RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BENGALURU
ANNEXURE-11
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION.
1. / NAME OF THE CANDIDATE / MR. D. SAM JAYAKARAN2. / NAME OF THE INSTITUTION
AND ADDRESS / K. R. COLLEGE OF NURSING ,
PROPERTY NO.59, 25/4/74, KATHA NO.1935, C & M COMPLEX, OMKAR LAYOUT, UTTARAHALLI-KENGERI MAIN ROAD, BENGALURU-560060.
3. / COURSE STUDY AND SUBJECT / 1 ST YEAR MSC NURSING
MEDICAL-SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE. / 27/06/2012
5. / TITLE OF THE STUDY:
“A CORRELATION STUDY ON PERCEPTION AND ATTITUDE OF NURSING STUDENTS REGARDING DYING AND DEATH IN A SELECTED NURSING COLLEGE, BENGALURU”.
6 / BRIEF RESUME OF THE INTENDED WORK:
INTRODUCTION
“Let us touch the dying, the lonely and unwanted according to the grace we received. Let us not be ashamed or slow to do humble work as we all are human beings”.
- Mother Theresa
Birth and death are two aspects of life, which will happen to everyone. Dying and death are painful and personal experiences for those that are dying and their loved ones caring for them. Death affects everyone physically, psychologically, emotionally, spiritually and financially. Whether the death is sudden and unexpected, or ongoing and expected, there is information and help available to address the impact of dying and death 1.
Nurses caring for clients with advanced and life threatening diseases will ultimately witness the final stage of life-dying and death. The dying process is often accompanied by a myriad of psychological, spiritual and physical needs and nurses are in the ideal position to identify and address them. Nurses must be knowledgeable about the normal dying process, symptom management especially pain, and the role of the interdisciplinary team to provide optimal support for dying clients and their families. Nurses spend more time with patients and their families than any other health professionals and are in the most immediate position to provide care, comfort and counseling at the end of life2.
In the past three decades there has been a surge of interest in the care of the dying, with an emphasis on the settings in which death occurs, the technologies used to sustain life, and the challenges of trying to improve end-of-life care. The focus on care of the dying has been motivated by the aging of the population, prevalence and the publicity surrounding life-threatening illnesses such as cancer and AIDS, and the efforts of health care providers to build a continuum of service that spans the lifetime from birth until death3.
Student nurses are involved in caring for patients who are actively dying or who have been told they have a terminal illness and are faced with the process of dying. Students encounter these patients in various health care settings like hospitals, nursing homes, community, hospice etc. Management of the dying patient often elicits anxiety in nursing staff especially among nursing students. Most nursing students meet dying patients for the first time in their clinical experiences. When first meeting a dying patient, nursing students often lacked help or support from health care team members and educators, causing a negative experience in their nursing careers. Some of the students who showed more positive perceptions, views, attitudes and behaviors towards death indicated that they had good instruction in their clinical practice before meeting with a dying patient. Even as they cared for dying patients, their clinical educators helped them4.
Death is inevitable for all living beings and, as health care providers; nurses play a principle role in the care of dying individuals and their families. Consequently, the care that nurses provide to terminal or dying patients may be affected by their own attitudes toward death. According to Rooda, “Determinants of attitudes toward death and dying encompass not only cultural, societal, philosophical, and religious belief systems, but also personal and cognitive frameworks from which individual attitudes toward death and dying are formulated and interpreted”. Therefore, nurses’ personal feelings also may influence how they cope with dying patients5.
6.1 NEED FOR THE STUDY
Nurse educators have identified that historically nurses have not been prepared to care for dying patients. Research also has identified that nursing students have anxieties about death and dying and also caring for dying patients. As part of a national movement in North Carolina to improve end-of-life (EOL) care, schools of nursing are starting to implement End of Life (EOL) education in their curricula. This research looked at one component of End of Life (EOL) education, which incorporates experiential learning using Quintís model of death education and transformative learning theory. The educational experiences were geared to help students understand the skills needed to competently and compassionately care for the dying6.
Hospice care has steadily expanded in the United States. In 1985 about 160,000 clients were served. In 1999 about 700,000 received hospice care. Yet, despite this increase, only 29% of all clients who died in the United States in 1999 were enrolled in a Medicare Hospice Programme7.
A phenomenological study was conducted to explore the meaning of twenty six undergraduatenursing students' experiences in caring fordyingpatients. Thenursing students' written descriptions of their experiences were analyzed using Colaizzi's phenomenological method. Six themes emerged from this analysis. While caring fordyingpatients,nursing studentsexperienced emotions such as fear, sadness, frustration, and anxiety. Contemplation of the patient's life anddeathoccurred as thestudentscared for their patients. In addition to providing physical, emotional, and spiritual support fordying patients, an integral part ofnursing students' care involved supporting the patients' families. Helplessness was experienced by thestudentsregarding their role as patient advocates. While caring fordyingpatients,nursing students' learning flourished. Educational strategies for preparingnursing studentsto care for thedyingare addressed based on the findings of this qualitative study8.
According to Mallory, nursing education has historically lacked an effective approach to providing education on dying patients. Education on care of the dying, either at the academic level or as continuing education, should be provided if nurses are expected to effectively care for dying patients. In a study by Frommelt, 76.5% of nurses surveyed felt inadequately prepared to care for the terminally ill. The same study concluded that nurses who were educated to deal with the terminally ill had more positive attitudes toward care of the dying than those who were not educated. Providing end-of-life care to patients and their families may evoke stress if the nurse has not been sufficiently trained in the process (Beckstrand and Kirchhoff). Therefore, education on end-of-life care is a necessity for nurses6.
It is a paramount importance to teach nursing students on dying and death and now it is an integrated part of the nursing curriculum to prepare nurses with adequate cognitive and affective skills to care dying patients in clinical practice. During clinical meetings, it is necessary to discuss the perceptions and experiences of patients and their relatives regarding dying and death and how nurses provide holistic care in such crucial situations without fear by incorporating the principles of palliative care. This kind of discussions could assist student nurses to experience in caring patients who are in final stage of life-dying and death without fear9.
During my professional experience as a nurse, the researcher came across many Nursing students having inadequate perception and poor attitude towards dying and death. So the researcher felt that, there is a need to assess the perception and attitude of nursing students regarding dying and death.
6.2 REVIEW OF LITERATURE
“Literature review is a critical summary of research on a topic of interest often prepared to put a research problem in the context or as the basis for an implementation project”.
- Pilot Hungler
Review of literature related to the perception of nursing students towards dying and death
A qualitative study was conducted to understand the perception of the death and dying of the nursing students in the dependences of a situated state university in the city of the Salvador/Ba of Brazil. It was used half-structuralized interview as technique for collection of data. The corpus was composed for ten students of the course of nursing of varied semesters. The data had been analyzed on the basis of the categorical analysis of contents and emerged three categories: Coming close itself to the death in the process to take care of; Fear of the death and needing preparation to deal with the death. One concluded that the nursing academics are unprepared to deal with its emotions and feelings, as well as of its customers in whom he refers to the death process and dying 10.
A study was carried out to analyze the First year nursing students’ perceptions of death on 55 nursing students of Jen-Te Junior College of Medical Nursing and Management at Maio-Li, Taiwan. Glaser & Strauss’s grounded theory methodology allowed data to emerge from the open-ended interviews and questionnaires in order to understand the participants’ knowledge. The study results showed that nursing students had two major perceptions on death: positive and negative perceptions. In the positive perception setting, the nursing students’ families gave them support, encouraged them and viewed death as a normal process. In the negative setting, their families did not discuss death, viewed death as a taboo. Both these nursing perceptions had repercussions for other patients9.
A qualitative research was done through semi-structured interviews with students who attended the Eighth Semester in a private institution. The aim of the research is to understand the perceptions and experiences of nursing students in the process of death and dying. The six students testimonies were transcribed and analyzed based on content analysis, which ultimately resulted in four themes: I) Difficulty and denial of death; II) emotional management in the face of death and dying; III) Prepare for death and dying IV) Anxiety with the reality of future deaths. It was concluded that graduating students feel unprepared to deal with death and dying process and tend to deny the situation. Besides, they pointed to the need for greater academic preparation about the subject in order to assist the individual self and acceptance11.
An open-ended, self-report questionnaire was administered to 110 senior Bachelor of Science in Nursing (BSN) students, in order to ascertain the perceptions of a group of Taiwan’s fourth-year BSN students regarding death and help expected from nurses during the dying process. The students recorded their thoughts on: their fears before physical death; afterlife destinations; and the help they would expect from nurses when dying. The data were analyzed using a three-layer qualitative thematic analysis. The students’ reported needs during the dying process were directed towards three main goals: help in reaching the ‘triple targets of individual life’; help in facilitating in-depth support so that both the dying person and significant others can experience a blessed farewell; and help in reaching a destination in the after life. The results support the belief of dying as a transition occurring when life weans itself from the mortal world and prepares for an after life12.
Review of literature related to the attitude of nursing students towards dying and death
A comparative study was conducted to evaluate the attitudes of Iranian and Swedish nursing students toward caring for dying persons were measured with the From melt’s Attitude Toward Caring of the Dying and the Death Attitude Profile Revised. The results indicated that the participating Iranian students were more afraid of death and less likely to give care to dying persons than the Swedish participants. The study suggested that theoretical education should be individualized and culturally sensitive in order to positively influence the students’ attitudes, and promote professional development13.
A qualitative and quantitative study was conducted in order to evaluate attitudes toward life and death among nursing students after attending the life and death studies (LDS) program The pre-test, post-test control group design randomly assigned students to an experimental (n = 47) or control group (n = 49). The 13-week course included lectures, video appraisal, games, simulations, films, books, assignments and group sharing. Statistical and content analysis were used to analyze qualitative and quantitative data. The findings showed a significant improvement in perception of the meaningfulness of life in four categories of improvement: expanded viewpoint, sadness about death, treating life sincerely, and instilling hope in life. The qualitative data indicated that a positive change in meaning of life was associated with interaction with others and self-reflection14.
A cross sectional study was done to assess the attitudes towards death in a sample of 52 Indian nursing students by the use of Death Attitudes Profile-Revised (DAP-R) 32-item scale with five distinct dimensions- Fear of Death (7 items), Death Avoidance (5 items), Neutral Acceptance (5 items), Approach Acceptance (10 items) and Escape Acceptance (5 items). The findings indicated that fear of Death score was 32.78 ± 4.02 (4.68 ±.57%), Death Avoidance was 23.78 ± 4.03 (4.75 ±.80%), Neutral Acceptance was 24.96 ± 4.53 (4.99 ±.90%), Approach Acceptance was 47.82 ± 5.77 (4.78 ±.57%), Escape Acceptance was 21.44 ± 4.92 (4.28 ±.98%). Overall DAP-R score was 150.78 ± 17.48 and it was found that Death avoidance and Escape acceptance was significantly higher (p<.05) in younger students and Christian students respectively. The study findings concluded that nursing students had fairly neutral attitudes towards death, while death avoidance was common in younger students and escape acceptance was higher among Christian students15.
A multicenter survey was conducted among undergraduate nursing education regarding the care of dying patients at eight schools of nursing in Buenos Aires, Argentina. We enrolled 680 students from first to fifth year. Students acknowledged interacting directly with dying patients. Attitudes toward dying patients were highly positive. Students of the fifth year expressed a less satisfying relationship with their patients than those from the first year; considered it as a less gratifying occupation, and also showed a greater preference for avoiding emotional involvement with those patients. Students perceived that this issue received more attention in humanistic rather than clinical subjects. Ninety-eight percent of students spontaneously demanded more training to care dying patients16
Review of literature related to the correlation study
A descriptive correlation study was done on sample of 360 nurses from the internal medicine, oncology, hematology, and palliative care departments of five health institutions in Lisbon (response rate 70.6% of all nurses). Data were collected using a socio demographic and professional questionnaire (QSDE) and the Portuguese versions of the Death Attitude Profile-Revised (DAP-R) scale and the Adult Attachment Scale (AAS). Older nurses (P<0.0001) and nurses with more work experience (P<0.0001) had higher escape acceptance. Female nurses had higher religious acceptance (P<0.0001). Medicine, oncology, and hematology nurses had significantly higher fear attitudes (P<0.01), avoidance of death attitudes (P<0.0001), and escape acceptance attitudes (P<0.0002) than palliative care nurses. This study contributes to a better understanding of the factors that underlie nurses' attitudes toward death. This may be useful for creating relevant and effective pre- and post-graduate nursing training17.