Failure to discuss death as part of normal life may have a number of consequences, including fear of the process of dying, a lack of awareness and openness between close family members, and lack of knowledge about how to request and provide services when a person is dying. It is necessary to better understand death, accept, and prepare for it with a mature attitude [
Those nearing the end of their lives deserve to be given optimum care, attention, compassion, and consideration [
Attitudes towards death are, to some extent, based upon people’s faith, ethnicity, education, and other socioeconomic and religious characteristics [
Work experience and continuing education also play roles in shaping nurses’ attitude towards death. More exposure and experience in working with dying patients correlated to more positive attitude in caring for dying patients. The experienced nurses appeared to have more flexible attitude, and adhered less strictly to the palliative treatment than the inexperienced students did. A study conducted in New York indicated that older nurses of a Comprehensive Cancer Center had a more positive attitude towards caring for dying patients than their younger counterparts. In contrast, nurses who lacked such experience showed more negative attitude, and reported more feelings of fear for death [
Because of the traditional beliefs, to Chinese, it is taboo and discouraged to discuss death in daily life. In general, Chinese people tend to use metaphorical expressions and/or rhetorical pictures to convey meanings and emotions implicitly, especially when they talk about death. The knowledge of these death metaphors and pictures can provide a better understanding of Chinese personal perceptions of death [
In Kangda College of Nanjing Medical University, the students of the four-year program of Bachelor of Science in Nursing begin their internship in the fourth year of their study. The death education is given throughout the first three years both in class and hospital exercitation before internship, by using lectures/courses, focus group discussion, and/or problem based learning. The contents of the education include Death and Dying, Evolution and Development of Humans’ Knowledge of Death, Progress of Life Cycle, Meaning of Death, Death Epidemiology, Socioeconomic Issues of Death, and Hospice and Palliative Care [
This study was conducted between July, 2017 and September, 2018 in eight teaching hospitals in Jiangsu Province, China. The approval for conducting this study was obtained from the Institutional Ethics Committee of the First People’s Hospital of Lianyungang (approval number: KY20170701001).
The study is a questionnaire survey on the knowledge, attitude, and practice (KAP) using standardized questionnaires. The convenience sampling method was used to recruit 366 nursing interns from the eight teaching hospitals affiliated to Kangda College of Nanjing Medical University in Jiangsu Province, China. The nursing interns had worked more than 5 months in the teaching hospitals, and participated in the survey voluntarily with signed consent form. As a descriptive and explorative study, no predefined power and type I error were used for sample size determination.
Two standardized questionnaires were used in the KAP survey. One collected the data regarding the nursing interns’ general information, including gender, age, religious belief, the only child in the family, living with single parent, living area, education level, perception of mind and body, experience in caring for dying patients, experience of a deceased relative in family, death education, and family atmosphere of discussing death. The other questionnaire was the Death Attitude Profile-revised (DAP-R) [
The Chinese version of DAP-R included 32 items of the above five domains of attitude towards death. Each item is scored using five-point Likert scale from strongly disagree (1 point) to strongly agree (5 points). Therefore, the total scores of questionnaire may range from 32 to 160 points, with a higher score indicating a more positive attitude towards caring for dying patients.
Previous study showed that the Cronbach’s coefficients of most domains in the Chinese DAP-R were above 0.7, and the split-half correlation coefficient was 0.864, which indicated that the Chinese DAP-R had good internal consistency. The overall reliability of the questionnaire was 87.5% [
The researchers gave detailed introduction and guidance to the nursing interns on how to fill in the questionnaires before the survey. Questionnaires were collected immediately after the nursing interns completed them. Of the 366 recruited nursing interns, 357 valid questionnaires were returned, and the response rate was 97.5%.
The attitude scores were summarized using mean and standard deviation (SD). The difference between the groups was tested using the Student’s
The rank of the five domains’ average scores of the nursing interns’ attitude towards death from high to low is: natural acceptance, death avoidance, fear of death, escape acceptance and approach acceptance (Table
Comparison of the attitude domains’ scores (mean ± standard deviation) between the norms and the nursing interns (
Domain | Number of items | Domain score | Average item score | Rank | Norms [ |
|
|
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Natural acceptance | 5 | 18.36 ± 2.62 | 3.67 ± 0.52 | 1 | 21.95 ± 2.90 | −25.91 | 0.001 |
Death avoidance | 5 | 14.94 ± 3.30 | 2.99 ± 0.66 | 2 | 11.10 ± 4.80 | 22.00 | 0.001 |
Fear of death | 7 | 20.34 ± 3.98 | 2.90 ± 0.57 | 3 | 19.04 ± 6.58 | 6.204 | 0.001 |
Escape acceptance | 10 | 13.64 ± 3.64 | 2.73 ± 0.73 | 4 | 15.05 ± 4.75 | −7.31 | 0.001 |
Approach acceptance | 5 | 26.18 ± 5.16 | 2.62 ± 0.52 | 5 | 24.20 ± 7.80 | 7.24 | 0.001 |
As shown in Table
Comparison of the attitude domains’ scores (mean ± standard deviation) between the subgroups by demographic characteristics.
Demographic group | n | Fear of death | Death avoidance | Natural acceptance | Approach acceptance | Escape acceptance | |
---|---|---|---|---|---|---|---|
Gender | Male | 20 | 21.20 ± 3.97 | 15.75 ± 2.82 | 18.25 ± 3.43 | 26.30 ± 7.57 | 15.45 ± .524 |
Female | 337 | 20.29 ± 3.94 | 14.89 ± 3.32 | 18.36 ± 2.57 | 26.10 ± 5.00 | 13.53 ± 3.56 | |
Statistic |
|
|
|
|
| ||
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0.322 | 0.260 | 0.849 | 0.916 | 0.022 | ||
|
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Age | ≤20 | 124 | 20.69 ± 4.12 | 15.18 ± 3.19 | 17.88 ± 2.65 | 25.6 ± 4.72 | 13.72 ± 3.51 |
21–22 | 186 | 20.13 ± 3.99 | 14.6 ± 3.29 | 18.64 ± 2.59 | 26.20 ± 5.12 | 13.51 ± 3.70 | |
≥23 | 47 | 20.28 ± 3.50 | 15.30 ± 3.59 | 18.51 ± 2.51 | 27.3 ± 6.22 | 13.98 ± .380 | |
Statistic |
|
|
|
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| ||
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0.469 | 0.328 | 0.039 | 0.158 | 0.700 | ||
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Religious belief | Yes | 32 | 20.14 ± 3.93 | 14.84 ± 3.23 | 18.29 ± .2.59 | 25.70 ± 4.76 | 13.41 ± .53 |
No | 325 | 22.44 ± 3.91 | 16.00 ± 3.83 | 19.06 ± .2.89 | 30.97 ± 6.52 | 16.03 ± .97 | |
Statistic |
|
|
|
|
| ||
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0.020 | 0.057 | 0.110 | 0.001 | 0.001 | ||
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The only child in the family | No | 245 | 20.42 ± 3.72 | 14.93 ± 3.30 | 18.16 ± 2.53 | 26.27 ± 4.76 | 13.7 ± 3.43 |
Yes | 112 | 20.18 ± 4.50 | 14.96 ± 3.31 | 18.80 ± 2.77 | 25.96 ± 5.96 | 13.5 ± 4.07 | |
Statistic |
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|
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| ||
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0.598 | 0.96 | 0.03 | 0.60 | 0.60 | ||
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Living with single parent | No | 327 | 20.38 ± 4.03 | 15.02 ± 3.30 | 18.28 ± 2.59 | 26.14 ± 5.056 | 13.67 ± 3.57 |
Yes | 30 | 19.97 ± 3.39 | 14.07 ± 3.17 | 19.27 ± 2.80 | 26.57 ± 6.27 | 13.30 ± 4.40 | |
Statistic |
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| ||
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0.587 | 0.129 | 0.407 | 0.67 | 0.592 | ||
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Living area | City | 99 | 20.85 ± 3.88 | 15.29 ± 2.80 | 18.39 ± 2.50 | 26.14 ± 4.48 | 12.95 ± 3.53 |
Town | 141 | 20.39 ± 4.29 | 15.05 ± 3.32 | 18.54 ± 2.85 | 26.01±5.93 | 14.06 ± 3.95 | |
Countryside | 117 | 19.86 ± 3.62 | 14.513.63 | 18.11 ± 2.43 | 26.40 ± 4.71 | 13.73 ± 3.27 | |
Statistic |
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| ||
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0.190 | 0.197 | 0.422 | 0.833 | 0.064 | ||
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Education level | Undergraduate | 200 | 20.25 ± 3.98 | 14.72 ± 3.21 | 18.60 ± 2.62 | 26.21 ± 5.52 | 13.50 ± 3.65 |
Graduate | 55 | 20.09 ± 3.75 | 15.56 ± 3.68 | 18.33 ± 2.53 | 26.60 ± 4.61 | 13.64 ± 3.54 | |
Other | 102 | 20.67 ± 4.10 | 15.05 ± 3.23 | 17.902.63 | 25.88 ± 4.72 | 13.93 ± 3.69 | |
Statistic |
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| ||
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0.605 | 0.223 | 0.090 | 0.702 | 0.617 | ||
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Perception of mind and body | Poor | 40 | 19.38 ± 3.66 | 14.05 ± 2.98 | 18.98 ± 2.61 | 25.65 ± 4.13 | 14.53 ± 4.06 |
Moderate | 178 | 20.60 ± 3.76 | 14.80 ± 3.18 | 17.89 ± 2.49 | 26.28 ± 4.79 | 13.79 ± 3.22 | |
Good | 122 | 20.30 ± 4.42 | 15.34 ± 3.57 | 18.82 ± 2.65 | 26.22 ± 5.83 | 13.21 ± 4.15 | |
Very good | 17 | 20.24 ± 3.46 | 15.71 ± 2.78 | 18.53 ± 3.06 | 26.06 ± 6.29 | 13.12 ± 2.50 | |
Statistic |
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| ||
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0.370 | 0.115 | 0.008 | 0.920 | 0.197 | ||
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Experience in caring for dying patients | No | 103 | 20.98 ± 3.62 | 15.20 ± 3.17 | 17.83 ± 2.60 | 26.41 ± 5.47 | 14.00 ± 3.63 |
Yes | 254 | 20.09 ± 4.09 | 14.83 ± 3.35 | 18.57 ± 2.60 | 26.08 ± 5.04 | 13.50 ± 3.64 | |
Statistics |
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| ||
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0.054 | 0.339 | 0.014 | 0.590 | 0.237 | ||
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Experience of a deceased relative in family | No | 123 | 20.33 ± 3.78 | 14.79 ± 3.10 | 17.80 ± 2.53 | 25.79 ± 4.67 | 13.13 ± 3.49 |
Yes | 234 | 20.35 ± 4.08 | 15.02 ± 3.40 | 18.65 ± 2.63 | 26.38 ± 5.40 | 13.91 ± .70 | |
Statistics |
|
|
|
|
| ||
|
0.969 | 0.527 | 0.003 | 0.304 | 0.054 | ||
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Death education | No | 191 | 21.10 ± 4.09 | 15.61 ± 3.12 | 17.81 ± 2.43 | 26.33 ± |
14.01 ± .31 |
Yes | 166 | 19.48 ± 3.65 | 14.17 ± 3.334 | 18.99 ± .69 | 26.00 ± |
13.22 ± 3.95 | |
Statistic |
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|
|
|
| ||
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0.001 | 0.001 | 0.001 | 0.548 | 0.012 | ||
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Family atmosphere of discussing death | Open and free | 130 | 19.15 ± 4.51 | 13.80 ± 3.64 | 19.79 ± 2.41 | 25.84 ± 6.01 | 13.43 ± 4.47 |
Awkward, uncomfortable | 35 | 21.86 ± 2.88 | 15.51 ± 2.58 | 17.29 ± 2.24 | 25.86 ± 4.44 | 13.14 ± 3.02 | |
Avoiding | 71 | 21.83 ± 3.31 | 16.01 ± 2.84 | 18.21 ± 2.55 | 26.77 ± 4.90 | 14.18 ± 3.06 | |
Only when necessary, and avoiding children and elderly | 121 | 20.31 ± 3.57 | 15.37 ± 3.01 | 17.21 ± 2.24 | 26.28 ± 4.47 | 13.69 ± 3.07 | |
Statistic |
|
|
|
|
| ||
|
0.065 | 0.001 | 0.001 |
|
0.440 |
In the generalized linear regression models, scores of the five attitude domains were treated as the dependent variables, and gender, age, religious beliefs, and other demographic characteristics variables were included as explanatory variables. Both adjusted and non-adjusted results (Table
Generalized linear regression analysis of the nursing interns’ attitudes towards death.
Domain | Independent variables | adjusted |
|
|
|
---|---|---|---|---|---|
Fear of death | Norm | 2.988 | 74.087 | 0.001 | |
Religious belief | 0.355 | 0.179 | 3.487 | 0.001 | |
Death education | −0.244 | −0.215 | −4.196 | 0.001 | |
|
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Death avoidance | Norm | 3.513 | 32.422 | 0.001 | |
Death education | −0.249 | −0.189 | −3.681 | 0.001 | |
Family atmosphere of discussing death | −0.138 | −0.204 | −3.986 | 0.001 | |
|
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Natural acceptance | Norm | 3.541 | 24.104 | 0.001 | |
Experience on a deceased relative in family | 0.144 | 0.131 | 2.762 | 0.006 | |
Death education | 0.182 | 0.173 | 3.628 | 0.001 | |
Family atmosphere of discussing death | 0.147 | 0.362 | 7.601 | 0.001 | |
|
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Approach acceptance | Norm | 2.570 | 93.787 | 0.001 | |
Religious belief | 0.526 | 0.292 | 5.750 | 0.001 | |
|
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Escape acceptance | Norm | 3.086 | 18.719 | 0.001 | |
Gender | −0.339 | −0.107 | −2.076 | 0.039 | |
Religious belief | 0.519 | 0.204 | 3.943 | 0.001 | |
Death education | −0.181 | −0.124 | −2.413 | 0.016 |
Among the five domains of attitude towards death of the studied nursing interns, the average item score of the domain natural acceptance is the highest (3.67 ± 0.52), which is above 3 points and suggests that most of the nursing interns regarded death as a natural phenomenon in the life. They could accept death neutrally, neither welcome nor reject. The average item score of approach acceptance is the lowest (2.62 ± 0.52), which suggests that most of the nursing interns did not agree with the view that there is still life after death. In general, the nursing interns appeared to have a positive attitude towards death in general. Although their scores of natural acceptance and escape acceptance were statistically significantly lower the corresponding norms, their scores of death avoidance, fear of death and approach acceptance were statistically significantly higher (Table
Previous study conducted in China indicated that factors associated with inpatient department nurses’ attitude towards the care of dying patients include education level, fear of death, approach acceptance, religious beliefs, previous education on death and dying, natural acceptance, professional title, and experience with death or dying patients [
This KAP survey showed that the scores of the domain escape acceptance of the male interns were higher than those of females. The possible reason might be that males have more psychological pressure on their future [
In our survey, the nursing interns who had no religious belief showed higher scores in domains fear of death, approach acceptance, and escape acceptance, which was inconsistent with previous researches [
In summary, religious belief may have impact on nursing interns’ attitude towards death, which suggests that nursing educators should try to know the death culture in different religious beliefs and nursing students’ religious background before their nursing practices.
Studies showed that family atmosphere of discussing death played an important role in developing attitude towards death [
Few studies investigated the influence of the death of a relative on the attitude towards death. Our study showed that the nursing interns who experienced death of a relative in family could face death more calmly. It suggests that we could adopt scenario simulation, hospice ward visiting, or other ways in death education to let nursing students have more experience of death, and increase their understanding of dying patients, eliminate their fear, and make them calmer when facing dying patients.
Some studies showed that the death education had positive impact on the attitude towards death, such as more calm and less fear [
If nursing interns who had no death education before and been exposed to dying patients in clinical practice, they would have difficulty to cope with the situation psychologically. Therefore, they might have more negative and passive reactions to death such as fear and avoidance. In our survey, less than half (46.5%) of the nursing interns had death education. It indicates the deficiency of the death education in the nursing education in China.
Nursing students would benefit from an educational program focused on caring for terminally ill people and their families [
We recognize that there are limitations in our study. The study is crosssectional, therefore, no causal relationship can be confirmed in the study. Our sample is a convenient sample, which might not represent the nursing intern population in China, even in the studied city. The sample size is small, which means the power might be low in some subgroup analyses. We have planned to replicate and confirm our findings using a prospective design with a larger random sample in the future. Because of the tradition concept in China that nurse is a job for women, there were only few male nurses could be recruited in our study. The limited number might hinder the generalization of our findings in male nurses.
The DAP‑R scores of attitude towards death are at a moderate level in the surveyed Chinese nursing interns. The positive attitude to death and death education before clinical practice are helpful to nursing interns when they care for dying patients. There is a lack of death education for nursing students in China, which should be reinforced in the future.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
Fengqin Xu, Kun Huang, and Yinhe Wang contributed equally to this work.
This work was supported by the Education Research Grant of Nanjing Medical University, China (YB2017114). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
The collaborating teaching hospitals of the survey are as follows: the First People’s Hospital of Lianyungang, Jiangsu Province Hospital, Nanjing Drum Tower Hospital, the Second Affiliated Hospital of Nanjing medical University, Taixing People's Hospital, Suqian First Hospital, the Second Changzhou People’s Hospital, and Suzhou Municipal Hospital.