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Student Nurses’ Attitudes Toward Dying Patients in Central Anatolia Dilek Arslan, RN, Msc, Nazan Kilic Akca, PhD, RN, Nuray Simsek, PhD, RN, and Pinar Zorba, RN, Msc Dilek Arslan, RN, Msc, is a Research Assistant at the Department of Medical Nursing, School of Health, University of Bozok, Yozgat, Republic of Turkey, Nazan Kilic Akca, PhD, RN, is an Assistant Professor at the Department of Medical Nursing, School of Health, University of Bozok, Yozgat, Republic of Turkey, Nuray Simsek, PhD, RN, is an Assistant Professor at the Department of Psychiatric Nursing, School of Health, University of Erciyes, Kayseri, Republic of Turkey, and Pinar Zorba, RN, Msc, is a Research Assistant at the Department of Medical Nursing, Health Science Faculty, University of Hacettepe, Ankara, Republic of Turkey.
Search terms: Attitude, dying patient, nursing education, student nurse Author contact: [email protected], with a copy to the Editor: [email protected] Declaration of conflicting interest: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding: The author(s) received no financial support for the research and/or authorship of this article.
PURPOSE: This study was descriptively conducted to explore attitudes of nursing students related to caring for dying patients in central Anatolia. METHODS: The study was completed with 222 third-year students of nursing school originating from three universities in Turkey. RESULT: It was explored that Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) scores of the students who had previously cared for terminal patients at the clinics were significantly higher, and the scores of those who regarded themselves as nonbeliever in terms of religion were significantly lower (p < .05). CONCLUSION: It was seen that nursing students’ FATCOD scores were at a moderate level. IMPLICATIONS FOR NURSING PRACTICE: We are of the opinion that it will be helpful that nursing students should be trained about the care for dying patients during their formal education. AMAÇ: Bu çalıs¸ma Orta Anadolu’daki hems¸irelik ög ˘ rencilerinin ölmekte olan bireye bakım vermeye ilis¸kin tutumlarını belirlemek amacı ile tanımlayıcı olarak yapıldı. GEREÇ VE YÖNTEM: Bu çalıs¸ma, Türkiye’deki üç üniversitenin üçüncü ve dördüncü sınıf hems¸irelik bölümü 222 ög ˘ rencisiyle tamamlandı. Veriler ög ˘ renci bilgi formu ve Frommelt Ölmekte Olan Bireye Bakım Vermeye ˙I lis¸kin Tutum Ölçeg ˘i (FATCOD) ile toplandı. Mann-Whitney U ve Kruskal-Wallis testi kullanıldı. BULGULAR: Daha önce kliniklerde terminal dönemdeki hastalara bakım veren ög ˘ rencilerin FATCOD ölçek puanlarının anlamlı ¸sekilde yüksek oldug ˘ u ve ög ˘ rencilerden kendini dini açıdan inançsız olarak ifade edenlerin puanları da anlamlı olarak düs¸ük bulundu (p < .05). SONUÇ: Hems¸irelik ög ˘ rencilerinin FATCOD puanlarının orta düzeyde oldug ˘u saptandı. HEMSIRELIK UYGULAMALARI IÇIN ÖNERILER: Hems¸irelik ög ˘ rencilerine eg ˘ itimleri süresince ölmekte olan bireyin bakımına ilis¸kin eg ˘ itimlerin verilmesinin yararlı olacag ˘ ı düs¸ünülmektedir.
Death is a universal phenomenon that happens to every human being regardless of their life conditions. In a general sense, death may be defined as a qualitative and quantitative transformation that occurs with the termination of one’s existence on earth. The concept of death in people’s minds determines their behaviors and lifestyles in religious, philosophical, and moral aspects. While birth is a celebrated event, death is a feared one, which people are usually reserved to talk about in public. Although the effect of death on human life is inevitable, an individual’s conception © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
of death in an exaggerated, disproportional, or pathological way can adversely affect his/her psychology. At times when attitudes toward death lack balance and harmony, the anxiety level of a person increases and it becomes more difficult for him/her to adapt to his/her social environment (Civaner, 2003; ˙I nci & Oz, 2009; Peters et al., 2013). Today, death is considered as more than a natural outcome of life cycle, but as a disease against which struggle is required. Nowadays, many deadly diseases can be cured thanks to advances in diagnostic and treatment 183
Student Nurses’ Attitudes Toward Dying Patients techniques as well as sophisticated technology (Oz, 2004). As a result, the reality of death, which has gradually been removed from the walks of life, has begun to be a usual encounter for the health staff in hospitals, which, to a great extent, puts the emotional burden of death upon health professionals. This situation may increase the negative attitudes about death for healthcare staff (particularly the nurses) who regularly work with the dying patients in hospitals (Cimete, 2002; Karakurt, 2012). Although death is described as a natural process of the life cycle and an inevitable reality of life, it is typically one of the most painful experiences of loss undergone by the patient and his/her family (Cimete, 2002). Nurses’ knowledge about the dying patient and his/her family’s sociocultural status will play a key role in designating the type of care strategies to be implemented (Bahar, Beser, Ersin, Kissal, & Aydogdu, 2012; ˙I nci & Oz, 2009). It is everybody’s right to receive a holistic and sensitive care from the medical staff. The basic objective of the care to be given to the dying patients is to provide them with the necessary physical and psychological comfort and to increase the quality of their remaining lifespan (Akdemir & Birol, 2004). However, in Turkey the nursing practices have been inadequate in terms of providing holistic care for the dying and their families. This is because the nurses predominantly focus on the dying patient’s physical well-being without paying enough attention to other aspects of the holistic care (Cimete, 2002). Some international studies conducted with nursing students who have dealt with death in the clinical settings indicate that students experience fear about the care for the dying patients, and think that their educational programs are not sufficient to prepare them for these situations (Cooper & Barnett, 2005; Loftus, 1998; Shin, Gau, Lin, Pong, & Lin, 2006). Likewise, in Turkey, in a limited number of studies, it has been observed that the education programs offered to the nursing students are insufficient to prepare them to provide comprehensive care for dying patients (Koc & Saglam, 2008; Oz, ˙I nci, & Bahadir Yilmaz, 2012; Tasdemir & Gok, 2012). As part of their formal educational practices, the nursing students are provided the responsibility to ensure the continuation of the life of a dying patient (Oz, 2004). The aim of educating the nursing students about the concept of death is to enable them to provide a holistic care to the patients and their close relatives, and to develop positive attitudes toward care of the dying patients by being aware of their own attitudes and behaviors toward the matter of death (Mok & Chiu, 2004). Nursing aims to assist people to cope with the reality of death as well as health and illness (Iranmanesh, Rayyani, & Azizzadeh Forouzy, 2012; Kelleci, 2005). As a result, nurses’ perceptions about death should be explored early in their education. Nursing students should also be given opportunities to express their emotions and to improve their knowledge about caring for the dying (Hurtig & Stewin, 1990). Along with less than adequate managed practices of the caring for the dying, the nurses’ negative attitudes may lead to the use of insufficient methods for coping with 184
D. Arslan et al. death, and may cause unnecessary pain to the patients and stress among their family members. Within the nursing curriculum newly adopted in the Turkish universities, nursing students are educated from a holistic perspective about how to care for terminal patients during the 4 years at university. Additionally, congruent with holistic care, the nursing programs integrate many opportunities during the entire program for nursing students to reflect on their experiences, to discuss their attitudes, beliefs, and personal feelings in a safe environment in which they are supported. Emphasis in the following 3 years is around communication at the end of life. This includes having difficult conversations with both the terminal patients and their families in the following 3 years and about how to approach the terminal patients and their families. Therefore, the concept of death and the care of the dying should be well integrated within the educational programs for the nurses over the course of the 4 years. Methods Aim of the Study As a result of these changes in the nursing education, it was important to explore the attitudes of nursing students who had been exposed to this curriculum toward the dying. To do so, a quantitative descriptive methodology was conducted in three different universities that adopted this curriculum. Samples and Procedures The population of the study consisted of third- and fourth-year university students who had previous practical experience with different patient groups at clinics of internal diseases and surgery. There were a total of 248 students (101 students at Bozok University Health School, 72 students at Selcuk University Kadir Yallagul Health School, and 75 students at Nevsehir University Semra and Vefa Kucuk Health School). Instruments Data were gathered by means of a 10-item student information form designed by the researchers after screening of the relevant literature (Akdemir & Birol, 2004; Cevik, 2010; Civaner, 2003; Dunn, Otten, & Stephens, 2005; Lange, Thom, & Kline, 2008; Rooda, Clements, & Jordan, 1999; Yigit, 1998) and Frommelt Attitudes Toward Care of the Dying Scale (FATCOD; Frommelt, 2003) to assess nurses’ attitudes toward the caring for the terminally ill individuals and their families, and the potential thoughts and feelings they might have at the time of death. The FATCOD is a 30-item scale consisting of an equal number of positively and negatively worded statements with response options of strongly disagree, disagree, uncertain, agree, and strongly agree on a 5-point Likert scale.
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Items 1, 2, 4, 16, 18, 20, 21, 22, 23, 24, 25, 27, and 30 are positively worded statements. The other items of the scale are negatively worded (Cevik & Kav, 2013; Frommelt, 1991, 2003). Positive items are scored from 1 (strongly disagree) to 5 (strongly agree). Scores are reversed for negative items. Possible scores range from 30 to 150. A higher score indicates a more positive attitude toward caring for the dying patients. The validity and reliability of the scale were established by Cevik, who found Cronbach alpha value of the scale as 0.73 (Cevik, 2010). The Cronbach alpha reliability of the scale in this study was 0.77. Data Analysis Statistical analyses of the data were performed using Statistical Package for Social Sciences (SPSS). Mann– Whitney U-test was used to perform pairwise comparisons for binary variables because the data relating to the scale score and independent variables did not follow a normal distribution. Kruskall–Wallis variance analysis was used for three groups. The value for significance was set at .05. Ethical Considerations Official permission was obtained from the institutions where the study was conducted following a briefing explaining the objectives and the scope of the study. The nursing students were informed about the research study orally and given the option to participate. Once the nursing students expressed an interest in participating, the researchers obtained written consents. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki (revised October 2000).
Table 1. Sociodemographic Characteristics of the Nursing Students and Their Perceptions of Death (n = 222) Characteristics Gender Female Male Age 21 years 22 years 23 years 24 ≥years Place of residence City Rural area Metropolitan Choosing the profession by their own will Yes No Religious beliefs Believer Devoted believer Nonbeliever The most important knowledge and information caring for a dying patient should know Legal and ethical Issues Communicational knowledge Cultural differences Experiencing death of a significant other Yes No Caring for the dying in clinical settings before Yes No Willingness to care for the dying Yes No
n
%
156 66
70.3 29.7
85 60 51 26
38.3 27.0 23.0 11.7
108 75 39
48.6 33.8 17.6
138 84
62.2 38.8
115 51.8 97 43.7 10 4.5 that a nurse 84 83 55
37.8 37.4 24.8
114 108
51.4 48.6
80 142
36.0 64.0
106 116
47.7 52.3
Results In total, 222 students (89.5%) participated in the study. The results of the study indicated that: (a) the mean age of the students was 22.18 ± 1.32; (b) 70.3% were female; (c) 48.6% lived in cities; (d) 38.8% of the students were satisfied with their decision to be a nurse; (e) 51.8% considered themselves as a believer of a religion; and (f) 37.8% thought that it is significant to get information about legal and ethical issues in order to give the proper care for the dying. In addition, more than half of the students reported that they had experienced the loss of a significant other, while 36.0% stated that they had previously cared for a dying patient in clinical settings. More than half (52.3%) of the participants were unwilling to care for the dying (Table 1). Table 2 demonstrates the sociodemographic characteristics of the nursing students and their mean FATCOD scores for their opinions about caring for the dying. The students’ overall FATCOD mean score was found to be 95.2 ± 14.1. The FATCOD mean scores of the students who regarded themselves as nonbelievers in terms of religious
beliefs were found to be significantly lower (p < .05) than those who reported to believe in a religion. In addition, the FATCOD mean scores of the students with previous experience of caring for terminal patients in clinics were significantly higher (p < .05) than those lacking such an experience. The FATCOD scores of the students who wanted to provide care for terminal patients in the clinics were significantly higher (p < .05) than those who did not. No statistically significant difference was observed in nursing students’ attitudes toward the caring for the dying (p > .05) in terms of gender, age, previous living place, voluntary choice of the profession, and facing death reality in the close circle (death of a significant other). Discussion and Conclusions As part of their profession, nurses always have to deal with the dying patients and their families. The care for the dying is one of the most challenging parts of the nursing practice. Also, the fact that attitudes the individual nurses 185
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D. Arslan et al.
Table 2. Characteristics of the Nursing Students and the Distribution of the Mean Scores of Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) Mean scores of Frommelt Attitudes Toward Care of the Dying Scale Demographic characteristics
X ± SD
Test
Frommelt Attitudes Toward Care of the Dying Scale 95.2 ± 14.1 (47.00–142.00) Gender Female 95.18 ± 14.06 Male 93.89 ± 13.17 Age 21 years 94.67 ± 13.68 22 years 96.28 ± 14.80 23 years 94.17 ± 17.33 ≥24 years 96.26 ± 11.11 Place of residence Rural area 96.85 ± 13.03 City 93.26 ± 15.46 Metropolitan 97.28 ± 11.20 Choosing the profession by their own will Yes 95.26 ± 14.38 No 95.03 ± 13.59 How did nursing students describe themselves in terms of religious beliefs Nonbeliever 83.70 ± 7.97 Believer 97.10 ± 12.18 Devoted believer 94.08 ± 15.93 Experiencing death of a significant other Yes 96.42 ± 15.59 No 93.87 ± 12.17 Caring for the dying clinical settings Yes 97.49 ± 14.75 No 93.88 ± 13.53 Willingness to care for the dying Yes 96.95 ± 16.98 No 93.56 ± 10.54 a
p
4718.000
.325a
1.163
.762b
4.023
.134b
5790.500
.991a
10.406
.005b
5307.500
.076a
4685.500
.030a
4943.500
.012a
Mann–Whitney U analysis was used. Kruskal–Wallis test was used.
b
develop toward death may vary from person to person makes the situation more viable (Akdemir & Birol, 2004; Cimete, 2002). According to the findings discerned from the current study, it may be argued that the nursing students have moderately positive attitudes toward caring for the dying (95.2 ± 14.1). In a relevant study conducted previously in Turkey, the mean score obtained from the FATCOD scale was 99.9 ± 8.7 (Cevik, 2010). Similarly, the mean scores achieved in some studies performed in other countries were over 100 (Dunn et al., 2005; Lange et al., 2008; Rooda et al., 1999). Therefore, the mean score obtained in this study (95.2 ± 14.1) is more in agreement with the mean scores obtained in Turkey than those obtained abroad, which may suggest that the educational and cultural contexts affect the attitudes toward the caring for the dying. Some previous studies indicated that religious beliefs of the individuals may also affect their perspectives on death and the caring for the dying (Civaner, 2003; Dunn et al., 2005; Eues, 2007; Iranmanesh, Dargahi, & Abbaszadeh, 2008). In Islam, it is believed that the soul of the dying person is removed from his body and transcends to Allah following his/her demise. This belief gives spiritual strength 186
to the patient’s family and the nurses providing care to them, thus contributing to their forming positive attitudes when they experience the time of death (Oz et al., 2012; Tanhan & Ari, 2006). In this study, the mean FATCOD score of 51.8% of the students who considered themselves as religious was found to be higher than those who considered themselves nonreligious. In a similar study, Cevik (2010) demonstrated that 68.0% of the nurses indicated that they had strong religious beliefs, with 45.0% of them emphasizing that devoutness affects attitudes toward the dying. However, it was observed that the attitude scores were lower for those who stated that they were very religious. According to the literature, the more religious the people, the more often they develop negative attitudes toward death. The reason for this is that the individuals believe that they will be punished in the afterlife (Oz et al., 2012). Facing the death of a significant other or a patient in a clinical setting is one of the most defining moments that may later influence the attitudes of the nurses toward caring for the dying. In the related literature, it has been demonstrated that the nursing students can develop more favorable attitudes toward death as long as they are educated about the efficient methods of dealing with the dying
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patients (Cooper & Barnett, 2005; Koc & Saglam, 2008; Loftus, 1998; Shin et al., 2006; Tasdemir & Gok, 2012). This study revealed that half of the participating students experienced death of a significant other and 36% of them cared for a dying patient in a clinical setting. The students who reported to have cared for a dying patient in a clinical setting were found to hold more positive attitudes toward death than those who had not done so. In literature, there are similar studies showing that nurses who experienced death or provided care for the dying had more positive attitudes toward caring for the dying (Lange et al., 2008; Yigit, 1998). These findings suggest that the reality of death should be an integral part of the classroom teaching/ learning process, and the nursing students should be involved in role plays and simulations at school to help them to develop more positive attitudes toward caring for the dying in the clinical setting. It is generally argued that willingness to care for the dying may be as influential on the students’ attitudes as the experience of death. In the current study, more than half of the students (52.3%) reported that they are unwilling to provide care for the dying. This study did not explore this phenomenon, but this unwillingness to care for the dying may be a result of a lack of knowledge and experience about the issue, but needs further exploration in future studies. Overall, the findings obtained from the current study indicated that the nursing students exposed to this curriculum around providing holistic end-of-life care had moderately positive attitudes toward caring for the dying. Further, their beliefs, past experiences, and willingness to care for the dying affect their attitudes pertaining to death and dying. Limitations The findings of this study cannot be generalized to Turkey as a whole since it was carried out in a specific region in the central Anatolia. The majority (98%) of the population in Turkey are Muslims, with the remaining 2% consisting of Christians, Jewish, Atheists, and other religious groups (Pew Research Center, 2009). Further studies with a larger, more diverse population are necessary to understand if the findings of this study on nursing students’ attitude about death and dying after exposure to this curriculum are generalizable. Recommendations This study suggests that courses about death and palliative care are essential and should be extensively integrated to the nursing curriculum. In this sense, proper classroom environment should be formed for students to discuss their beliefs and emotions about death. Role plays concerning care for the dying should be incorporated within relevant courses to prepare students for dealing with the dying
patients and their families. In addition, nursing students should be offered opportunities to reflect on their experiences, feelings, actions, and reactions regarding death and care for the dying people in their own families in order to cater for the possibilities to utilize personal experiences as a part of positive and constructive learning. References Akdemir, N., & Birol, L. (2004). Terminal hasta bakimi [Care of terminal patient]. In L. Birol (Ed.), ˙I c hastaliklari hemsirelik bakimi kitabi [Internal disease and nursing care] (2nd ed., pp. 207–211). Ankara, Turkey: Sistem Yayincilik. Bahar, Z., Beser, A., Ersin, F., Kissal, A., & Aydogdu, N. G. (2012). Traditional and religious death practices in western Turkey. Asian Nursing Research, 6(3), 107–114. Cevik, B. (2010). Hemsirelerin olume ve olmekte olan bireye bakim vermeye iliskin tutumlari ve deneyimleri [Attitudes and experiences of nurses about death and dying patient]. Ankara, Turkey: Baskent Universitesi Saglik Bilimleri Enstitusu, Hemsirelik Bolumu [Baskent University Health Sciences Institute, Nursing Department]. Cevik, B., & Kav, S. (2013). Attitudes and experiences of nurses toward death and caring for dying patients in Turkey. Cancer Nursing TM, 36(6), 58–65. Cimete, G. (2002). Olumcul hastalara butuncul yaklasim [Holistic Care for dying patients] (pp. 1–20). Istanbul, Turkey: Nobel Yayincilik. Civaner, M. (2003). Onemli bir etik sorun alani olarak yasamin son donemi [End of life period as an important ethical problem]. Toplum ve Hekim [Community and Physician], 18, 148–151. Cooper, J., & Barnett, M. (2005). Aspects of caring dying patients which cause anxiety to first year student nurses. International Journal of Palliative Nursing, 11(8), 423–430. Dunn, K. S., Otten, C., & Stephens, E. (2005). Nursing experience and the care of dying patients. Oncology Nursing Forum, 32(1), 97–104. Eues, S. K. (2007). End-of-life care; improving quality of life at the end of life. Professional Case Management, 12(6), 339–344. Frommelt, K. (2003). Attitudes toward care of the terminally ill: An educational intervention. American Journal of Hospice and Palliative Care, 20(1), 13–22. Frommelt, K. H. (1991). The effects of death education on nurses’ attitudes toward caring for terminally ill persons and their families. American Journal of Hospice and Palliative Care, 8(5), 37–43. Hurtig, W. A., & Stewin, L. (1990). The effect of death education and experience on nursing students’ attitude towards death. Journal of Advanced Nursing, 15(1), 29–34. Iranmanesh, S., Dargahi, H., & Abbaszadeh, A. (2008). Attitudes of Iranian nurses towards caring for dying patients. Palliative and Supportive Care, 6(4), 363–369. Iranmanesh, S., Rayyani, M., & Azizzadeh Forouzy, M. (2012). Caring at the end of life: Iranian nurses’ view and experiences. Journal of Nursing Education and Practice, 2(2), 9–17. ˙I nci, F., & Oz, F. (2009). Olum egitiminin hemsirelerin olum kaygisi, olume iliskin depresyon ve olumcul hastaya tutumlarina etkisi [Effects of death education on nurses’ death anxiety, depression regarding death, and attitudes towards the dying patient]. [Anadolu Psikiyatri Dergisi] Anatolian Journal of Psychiatry, 10, 253–260. Karakurt, P. (2012). Kayip ve olum sureci [Loss and death process]. In T. Atabek Asti & A. Karadag (Eds.), Hemsirelik Esaslari kitabi [Nursing fundamentals] (pp. 1155–1160). ˙I stanbul, Turkey: Akademi Yayincilik. Kelleci, M. (2005). Kanser hastalarinin umudunu gelistirmeye yonelik hemsirelik girisimleri [Nursing initiatives to improve hope of cancer patients]. Anadolu Psikiyatri Dergisi [Anatolian Psychiatry Journal], 6, 41–47. Koc, Z., & Saglam, Z. (2008). Hemsirelik ogrencilerinin yasam sonu bakim ve olum durumuna iliskin duygu ve goruslerinin belirlenmesi [Determination of emotions and thoughts of nursing students about end of life and death]. Cumhuriyet Univeristesi Hemsirelik Yuksekokulu Dergisi [Cumhuriyet University Nursing School Journal], 12(1), 14–21. Lange, M., Thom, B., & Kline, N. (2008). Assessing nurses’ attitudes toward death and caring for dying patients in a comprehensive cancer center. Oncology Nursing Forum, 35(6), 955–959. Loftus, L. A. (1998). Student nurses’ lived experience of the sudden death of their patients. Journal of Advanced Nursing, 27(3), 641–648. Mok, E., & Chiu, P. C. (2004). Nurse–patient relationships in palliative care. Journal of Advanced Nursing, 48(5), 475–483.
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Student Nurses’ Attitudes Toward Dying Patients Oz, F. (2004). Kayip, olum vey yas sureci [Loss, death and mourning process]. In Saglik alaninda temel kavramlar [Basic concepts in health] (pp. 276–313). Ankara, Turkey: ˙I maj ve Dis Ticaret AS. Oz, F., ˙I nci, F., & Bahadir Yilmaz, E. (2012). Hemsirelik ogrencilerinin olum kaygisi ile psikolojik saglamlik duzeyleri ve aralarindaki iliski. [The death anxiety and resilience levels of nursing students and relevance between these levels]. New/Yeni Symposium Journal, 50(4), 229–236. Peters, L., Cant, R., Payne, S., O’Connor, M., McDermott, F., Hood, K., et al. (2013). How death anxiety impacts nurses’ caring for patients at the end of life: A review of literature. Open Nursing Journal, 7, 14–21. Pew Research Center. (2009). Islam by country. Retrieved from http:// en.wikipedia.org/wiki/Islam_by_country (accesed 20 March 2014) Rooda, L. A., Clements, R., & Jordan, M. L. (1999). Nurses’ attitudes toward death and caring for dying patients. Oncology Nursing Forum, 26(10), 1683–1687.
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D. Arslan et al. Shin, F., Gau, M., Lin, Y., Pong, S., & Lin, H. (2006). Death and help expected from nurses when dying. Nursing Ethics, 13(4), 360–375. Tanhan, F., & Ari, F. (2006). Universite ogrencilerinin olume verdikleri anlam ve ogrenim gordukleri program acisindan olum kaygisi duzeyleri [The meaning university students give to death and death anxiety levels according to their department]. Yuzinci yil Univeristesi Egitim Fakultesi Dergisi [Yuzinci Yil University Faculty of Education Journal], 3(2), 44–45. Tasdemir, G., & Gok, F. (2012). Determining death anxiety among health school students. International Journal of Human Sciences, 9(2), 303–317. Yigit, R. (1998). Hasta ve ailesine olumle bas etmelerinde yardim etme [Helping patient and his/her family cope with death]. Cumhuriyet Univeristesi Hemsirelik Yuksekokulu Dergisi [Cumhuriyet University Nursing School Journal], 2(2), 9–15.
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Student Nurses’ Attitudes Toward Dying Patients in Central Anatolia Dilek Arslan, RN, Msc, Nazan Kilic Akca, PhD, RN, Nuray Simsek, PhD, RN, and Pinar Zorba, RN, Msc Dilek Arslan, RN, Msc, is a Research Assistant at the Department of Medical Nursing, School of Health, University of Bozok, Yozgat, Republic of Turkey, Nazan Kilic Akca, PhD, RN, is an Assistant Professor at the Department of Medical Nursing, School of Health, University of Bozok, Yozgat, Republic of Turkey, Nuray Simsek, PhD, RN, is an Assistant Professor at the Department of Psychiatric Nursing, School of Health, University of Erciyes, Kayseri, Republic of Turkey, and Pinar Zorba, RN, Msc, is a Research Assistant at the Department of Medical Nursing, Health Science Faculty, University of Hacettepe, Ankara, Republic of Turkey.
Search terms: Attitude, dying patient, nursing education, student nurse Author contact: [email protected], with a copy to the Editor: [email protected] Declaration of conflicting interest: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding: The author(s) received no financial support for the research and/or authorship of this article.
PURPOSE: This study was descriptively conducted to explore attitudes of nursing students related to caring for dying patients in central Anatolia. METHODS: The study was completed with 222 third-year students of nursing school originating from three universities in Turkey. RESULT: It was explored that Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) scores of the students who had previously cared for terminal patients at the clinics were significantly higher, and the scores of those who regarded themselves as nonbeliever in terms of religion were significantly lower (p < .05). CONCLUSION: It was seen that nursing students’ FATCOD scores were at a moderate level. IMPLICATIONS FOR NURSING PRACTICE: We are of the opinion that it will be helpful that nursing students should be trained about the care for dying patients during their formal education. AMAÇ: Bu çalıs¸ma Orta Anadolu’daki hems¸irelik ög ˘ rencilerinin ölmekte olan bireye bakım vermeye ilis¸kin tutumlarını belirlemek amacı ile tanımlayıcı olarak yapıldı. GEREÇ VE YÖNTEM: Bu çalıs¸ma, Türkiye’deki üç üniversitenin üçüncü ve dördüncü sınıf hems¸irelik bölümü 222 ög ˘ rencisiyle tamamlandı. Veriler ög ˘ renci bilgi formu ve Frommelt Ölmekte Olan Bireye Bakım Vermeye ˙I lis¸kin Tutum Ölçeg ˘i (FATCOD) ile toplandı. Mann-Whitney U ve Kruskal-Wallis testi kullanıldı. BULGULAR: Daha önce kliniklerde terminal dönemdeki hastalara bakım veren ög ˘ rencilerin FATCOD ölçek puanlarının anlamlı ¸sekilde yüksek oldug ˘ u ve ög ˘ rencilerden kendini dini açıdan inançsız olarak ifade edenlerin puanları da anlamlı olarak düs¸ük bulundu (p < .05). SONUÇ: Hems¸irelik ög ˘ rencilerinin FATCOD puanlarının orta düzeyde oldug ˘u saptandı. HEMSIRELIK UYGULAMALARI IÇIN ÖNERILER: Hems¸irelik ög ˘ rencilerine eg ˘ itimleri süresince ölmekte olan bireyin bakımına ilis¸kin eg ˘ itimlerin verilmesinin yararlı olacag ˘ ı düs¸ünülmektedir.
Death is a universal phenomenon that happens to every human being regardless of their life conditions. In a general sense, death may be defined as a qualitative and quantitative transformation that occurs with the termination of one’s existence on earth. The concept of death in people’s minds determines their behaviors and lifestyles in religious, philosophical, and moral aspects. While birth is a celebrated event, death is a feared one, which people are usually reserved to talk about in public. Although the effect of death on human life is inevitable, an individual’s conception © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
of death in an exaggerated, disproportional, or pathological way can adversely affect his/her psychology. At times when attitudes toward death lack balance and harmony, the anxiety level of a person increases and it becomes more difficult for him/her to adapt to his/her social environment (Civaner, 2003; ˙I nci & Oz, 2009; Peters et al., 2013). Today, death is considered as more than a natural outcome of life cycle, but as a disease against which struggle is required. Nowadays, many deadly diseases can be cured thanks to advances in diagnostic and treatment 183
Student Nurses’ Attitudes Toward Dying Patients techniques as well as sophisticated technology (Oz, 2004). As a result, the reality of death, which has gradually been removed from the walks of life, has begun to be a usual encounter for the health staff in hospitals, which, to a great extent, puts the emotional burden of death upon health professionals. This situation may increase the negative attitudes about death for healthcare staff (particularly the nurses) who regularly work with the dying patients in hospitals (Cimete, 2002; Karakurt, 2012). Although death is described as a natural process of the life cycle and an inevitable reality of life, it is typically one of the most painful experiences of loss undergone by the patient and his/her family (Cimete, 2002). Nurses’ knowledge about the dying patient and his/her family’s sociocultural status will play a key role in designating the type of care strategies to be implemented (Bahar, Beser, Ersin, Kissal, & Aydogdu, 2012; ˙I nci & Oz, 2009). It is everybody’s right to receive a holistic and sensitive care from the medical staff. The basic objective of the care to be given to the dying patients is to provide them with the necessary physical and psychological comfort and to increase the quality of their remaining lifespan (Akdemir & Birol, 2004). However, in Turkey the nursing practices have been inadequate in terms of providing holistic care for the dying and their families. This is because the nurses predominantly focus on the dying patient’s physical well-being without paying enough attention to other aspects of the holistic care (Cimete, 2002). Some international studies conducted with nursing students who have dealt with death in the clinical settings indicate that students experience fear about the care for the dying patients, and think that their educational programs are not sufficient to prepare them for these situations (Cooper & Barnett, 2005; Loftus, 1998; Shin, Gau, Lin, Pong, & Lin, 2006). Likewise, in Turkey, in a limited number of studies, it has been observed that the education programs offered to the nursing students are insufficient to prepare them to provide comprehensive care for dying patients (Koc & Saglam, 2008; Oz, ˙I nci, & Bahadir Yilmaz, 2012; Tasdemir & Gok, 2012). As part of their formal educational practices, the nursing students are provided the responsibility to ensure the continuation of the life of a dying patient (Oz, 2004). The aim of educating the nursing students about the concept of death is to enable them to provide a holistic care to the patients and their close relatives, and to develop positive attitudes toward care of the dying patients by being aware of their own attitudes and behaviors toward the matter of death (Mok & Chiu, 2004). Nursing aims to assist people to cope with the reality of death as well as health and illness (Iranmanesh, Rayyani, & Azizzadeh Forouzy, 2012; Kelleci, 2005). As a result, nurses’ perceptions about death should be explored early in their education. Nursing students should also be given opportunities to express their emotions and to improve their knowledge about caring for the dying (Hurtig & Stewin, 1990). Along with less than adequate managed practices of the caring for the dying, the nurses’ negative attitudes may lead to the use of insufficient methods for coping with 184
D. Arslan et al. death, and may cause unnecessary pain to the patients and stress among their family members. Within the nursing curriculum newly adopted in the Turkish universities, nursing students are educated from a holistic perspective about how to care for terminal patients during the 4 years at university. Additionally, congruent with holistic care, the nursing programs integrate many opportunities during the entire program for nursing students to reflect on their experiences, to discuss their attitudes, beliefs, and personal feelings in a safe environment in which they are supported. Emphasis in the following 3 years is around communication at the end of life. This includes having difficult conversations with both the terminal patients and their families in the following 3 years and about how to approach the terminal patients and their families. Therefore, the concept of death and the care of the dying should be well integrated within the educational programs for the nurses over the course of the 4 years. Methods Aim of the Study As a result of these changes in the nursing education, it was important to explore the attitudes of nursing students who had been exposed to this curriculum toward the dying. To do so, a quantitative descriptive methodology was conducted in three different universities that adopted this curriculum. Samples and Procedures The population of the study consisted of third- and fourth-year university students who had previous practical experience with different patient groups at clinics of internal diseases and surgery. There were a total of 248 students (101 students at Bozok University Health School, 72 students at Selcuk University Kadir Yallagul Health School, and 75 students at Nevsehir University Semra and Vefa Kucuk Health School). Instruments Data were gathered by means of a 10-item student information form designed by the researchers after screening of the relevant literature (Akdemir & Birol, 2004; Cevik, 2010; Civaner, 2003; Dunn, Otten, & Stephens, 2005; Lange, Thom, & Kline, 2008; Rooda, Clements, & Jordan, 1999; Yigit, 1998) and Frommelt Attitudes Toward Care of the Dying Scale (FATCOD; Frommelt, 2003) to assess nurses’ attitudes toward the caring for the terminally ill individuals and their families, and the potential thoughts and feelings they might have at the time of death. The FATCOD is a 30-item scale consisting of an equal number of positively and negatively worded statements with response options of strongly disagree, disagree, uncertain, agree, and strongly agree on a 5-point Likert scale.
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Items 1, 2, 4, 16, 18, 20, 21, 22, 23, 24, 25, 27, and 30 are positively worded statements. The other items of the scale are negatively worded (Cevik & Kav, 2013; Frommelt, 1991, 2003). Positive items are scored from 1 (strongly disagree) to 5 (strongly agree). Scores are reversed for negative items. Possible scores range from 30 to 150. A higher score indicates a more positive attitude toward caring for the dying patients. The validity and reliability of the scale were established by Cevik, who found Cronbach alpha value of the scale as 0.73 (Cevik, 2010). The Cronbach alpha reliability of the scale in this study was 0.77. Data Analysis Statistical analyses of the data were performed using Statistical Package for Social Sciences (SPSS). Mann– Whitney U-test was used to perform pairwise comparisons for binary variables because the data relating to the scale score and independent variables did not follow a normal distribution. Kruskall–Wallis variance analysis was used for three groups. The value for significance was set at .05. Ethical Considerations Official permission was obtained from the institutions where the study was conducted following a briefing explaining the objectives and the scope of the study. The nursing students were informed about the research study orally and given the option to participate. Once the nursing students expressed an interest in participating, the researchers obtained written consents. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki (revised October 2000).
Table 1. Sociodemographic Characteristics of the Nursing Students and Their Perceptions of Death (n = 222) Characteristics Gender Female Male Age 21 years 22 years 23 years 24 ≥years Place of residence City Rural area Metropolitan Choosing the profession by their own will Yes No Religious beliefs Believer Devoted believer Nonbeliever The most important knowledge and information caring for a dying patient should know Legal and ethical Issues Communicational knowledge Cultural differences Experiencing death of a significant other Yes No Caring for the dying in clinical settings before Yes No Willingness to care for the dying Yes No
n
%
156 66
70.3 29.7
85 60 51 26
38.3 27.0 23.0 11.7
108 75 39
48.6 33.8 17.6
138 84
62.2 38.8
115 51.8 97 43.7 10 4.5 that a nurse 84 83 55
37.8 37.4 24.8
114 108
51.4 48.6
80 142
36.0 64.0
106 116
47.7 52.3
Results In total, 222 students (89.5%) participated in the study. The results of the study indicated that: (a) the mean age of the students was 22.18 ± 1.32; (b) 70.3% were female; (c) 48.6% lived in cities; (d) 38.8% of the students were satisfied with their decision to be a nurse; (e) 51.8% considered themselves as a believer of a religion; and (f) 37.8% thought that it is significant to get information about legal and ethical issues in order to give the proper care for the dying. In addition, more than half of the students reported that they had experienced the loss of a significant other, while 36.0% stated that they had previously cared for a dying patient in clinical settings. More than half (52.3%) of the participants were unwilling to care for the dying (Table 1). Table 2 demonstrates the sociodemographic characteristics of the nursing students and their mean FATCOD scores for their opinions about caring for the dying. The students’ overall FATCOD mean score was found to be 95.2 ± 14.1. The FATCOD mean scores of the students who regarded themselves as nonbelievers in terms of religious
beliefs were found to be significantly lower (p < .05) than those who reported to believe in a religion. In addition, the FATCOD mean scores of the students with previous experience of caring for terminal patients in clinics were significantly higher (p < .05) than those lacking such an experience. The FATCOD scores of the students who wanted to provide care for terminal patients in the clinics were significantly higher (p < .05) than those who did not. No statistically significant difference was observed in nursing students’ attitudes toward the caring for the dying (p > .05) in terms of gender, age, previous living place, voluntary choice of the profession, and facing death reality in the close circle (death of a significant other). Discussion and Conclusions As part of their profession, nurses always have to deal with the dying patients and their families. The care for the dying is one of the most challenging parts of the nursing practice. Also, the fact that attitudes the individual nurses 185
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Table 2. Characteristics of the Nursing Students and the Distribution of the Mean Scores of Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) Mean scores of Frommelt Attitudes Toward Care of the Dying Scale Demographic characteristics
X ± SD
Test
Frommelt Attitudes Toward Care of the Dying Scale 95.2 ± 14.1 (47.00–142.00) Gender Female 95.18 ± 14.06 Male 93.89 ± 13.17 Age 21 years 94.67 ± 13.68 22 years 96.28 ± 14.80 23 years 94.17 ± 17.33 ≥24 years 96.26 ± 11.11 Place of residence Rural area 96.85 ± 13.03 City 93.26 ± 15.46 Metropolitan 97.28 ± 11.20 Choosing the profession by their own will Yes 95.26 ± 14.38 No 95.03 ± 13.59 How did nursing students describe themselves in terms of religious beliefs Nonbeliever 83.70 ± 7.97 Believer 97.10 ± 12.18 Devoted believer 94.08 ± 15.93 Experiencing death of a significant other Yes 96.42 ± 15.59 No 93.87 ± 12.17 Caring for the dying clinical settings Yes 97.49 ± 14.75 No 93.88 ± 13.53 Willingness to care for the dying Yes 96.95 ± 16.98 No 93.56 ± 10.54 a
p
4718.000
.325a
1.163
.762b
4.023
.134b
5790.500
.991a
10.406
.005b
5307.500
.076a
4685.500
.030a
4943.500
.012a
Mann–Whitney U analysis was used. Kruskal–Wallis test was used.
b
develop toward death may vary from person to person makes the situation more viable (Akdemir & Birol, 2004; Cimete, 2002). According to the findings discerned from the current study, it may be argued that the nursing students have moderately positive attitudes toward caring for the dying (95.2 ± 14.1). In a relevant study conducted previously in Turkey, the mean score obtained from the FATCOD scale was 99.9 ± 8.7 (Cevik, 2010). Similarly, the mean scores achieved in some studies performed in other countries were over 100 (Dunn et al., 2005; Lange et al., 2008; Rooda et al., 1999). Therefore, the mean score obtained in this study (95.2 ± 14.1) is more in agreement with the mean scores obtained in Turkey than those obtained abroad, which may suggest that the educational and cultural contexts affect the attitudes toward the caring for the dying. Some previous studies indicated that religious beliefs of the individuals may also affect their perspectives on death and the caring for the dying (Civaner, 2003; Dunn et al., 2005; Eues, 2007; Iranmanesh, Dargahi, & Abbaszadeh, 2008). In Islam, it is believed that the soul of the dying person is removed from his body and transcends to Allah following his/her demise. This belief gives spiritual strength 186
to the patient’s family and the nurses providing care to them, thus contributing to their forming positive attitudes when they experience the time of death (Oz et al., 2012; Tanhan & Ari, 2006). In this study, the mean FATCOD score of 51.8% of the students who considered themselves as religious was found to be higher than those who considered themselves nonreligious. In a similar study, Cevik (2010) demonstrated that 68.0% of the nurses indicated that they had strong religious beliefs, with 45.0% of them emphasizing that devoutness affects attitudes toward the dying. However, it was observed that the attitude scores were lower for those who stated that they were very religious. According to the literature, the more religious the people, the more often they develop negative attitudes toward death. The reason for this is that the individuals believe that they will be punished in the afterlife (Oz et al., 2012). Facing the death of a significant other or a patient in a clinical setting is one of the most defining moments that may later influence the attitudes of the nurses toward caring for the dying. In the related literature, it has been demonstrated that the nursing students can develop more favorable attitudes toward death as long as they are educated about the efficient methods of dealing with the dying
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patients (Cooper & Barnett, 2005; Koc & Saglam, 2008; Loftus, 1998; Shin et al., 2006; Tasdemir & Gok, 2012). This study revealed that half of the participating students experienced death of a significant other and 36% of them cared for a dying patient in a clinical setting. The students who reported to have cared for a dying patient in a clinical setting were found to hold more positive attitudes toward death than those who had not done so. In literature, there are similar studies showing that nurses who experienced death or provided care for the dying had more positive attitudes toward caring for the dying (Lange et al., 2008; Yigit, 1998). These findings suggest that the reality of death should be an integral part of the classroom teaching/ learning process, and the nursing students should be involved in role plays and simulations at school to help them to develop more positive attitudes toward caring for the dying in the clinical setting. It is generally argued that willingness to care for the dying may be as influential on the students’ attitudes as the experience of death. In the current study, more than half of the students (52.3%) reported that they are unwilling to provide care for the dying. This study did not explore this phenomenon, but this unwillingness to care for the dying may be a result of a lack of knowledge and experience about the issue, but needs further exploration in future studies. Overall, the findings obtained from the current study indicated that the nursing students exposed to this curriculum around providing holistic end-of-life care had moderately positive attitudes toward caring for the dying. Further, their beliefs, past experiences, and willingness to care for the dying affect their attitudes pertaining to death and dying. Limitations The findings of this study cannot be generalized to Turkey as a whole since it was carried out in a specific region in the central Anatolia. The majority (98%) of the population in Turkey are Muslims, with the remaining 2% consisting of Christians, Jewish, Atheists, and other religious groups (Pew Research Center, 2009). Further studies with a larger, more diverse population are necessary to understand if the findings of this study on nursing students’ attitude about death and dying after exposure to this curriculum are generalizable. Recommendations This study suggests that courses about death and palliative care are essential and should be extensively integrated to the nursing curriculum. In this sense, proper classroom environment should be formed for students to discuss their beliefs and emotions about death. Role plays concerning care for the dying should be incorporated within relevant courses to prepare students for dealing with the dying
patients and their families. In addition, nursing students should be offered opportunities to reflect on their experiences, feelings, actions, and reactions regarding death and care for the dying people in their own families in order to cater for the possibilities to utilize personal experiences as a part of positive and constructive learning. References Akdemir, N., & Birol, L. (2004). Terminal hasta bakimi [Care of terminal patient]. In L. Birol (Ed.), ˙I c hastaliklari hemsirelik bakimi kitabi [Internal disease and nursing care] (2nd ed., pp. 207–211). Ankara, Turkey: Sistem Yayincilik. Bahar, Z., Beser, A., Ersin, F., Kissal, A., & Aydogdu, N. G. (2012). Traditional and religious death practices in western Turkey. Asian Nursing Research, 6(3), 107–114. Cevik, B. (2010). Hemsirelerin olume ve olmekte olan bireye bakim vermeye iliskin tutumlari ve deneyimleri [Attitudes and experiences of nurses about death and dying patient]. Ankara, Turkey: Baskent Universitesi Saglik Bilimleri Enstitusu, Hemsirelik Bolumu [Baskent University Health Sciences Institute, Nursing Department]. Cevik, B., & Kav, S. (2013). Attitudes and experiences of nurses toward death and caring for dying patients in Turkey. Cancer Nursing TM, 36(6), 58–65. Cimete, G. (2002). Olumcul hastalara butuncul yaklasim [Holistic Care for dying patients] (pp. 1–20). Istanbul, Turkey: Nobel Yayincilik. Civaner, M. (2003). Onemli bir etik sorun alani olarak yasamin son donemi [End of life period as an important ethical problem]. Toplum ve Hekim [Community and Physician], 18, 148–151. Cooper, J., & Barnett, M. (2005). Aspects of caring dying patients which cause anxiety to first year student nurses. International Journal of Palliative Nursing, 11(8), 423–430. Dunn, K. S., Otten, C., & Stephens, E. (2005). Nursing experience and the care of dying patients. Oncology Nursing Forum, 32(1), 97–104. Eues, S. K. (2007). End-of-life care; improving quality of life at the end of life. Professional Case Management, 12(6), 339–344. Frommelt, K. (2003). Attitudes toward care of the terminally ill: An educational intervention. American Journal of Hospice and Palliative Care, 20(1), 13–22. Frommelt, K. H. (1991). The effects of death education on nurses’ attitudes toward caring for terminally ill persons and their families. American Journal of Hospice and Palliative Care, 8(5), 37–43. Hurtig, W. A., & Stewin, L. (1990). The effect of death education and experience on nursing students’ attitude towards death. Journal of Advanced Nursing, 15(1), 29–34. Iranmanesh, S., Dargahi, H., & Abbaszadeh, A. (2008). Attitudes of Iranian nurses towards caring for dying patients. Palliative and Supportive Care, 6(4), 363–369. Iranmanesh, S., Rayyani, M., & Azizzadeh Forouzy, M. (2012). Caring at the end of life: Iranian nurses’ view and experiences. Journal of Nursing Education and Practice, 2(2), 9–17. ˙I nci, F., & Oz, F. (2009). Olum egitiminin hemsirelerin olum kaygisi, olume iliskin depresyon ve olumcul hastaya tutumlarina etkisi [Effects of death education on nurses’ death anxiety, depression regarding death, and attitudes towards the dying patient]. [Anadolu Psikiyatri Dergisi] Anatolian Journal of Psychiatry, 10, 253–260. Karakurt, P. (2012). Kayip ve olum sureci [Loss and death process]. In T. Atabek Asti & A. Karadag (Eds.), Hemsirelik Esaslari kitabi [Nursing fundamentals] (pp. 1155–1160). ˙I stanbul, Turkey: Akademi Yayincilik. Kelleci, M. (2005). Kanser hastalarinin umudunu gelistirmeye yonelik hemsirelik girisimleri [Nursing initiatives to improve hope of cancer patients]. Anadolu Psikiyatri Dergisi [Anatolian Psychiatry Journal], 6, 41–47. Koc, Z., & Saglam, Z. (2008). Hemsirelik ogrencilerinin yasam sonu bakim ve olum durumuna iliskin duygu ve goruslerinin belirlenmesi [Determination of emotions and thoughts of nursing students about end of life and death]. Cumhuriyet Univeristesi Hemsirelik Yuksekokulu Dergisi [Cumhuriyet University Nursing School Journal], 12(1), 14–21. Lange, M., Thom, B., & Kline, N. (2008). Assessing nurses’ attitudes toward death and caring for dying patients in a comprehensive cancer center. Oncology Nursing Forum, 35(6), 955–959. Loftus, L. A. (1998). Student nurses’ lived experience of the sudden death of their patients. Journal of Advanced Nursing, 27(3), 641–648. Mok, E., & Chiu, P. C. (2004). Nurse–patient relationships in palliative care. Journal of Advanced Nursing, 48(5), 475–483.
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Student Nurses’ Attitudes Toward Dying Patients Oz, F. (2004). Kayip, olum vey yas sureci [Loss, death and mourning process]. In Saglik alaninda temel kavramlar [Basic concepts in health] (pp. 276–313). Ankara, Turkey: ˙I maj ve Dis Ticaret AS. Oz, F., ˙I nci, F., & Bahadir Yilmaz, E. (2012). Hemsirelik ogrencilerinin olum kaygisi ile psikolojik saglamlik duzeyleri ve aralarindaki iliski. [The death anxiety and resilience levels of nursing students and relevance between these levels]. New/Yeni Symposium Journal, 50(4), 229–236. Peters, L., Cant, R., Payne, S., O’Connor, M., McDermott, F., Hood, K., et al. (2013). How death anxiety impacts nurses’ caring for patients at the end of life: A review of literature. Open Nursing Journal, 7, 14–21. Pew Research Center. (2009). Islam by country. Retrieved from http:// en.wikipedia.org/wiki/Islam_by_country (accesed 20 March 2014) Rooda, L. A., Clements, R., & Jordan, M. L. (1999). Nurses’ attitudes toward death and caring for dying patients. Oncology Nursing Forum, 26(10), 1683–1687.
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D. Arslan et al. Shin, F., Gau, M., Lin, Y., Pong, S., & Lin, H. (2006). Death and help expected from nurses when dying. Nursing Ethics, 13(4), 360–375. Tanhan, F., & Ari, F. (2006). Universite ogrencilerinin olume verdikleri anlam ve ogrenim gordukleri program acisindan olum kaygisi duzeyleri [The meaning university students give to death and death anxiety levels according to their department]. Yuzinci yil Univeristesi Egitim Fakultesi Dergisi [Yuzinci Yil University Faculty of Education Journal], 3(2), 44–45. Tasdemir, G., & Gok, F. (2012). Determining death anxiety among health school students. International Journal of Human Sciences, 9(2), 303–317. Yigit, R. (1998). Hasta ve ailesine olumle bas etmelerinde yardim etme [Helping patient and his/her family cope with death]. Cumhuriyet Univeristesi Hemsirelik Yuksekokulu Dergisi [Cumhuriyet University Nursing School Journal], 2(2), 9–15.
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