (mean 4.6, SD 0.7); item 10: there are times when the dying
© 2016 MA Healthcare Ltd
❛Students at the beginning of their nursing education programme, early in semester one, report an overall positive attitude toward caring for dying patients.❜
International Journal of Palliative Nursing 2016, Vol 22, No 1
ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
Research
Table 1. Demographic characteristics and earlier experience (n=371) n
(%)
18–25 years
261
(70.4)
26–35 years
76
(20.5)
36–51 years
31
(8.4)
Missing data
3
(0.8)
Male
62
(16.7)
Female
309
(83.3)
Yes
289
(77.9)
No
81
(21.8)
Missing data
1
(0.3)
Yes
208
(56.1)
No
162
(43.7)
Missing
1
(0.3)
Age groups
Gender
❛The present study also shows that where the student is born could affect their attitude toward caring for dying patients.❜
Earlier care education
Earlier care experience
Earlier experience of meeting dying person No
135
(36.4)
Yes, as a: relative
87
(23.5)
carer
82
(22.1)
student
9
(2.4)
relative and carer
40
(10.8)
relative and student
7
(1.9)
carer and student
6
(1.6)
relative, carer and student
5
(1.3)
Yes
327
(88.1)
No
43
(11.6)
Missing data
1
(0.3)
331
(89.2)
Other European country
17
(4.6)
Africa3
1
(0.3)
Asia4
21
(5.9)
1
(0.3)
Born in Sweden
Countries Nordic countries1 2
South America
© 2016 MA Healthcare Ltd
3
1. Sweden, Finland, Iceland are represented. 2. Bosnia and Herzegovina, Bulgaria, Estonia, Italy, Poland, Portugal, Russia, Spain and Turkey are represented. 3. One country in the region is represented—due to anonymity not presented. 4. Countries within central-, south-, east- and west Asia are included.
person welcomes death (mean 4.6, SD 0.7); item 16: families need emotional support to accept the behaviour changes of the dying person
International Journal of Palliative Nursing 2016, Vol 22, No 1
(mean 4.6, SD 0.6); item 18: families should be concerned about helping their dying member make the best of his or her remaining life (mean
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ional Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.171.235 on February 19, 2016. For personal use only. No other uses without permission. . All rights re
Research
4.6, SD 0.7); and item 27: dying people should be given honest answers about their condition (mean 4.6, SD 0.7). A medium mean score was reported on item 3: I would be uncomfortable talking about impending death with the dying person (mean 2.9, SD 1.3). The lowest mean score for the total sample was made on: item 7: the length of time required to give nursing care to a dying person would frustrate me (mean 1.7, SD 1.0); item 17: as a patient nears death, the nurse should withdraw from his or her involvement with the patient (mean 1.2, SD 0.7); item 19: the dying person should not be allowed to make decisions about his or her physical care (mean 1.5, SD 0.8); and item 28: educating families about death and dying is not a nursing responsibility (mean 1.7, SD 1.0). Comparing the answers given to each question by the students at each university show the largest SD in items describing an inconvenience in meeting and caring for a dying person. This was in item 3, 26 (SD 1.3), and items 2, 5, 8, 11, 13, 14 (SD 1.2). In all but two (items 8 and 13), students at university D showed the highest mean levels (with an SD difference between 0.1 and 0.5), according to statement posed. These students, at university D, were, for example, more afraid to become friends with a dying person (item 14), would feel uncomfortable talking about impending death with the dying person (item 3), and would feel uncomfortable if entering the room of a terminally ill person they found him or her crying (item 26).
Factors that affect the attitude toward care of a dying person Factors that could affect the attitude toward care for a dying person were identified. These factors were as follows: gender; age group; university; earlier education, care experience, or meeting of a dying person; and place of birth of the student, and were initially analysed one at the time in the univariate linear regression model. Results showed that older age groups, universities, all but one (compared to the university with the lowest ratings, as a reference), having an earlier care education, an earlier experience of meeting a dying person, and an earlier care experience and if born in Sweden, all had statistically significant higher ratings, thus a more positive attitude, in the FATCOD scale (Table 2). Analysing significant variables, age groups, university, earlier education, care experience and of meeting a dying person, and place of birth in a multiple regression analysis showed that students born in Sweden reported a statistically significant higher score (ß=5.96, p
