American Journal of Hospice and Palliative Medicine http://ajh.sagepub.com/

The effects of death education on nurses' attitudes toward caring for terminally ill persons and their families Katherine H. Murray Frommelt AM J HOSP PALLIAT CARE 1991 8: 37 DOI: 10.1177/104990919100800509 The online version of this article can be found at: http://ajh.sagepub.com/content/8/5/37

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The effects of death education on nurses' attitudes toward caring for terminally ill persons and their families Katherine H. Murray Frommelt, RN, BSN, MSN

Abstract This study sought to determine the cffectiveness of an education program on nurses' attitudes toward caring for terminally ill persons and their family members. The program, based on the hospice concept of care, included a didactic section based on Kubler-Ross' stages of death and dying, and a roleplay model designed by the researcher. Data were collected from 34 licensed nurses, aged 18 to 65, practicing in the midwestern United States. The FrommeltAttitude Toward Care of the Dying

Katherine H. Murray Frommelt, RN, BSN, MSN, isNursing Instructor, Clarke College, andNurse Coordinator, Hospice of Dubuque County, Dubuque, Iowa.

Scale (FATCOD) was designed by the researcher to assess nurses' attitudes. The FATCOD was found to be a valid and reliable tool. All nurses completed the tool before and after the education program (pre-test, post-test). Compared by a t-test, the scores for the nurses were signQflcantly higher after participation in the educational program. The t-value wasfound to be 2.97, significant at the < 0.01 level, 2-tailed probability = 0.006. These findings support the hypothesis that nurses have a more positive attitude toward caring for terminally ill persons and their family members after participation in the program, than the same nurses had before participating in the program. Demographic information including age, years of experience in nursing, highest degree held, basic type of nursing preparation and previous education on death and dying were analyzed to determine their relationship to the nurses' attitudes. The only information which demonstrated any significant relationship to the nurses' attitudes was that ofprevious education on death and dying. These were computed by an analysis of variance (ANOVA) F = 3.22, F prob = 0.04, significant at < 0.05 level. Of the nurses who participated in the study, 76.5 percent indicated that they were unhappy with the educa-

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tion which they hadpreviously received on the subject of death and dying. The effects of death education on nurses' attitudes toward caring for terminally ill persons and

their families Several authors have stated that Americans are known to live in a deathdenying society. -6 In the past, this has been reflected in nurse education, which has not included content to prepare nurses to interact with terminally 1il persons and their families. Because the health professional with the greatest exposure to the dying patient is the nurse, society expects nurses to be prepared to provide reassuring and humane care. Present research offers "ample evidence that instruction concerned with the psychosocial aspects of death and dying as a structured experience,is a relatively neglected area of formal nursing

education."7 Nurses need proper education in the field of death and dying. The content of this education needs to include specific information on exploring the feelings, attitudes and beliefs of self and others. The purpose of this research was to determine the effectiveness of an education program on nurses' attitudes toward caring for terminally ill persons and their family members.

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Problem of study The problem of study began with three separate findings: * Nursing education has not kept up with societal changes in regard to the terminally ill;7-9 * Nurses have been found to exhibit negative behavior toward caring forthe termirially ill;1014 * Although many tools could be found which could be used to test nurses' attitudes toward their own death, no tool could be found which adequately tested nurses' attitudes toward caring for the terminally ill and their families. *Boyar's, 1964, Fear of Death Scale

*Lester's, 1966, Fear of Death Scale *Hardt's Attitudes Toward Death Scale *Kurlychek's Death Acceptance Scale *Leming's Death Anxiety Scale *Templer's Death Anxiety Scale

Hypothesis The hypothesis developed for the study is: Nurses who participate in a structured educational program based on the hospice concept of care will have a more positive attitude toward caring for terminally ill persons and their

Demographic data sheet Last 4 digits of your Social Security No. Completion and return of this questionnaire will be construed as your consent to be a research subject in this study. Your anonymity is guaranteed. Please check the appropriate spaces: Years of experience in nursing 1. 2. Age _ 18-22 years 0-2 years 3-5 years 23-27 years _ 28-35 year 6-10 years 36-45 years 11-15 years 16-20 years 46-55 years 21-25 years 56-65 years over 25 years 66 years and over 4. 3. Basic type of nursing preparation Highest degree held PN certificate LPN ADN Diploma BSN Diploma Baccalaureate MSN Masters in other field (Generic 4 year program) Other (please specify) _

5.

6.

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Previous education on death and dying I took a course in death and dying as part of my basic nursing education. I did not take a specific course on death and dying, but material on the subject was included in other nursing courses. No information dealing with death and dying was included in my nursing education. about Feelings previous education on the subject of death and dying. I feel that my nursing education prepared me adequately to deal with death and dying. I feel that my nursing education did not prepare me adequately to deal with death and dying.

family members than the attitude which the same nurses had before participating in the program. The following research question and sub-questions were developed in relation to this hypothesis: Research question What is the difference in nurses' attitudes toward caring for terminally ill persons and their families after participation in a structured teaching program based on the hospice concept of care compared to the same nurses' attitude before participating in the educational program? Sub-questions * How does demographic information such as age, years of experience in nursing, basic type of nursing preparation, previous type of education on death and dying, and nursing degree influence the nurses' attitudes toward caring for the terminally ill and their families? * What type of previous education about death and dying have these nurses had, if any? * What kind of feelings do these nurses have about the previous education which they received on the subject of death and dying? Limitations * A quasi-experimental design with non-probability sampling was used. * Sample was limited to a three state geographical region. * Small sample size (N = 34). * Limited time available for the teaching program (two hours). Instrument Design The study instrument, the Frommelt

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Attitudes toward Nursing Care of the Dying Scale (FATCOD) was designed by the researcher in 1988 (see Appendix A). A blueprint for the tool was designed to assure that the items addressed nurses' attitudes toward terminally ill persons and their family members. Two-thirds of the items relate directly to the nurses' attitudes toward the patient and one-third relate directly to the nurses' attitudes toward the family members of the terminally ill person. Ideas for several of the items came from Wiccezorek's Attitude Toward Nursing Care ofthe Dying Child Scale, developed in 1975.15 These items were adapted so as to relate to any terminally-ill person regardless of age. Other items came from personal experience with terminally-ill persons and from concerns expressed by nurses who attended various workshops presented by the researcher on the subject of death and dying. The instrument consists of 30 Likert-type items which are scored on a five-point scale. The instrument is made up of an equal number of positively and negatively worded items. Possible responses to each item are: SD = strongly disagree, D = disagree, U = uncertain, A= agree, and SA= strongly agree. Positive items are scored from one for strongly disagree to five for strongly agree. For negative items the opposite scoring system is used. Higher scores reflect more positive attitudes.

Validity To assess validity, a content validity index (C'VI) was computed. The CVI for the tool was a 1.00. A determination of interrater agreement was then computed. An interrater agreement of 0.98 was obtained. Reliability The test-retest procedure was used

Appendix A. Frommelt attitudes toward care of the dying scale. In these items the purpose is to lea.-n how nurses feel about certain situations in which they are involved with patients. All statements concem the giving of nursing care to the dying person and/or, his/her family. Where there is reference to a dying patient, assume it to refer to a person who is considered to be terminally ill and to have six months or less to live. Please circle the letter following each statementwhichcorresponds to your ownpersonal feelings about the attitude or situation presented. Please respond to all 30 statements on the scale. The meaning of the letter is: SD = Strongly Disagree D = Disagree U = Uncertain A = Agree SA = Strongly Agree 1. Giving nursing care to the dying person is a worthwhile learning experience. U SA A D SD 2. Death is not the worst thing that can happen to a person. U SA A D SD 3. I would be uncomfortable talking about impending death with the dying person. U SA A D SD 4. Nursing care for the patient's family should continue throughout the period of grief SA U A D SD and bereavement. 5. I would not want to be assigned to care for a dying person. U SA A D SD 6. The nurse should not be the one to talk about death with the dying person. U SA A D SD 7. The length of time required to give nursing care to a dying person would frustrate me. U SA A D SD 8. I would be upset when the dying person I was caring for gave up hope of getting better. U SA A D SD 9. It is difficult to form a close relationship with the family of a dying person. U SA A D SD 10. There are times when death is welcomed by the dying person. U SA A D SD 11. When a patient asks, "Nurse am I dying?", I think it is best to change the subject to U SA A D SD something cheerful. 12. The family should be involved in the physical care of the dying person. SA A D U SD 13. I would hope the person I'm caring for dies when I am not present. U SA A D SD 14. I am afraid to become friends with a dying person. U SA A D SD 15. I would feel like running away when the person actually died. U SA A D SD 16. Families need emotional support to accept the behavior changes of the dying person. U SA A D SD 17. As a patient nears death, the nurse should withdraw from his/her involvement with U SA A D SD the patient. 18. Families should be concemed about helping their dying member make the best of U SA A D SD his/her remaining life 19. The dying person should not be allowed to make decisions about his/her physical care. U SA A D SD 20. Families should maintain as normal an environment as possible for their dying member. U SA A D SD 21. It is b!eneficial for the dying person to verbalize his/or feelings. SA A U D SD 22. Nursing care should extend to the family of the dying person. U SA A D SD 23. Nurses should permit dying persons to have flexible visiting schedules. U SA A D SD 24. The dying person and his/her family should be the in-charge decision makers. U SA A D SD 25. Addiction to pain relieving medication should not be a nursing concern when dealing U SA A D SD with a dying person. 26. I would be uncomfortable if I entered the room of a terminally ill person and found U SA A D SD him/her crying. 27. Dying persons should be given honest answers about their condition. U SA A D SD 28. Educating families about death and dying is not a nursing responsibility. U SA A D SD 29. Family members who stay close to a dying person often interfere with the professionals' U SA A D SD job with the patient. 30. It is possible for nurses to help patients prepare for death. U SA A D SD 01988, Katherine H. Murray Frommelt

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Appendix B. Role-play model.

Situation A You have been told that you have less than six months to live. What are my first three "gut reactions" (emotions felt)? I. 1. 2. , 3. II. What three things do I want most from the person who is going to care for me? 1., 2. 3. m. What three things do I definitely not want from the person who is going to care for me? 1. 2. 3. IV. What attributes do I bring to this situation (positive things about oneself)? 1. 2. 3. V. What deficits do I bring to this situation? 1. 2. 3. VI. What changes do I need to make in order to be able to deal with this situation? 1. 2. 3.

Situadon B You have been assigned to care for someone who has just been told that he/she has less than six months to live. Please answer the following questions. I. What are my first three "gut reactions" (emotions felt)? 1. 2. II.

3. What three things do I want most from the patient?

Im.

2. 3. What three things do I definitely not want from this patient?

1.,

1., IV.

V.

VI.

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2. 3. What attributes do I bring to this situation? 1. 2. 3. What deficits do I bring to this situation? 1. 2. 3. What changes do I need to make in order to be able to deal with this situation? 1. 2. 3.

to assess the reliability of the instrument. Reliability was tested at two different times. The first time the sample was composed of 18 nurses from an oncology unit. Scores were compiled and a Pearson Product-Moment Correlation Coefficient was computed with a resulting score of r = 94. To strengthen the reliability, a second test-retest was done using a larger sample composed of 30 nurses from both an oncology and a surgical unit. The Pearson's Coefficient computed from this sample was a 0.90.

Subjects A quasi-experimental design with non-random sampling was used. Aconvenience sample was used consisting of 34 nurses who are licensed and currently practicing in the Midwest. All nurses were asked to participate in a two-hour educational program on death and dying based on the hospice concept of care. They were asked to fill out the FATCOD questions including demographic information before the educational program began and again after completion of the program. Educational program Teaching content area and teaching methods were designed both to match the educational level of the leamers and to meet objectives designed for the course. A specific roLe-play model (Appendix B) was designed to aid the nurse in self-assessment. A case study approach was designed to exemplify the work of Kubler-Ross (This researcher has found the role-play model to be very helpful in terms of getting people in touch with their feelings related to death and dying, and has been used extensively with a variety of both professional and nonprofessional groups of all ages)."6 Open-ended questions and group problem solving methods were used during the educational session. All par-

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ticipants were given an annotated bibliography on the subject of death and dying which was to be used as a basis on which participants could further their own education in the area and which could be used by nurses or families when working with the terminally ill. Conclusions Demographic information for all participants seemed to reflect the national average. Of the 34 nurses who participated in the study, the average age of the participants was between 28 and 35 years with between six and 10 years of experience in nursing. Over 50 percent of the nurses received their basic education from diploma schools, and over 60 percent identified this degree as the highest held, with 20.6 percent reporting a BSN, 2.9 percent an MSN and 5.9 percent a master's degree in another field. As expected, the majority (76.5 percent) of the nurses who participated in the study felt they were inadequately prepared to deal with the terminally ill. The only demographic variable which proved to have a significant effect on the nurses' attitudes toward caring for the tenninally ill was having taken a specific course on death and dying previously (F prob = 0.04). Those nurses who had been specifically prepared to deal with the terminally ill reflected a more positive attitude toward caring for the dying than those who had not been specifically prepared. An unexpected finding was that one of the educational groups consisted of all hospice nurses. These nurses reflected a more positive attitude toward caring for terminally ill persons than the non-hospice nurses; but even with their previous experience, their attitudes became more positive after participating in the educational program. There was no significant difference in the amount of attitude change between the non-hospice nur-

ses and the hospice nurses when comparing pre-attitude scores with postattitude scores (Sig. of F = 0.3 11). An analysis of variance (ANOVA) was computed by tests of significance for identification of effect using sequential sums of squares. Based on the scores obtained on the FATCOD at the time of pre-test it was found that the hospice nurses (group A) did reflect a more positive attitude toward caring for terminally ill persons than the non-hospice nurses (group B) (see Table 1). Because it was found that the hospice nurses reflected a more positive attitude on the pre-test than the nonhospice nurses, a second question was chosen to be researched: Is it possible to improve the hospice nurses attitude further by participation in the educational program? To attempt to answer the question the pre-attitude and postattitude scores of the hospice nurses were compared to the pre- and post-attitude scores ofthe non-hospice nurses.

A repeated

measure

ANOVA

computed using sequential

was sums of

squares, which is the method used for positioning the sum of the squares,

based

on a

system that adjusts each

term only for the terms that precede it.

There was no significant difference in the amount of improvement (Sig. of F = 0.311). Both groups did significantly better on the post-test than they did on the pre-test. This finding indicates that it was possible to improve the hospice nurses' attitudes through participation in the educational program. A second comparison was computed on the post-attitude scores of the hospice nurses compared to the non-hospice nurses. Both groups reflected significant improvement with the hospice nurses showing a significant difference in post-attitude as compared with the non-hospice nurses (Sig. of F = 0.006). This finding appears to indicate that the combination of education plus experience is reflected in a more positive attitude toward caring for terminal-

Table 1. Tests of between-subjects effects of pre-education attitude of hospice nurses compared to non-hospice nurses Source of variation DF SS F MS Sig of F Within groups A & B 5.04 32 0.16 0.000 Between groups A &B 0.86 1 0.86 5.43 0.026* *p = < .05 Table 2. Tests involving attitude within-subject effect of pre and post attitude of hospice nurses as compared to non-hospice nurses. Source of variation DF SS F MS SigofF Witiin cells 0.76 32 0.02 Difference in post-attitude 0.21 1 0.21 8.83 0.006* Difference in improvement ID 0.02 1 0.02 1.06 0.311 by attitude *p=< .01 Table 3. Pre-education attitude compared to post-education attitudes. Paired t-test results Standard Standard Nurses' attitudes N Mean Deviation Error t Pre-education 34 4.3049 0.310 0.056 2.97 Post-education 4.4157 0.326 0.053 *p =

The effects of death education on nurses' attitudes toward caring for terminally ill persons and their families.

This study sought to determine the effectiveness of an education program on nurses' attitudes toward caring for terminally ill persons and their famil...
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