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Effects of the Heal-Dying Program on Meaning of Life, Death Anxiety, and Life Satisfaction in Nursing Students

Ji Min Lee1, Sung Jung Hong*2

1 Department of Nursing, Semyung University,579 Sinwoul-Dong, Jechon 390-711, Korea 2Department of Nursing, 1375 Gyeongdong-ro, Andong-si, Gyeongsangbukdo 36729, Korea

Abstract

This study aimed to investigate the effects of the Heal-Dying Program on nursing students’ perceptions of the meaning of life, anxiety regarding death, and life satisfaction.The study design was a nonequivalent control group pretest-posttest design. The subjects were 70 students (experimental group = 35, control group = 35) from a nursing college in South Korea. This five-week program involved taking photos of the deceased, lectures on death and dying, preparation and reading of wills, experiencing lying in the casket, and watching a life documentary. The students in the experimental group showed increased level of meaning of life, and life satisfaction, and decreased level of death anxiety when compared to the control group. This study confirmed that the Heal-Dying program is an effective intervention strategy to facilitate an understanding of the meaning of life and reduce death-related anxiety among nursing students.

Keywords: Death, Education, Anxiety, Life Satisfaction, Nursing Students

*Corresponding Author : Name : Sung Jung Hong Email : [email protected] Contact : +82-54-820-6804 Fax : +82-54-820-6730

Date of Submission : 05-10-2020

Introduction

Recent advances in medical technology, increased medical supply, increased access to health care (Vatandoost M., et al, 2019) and urbanization of small families have led to an increasing number of people experiencing the end of life in medical institutions (Field M J et al, 1997).

According to Statistics Korea in 2018, the number of deaths at medical institutions accounted for 91.2% of all deaths and has been on a steady rise to 74.9% in 2018 (Vital Statistics Division et al, 2018). As such, due to the increase in the number of deaths within medical institutions, nursing students often experience death directly and indirectly through clinical practice (Parry M, 2011).

Indeed, nursing students experience anxiety, helplessness, and fear about death as they watch the

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patients on their deathbeds (Edo-GualM et al., 2014; Edo-Gual Met al, 2015).

It has been reported that nursing students tend to be stressed and anxious when they have to take care of patients on their deathbed without establishing their own philosophy of death and they generally avoid it with an indifferent look (Edo-Gual Met al., 2015; Peters Let al., 2013). Failing to address this mental burden and taking care of a dying patientwill result in physical and mental exhaustion, and negative attitudes toward death and anxiety (BraunM et al., 2010; Sharif Nia Het al, 2015). Nursing college students should take time to think about the meaning of life, because when faced with a patient's death without reflection on life and death, they will experience internal and external confusion even about their self-identities, including conflicts related to their lives and the world (Becker C T, 1997;Mallory J L, 2003). Death education has to do with ourselves, our lives, and our feelings about the world we live in, and it helps us to deal creatively with death, without avoiding grief (Kim E H et al, 2009). In addition, nursing students, as future nurses, need to be prepared to accept situations in which they face death in their clinical practice. This will help nurses to lift the burden of caring for dying patients and supporting their families. Therefore, nurses will be able to approach dying patients with more positive manner (Tang P L et al, 2011).

However, according to previous studies (LeombruniP et al., 2014;Youn J H et al, 2013;), nurses and nursing college students lack preparation to face death, and do not have adequate support even after experiencing the death of a patient. Therefore, for nursing students to understand death, accept it as part of the course of life, and to have a positive attitude toward dying care, an environment of death-related education should be created in the nursing curriculum (HenochI et al., 2017). Death-related education can also help dying patients and their families by positively changing their attitudes towards dying so that they can deal with the situation on their deathbeds (Diener E et al, 1999; Dobbins E H, 2011; HenochI et al., 2017).

Foreign countries’ death education programs for nursing students were developed from the late 1900s (Imogie A O, 2000). In 2000, the United States American Association of Colleges of Nursing urged the nursing schools to incorporate the End of Life Care Program in their curriculum to promote death as a part of the normal process of life. Such a program prompted the students the meaning of life through education to help students to have positive attitudes toward death so that patients can be treated well on their deathbeds (Mooney D C, 2005; Mallory J L, 2003).

Death education programs have been developed for college students in Korea as well, but in previous studies (Kim E H et al., 2009; Kang K A et al.,2010; Park Y S et al, 2017) most of the programs had limitations in considering the situation of nursing students facing the death of others through clinical practice. Therefore, this study attempted to provide opportunities for nursing

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students to think about the life meaning and to understand death correctly, subsequently establishing positive points of view of death and life values.

Materials and Methods Research Design

The design of this study was a nonequivalent control group pretest-posttest design.

Participants

The sample consisted of first-year nursing students at XXX University in Chungbuk province, South Korea. This study used G*Power to calculate the sample size with the effect size of 0.8,significance level (p)=0.05, and power of o.8. Power analysis indicated that the appropriate ample size was for this study 34 participants in each group (intervention and control). Participants were randomly selected from among 70 respondents. In a pouch, 35 pieces of black paper and 35 pieces of white paper were placed, with every participant asked to pick one piece. Students who picked the black and white pieces of paper were assigned to the experimental and control groups, respectively. A one-tailed t-test was used to analyze the differences between two independent groups.

Measurements

Heal-Dying Program

We developed the Heal-Dying Program based on a literature review (Corr&Corr, 2013; Kim &

Lee, 2009) conducted by a research team and validated by certified hospice specialists. The five-week program, the duration of which was determined based on previous studies, consisted of five two-hour sessions (Kim & Lee, 2009; Kim & Kim, 2015). Each week, some students were either attended a teaching session or watched a video clip on topics, followed by a discussion.

Previous studies revealed that death training was most effective when students were given opportunities to reflect or discuss after a session, when compared to a long lecture (Kang, 2010;

Wynne, 2013).Based on this result, the researchers formed small groups consisting six or seven students in each group to allow intentional, purposeful dialogue among themselves.

The Healing Dying program promoted students' level of understanding using self-reflection, and realistic limitations were applied in consideration of the students' experience and knowledge.

Furthermore, the program readied subjects for simulated death experience including will writing and, preparation of funeral for themselves, and mental preparation. The program contents are presented in [Table 1]. The order of activities was as follows: taking a photograph that would be used for his or herown funeral, a lecture, donning the white funeral attire, writing and reading a will, and lying in the casket. After the participants took photos for their own symbolic funeral,

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they attended a classroom session about life and death that included watching a video clip about death for roughly 30 minutes. Subsequently, 30 minutes were dedicated for the participants to write their wills in a dark room and read them to an audience while wearing the white clothing characteristic of corpses. During this time, the participants expressed their love for their parents, relatives, and friends, which is often overlooked in normal circumstances. Thereafter, they laid in a closed casket for ten minutes, reflected on their lives, and calmly thought about their deaths.

Lastly, the experimental group watched a documentary on people who persevered through difficult situations. This educational experience culminated with words of encouragement by the organizer.

Meaning of Life

Meaning of life was assessed with the tool developed by Choi et al (2005) for adults. This instrument had 46 items, each of which was measured using a four-point Likert scale (1: strongly disagree, 2: disagree, 3: agree, 4: strongly agree). The higher the score, the greater the perception of the meaning of life. The Cronbach’s α of this measurement tool’s was .94 in this study.

Death-Related Anxiety

Participants’ death-related anxiety was evaluated using Templer’s (Templer D I, 1970) Death Anxiety Scalethat was translated into Korean by Ko (KoH G et al, 2006). This tool consisted of 15 items, each of which was scored on a five-point Likert scale from 1 (not at all likely) to 5 (very likely). Negative questions were reverse coded. The higher the number reflects the high anxiety related to death. Cronbach’s α was .87 in this study.

Life Satisfaction

To measure life satisfaction, a tool originally developed by Sirgy et al (Sirgy M L et al., 2007) and modified by Kim and Lee (Kim E H et al., 2009) by removing questions that were not appropriate for college students was used. This 43-item tool consisted of 11 questions about family life, seven about life in school, eight related to satisfaction with interpersonal relationships, and 17 related to subjective points of view of life satisfaction. Each question was measured by a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Reverse coding was used for the negative questions. The higher score indicated high satisfaction and lower score indicated low satisfaction. Cronbach’s αwas .908 in this study.

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Table 1.Overview of the Heal-Dying Program.

Topics Level

(minutes)

Contents and activities Methods

At admission 100 min  Induction of the researcher and research assistants

 Program overview(General)

 Obtain consent from the samples

 Listening to poetry and watching the death documentary

 Self-introduction of participants

 Taking photos of the deceased and writing the goodbye letter

Listening to background music and discussion

1st session 120 min  Watching a movie

 Lectures on death and dying

 Sharing how they feel about the dying process within small group

Animation Lecture

2nd session 120 min  Watching a life documentary Animation

3rd session 120 min  Preparation and reading of wills, lying in casket experience Presentation

4th session 120 min  Setting and sharing life goals

 Presentation of self-reflection of the experience after the death education program

Data Collection Procedure

The experimental and control group completed the 46 questions related to meaning of life, 15 questions related to anxiety about death, and 43 questions related to life satisfaction. Subsequently, the Heal-Dying program was implemented for the experimental group. Before its commencement, pre-program survey was conducted in experimental and control groups using a questionnaire to determine their views about meaning of life, anxiety, and life satisfaction. After the pre-program survey, only the experimental group received the death education program. The post-program survey was conducted at the end of the program using the same questionnaire. After the data collection, the death education program was provided to the control group to allow to take advantage of the program as well. At the conclusion of data collection, all participants received a small gift.

Data Analysis

The IBM SPSS WIN version 25.0 (SPSS, Chicago, IL, USA) was used to analyze data. The homogeneity of general characteristics, meaning of life, death anxiety, and life satisfaction in the experimental and control groups were verified using the t-test and χ2-test. The differences of dependent variables before and after the intervention was used to measure paired t-test and the

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t-test was used to analyze differences between the experimental and control groups.

Ethical Considerations

Institutional Review Board of University approval was obtained before collecting data.

Students were informed about the purpose and process of the study and potential risks and benefits of the study. Subsequently, the students who volunteered to participate were informed of the time required for completing the survey (20 to 30 minutes), and informed consents were consents were obtained.

Results and Discussion

General Characteristics of Participants

The results of the analysis of homogeneity of the general characteristics of participants in the experimental and control groups prior to the Heal-Dying program are presented in [Table 2].

Among the participants, 80% in the experimental group and 82.9% in the control group were females. The mean age in the experimental and control groups was 20.11 years and 20.14 years, respectively. Considering the total sample, 62.9% of the experimental group and 68.6% of the control group stated that they did not follow a religion and 60% of the experimental group and 80.0%

of the control group indicated that their household economic level was in the medium category.

Regarding self-rated health status, 50% of the participants in both groups indicated that it was good.

Further, 78.6% of the participants in the experimental group and 81.6% in the control group had volunteer experience. As there were no significant differences in general characteristics between the experimental and control groups, their general characteristics were considered homogeneous.

Meaning of Life, Death Anxiety, and Life Satisfaction

The results of the homogeneity test for the dependent variables—meaning of life, death anxiety, and life satisfaction—before the implementation of the Heal-Dying program are shown in [Table 2].

The mean score of the meaning of life before the Heal-Dying program was 2.80 (± 0.20) in the experimental group and 2.90 (± 0.23) in the control group; there were no significant differences between the two groups (t = 1.769, p = .081). The mean score of death anxiety was 3.24 (± 0.41) in the experimental group and 3.36 (± 0.42) in the control group; there were no significant differences between the two groups (t = 1.136, p = 0.260). The mean score of life satisfaction was 3.50 (± 0.38) in the experimental group and 3.64 (± 0.38) in the control group, also showing a lack of significant differences between the two groups (t = 1.606, p = 0.113). As per the results, there were no significant differences in the meaning of life, death anxiety, and life satisfaction before the

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Heal-Dying Program between the experimental and control groups, which confirmed the homogeneity of the two groups before the intervention.

Table 2.General Characteristics of Participants.

Demographic Characteristics

Exp.(n = 35) n(%)

Cont.(n = 35) n (%)

χ2 or t p

Gender

Male 7 (20.0) 6 (17.1) .094 .759

Gender Female 28 (80.0) 29 (82.9) .094 .759

Age Mean ± SD 20.11 ±.32 20.14 ±.36 .352 .726

Religion Yes 13 (37.1) 11 (31.4) .254 .615

Religion No 22 (62.9) 24 (68.6) .254 .615

Household

economic level High 5 (5.7) 2 (5.7) 3.429 .180

Household

economic level Medium 21 (60.0) 28 (80.0) 3.429 .180

Household

economic level Low 9 (25.7) 5 (14.3) 3.429 .180

Self-rated health Excellent 18 (51.4) 21 (60.0) .564 .754

Self-rated health Good 15 (42.9) 12 (34.3) .564 .754

Self-rated health Poor 2 (5.7) 2 (5.7) .564 .754

Parents alive Both parents alive

33 (82.9) 32 (91.4)

.215 .643

Parents alive One parent

alive 2 (5.7) 3 (8.6) .215 .643

Death experience Yes No

8 (22.9) 27 (77.1)

10(28.6)

25(71.4) .299 .584

Meaning of life 2.80 ± 0.20 2.90 ± 0.23 1.769 0.081

Death anxiety 3.24 ± 0.41 3.36 ± 0.42 1.136 0.260

Life satisfaction 3.50 ± 0.37 3.64 ± 0.38 1.606 0.113

Exp=experimental group; Cont= control group; SD=standard deviation.

Analysis of the Effectiveness of the Heal-Dying Program

The comparison of dependent variables before and after the implementation of the Heal-Dying Program within the experimental group is shown in [Table 3] and the comparison of dependent variables between the experimental and control groups is shown in [Table 3]. The mean meaning of life score after the intervention was significantly higher in the experimental group than the control group (t = 4.378, p = 0.000). Furthermore, this score increased significantly (t = 5.835, p =.000) after the intervention in the experimental group. However, there was no significant differences in the meaning of life in the control group [Tables 3]. As seen in [Table 3], death anxiety was significantly lower in the experimental group than the control group (t = 2.934, p = 0.005) after the

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intervention. In the experimental group, the death anxiety scores significantly decreased (t= 2.280, p= 0.029). In contrast, death anxiety levels in the control group increased as time elapsed [Tables 4, 5]. Life satisfaction was significantly higher in the experimental group than in the control group (t = 2.280, p = 0.029) after the intervention. In the experimental group, life satisfaction scores increased significantly (t = 4.605, p = 0.000). In contrast, there was no significant change in meaning of life scores in the control group [Tables 3].

Table 3.Effect of Heal-dying Program on Meaning of Life, Death Anxiety, and Life Satisfaction.

Variables Pre-test

Mean ± SD

Post-test

Mean ± SD t p

Meaning of life Exp.

Cont.

t(p)

2.80 ± 0.20 2.90 ± 0.23 1.769 (.081)

3.27 ± 0.39 2.92 ± 0.26 4.378 (.000)

5.835 .530

.000 .600

Death Anxiety

Exp.

Cont.

t(p)

3.24 ± 0.41 3.36 ± 0.42 1.136 (.260)

2.82 ± 0.53 3.08 ± 0.49 2.934 (.005)

2.280 .180

.029 .858

Life Satisfaction

Exp.

Cont.

t(p)

3.50 ± 0.37 3.64 ± 0.38 1.606(.113)

4.07 ± .44 3.84 ± .40 4.605(.000)

5.428 1.972

.000 .057

Exp=experimental group; Cont= control group; SD=standard deviation.

Discussion

Death education programs are important because they allow individuals to understand life and death, as well as the value of life. Such programs help individuals to be more positive in accepting death as death as natural component of one’s life, thus helping them live the rest of their lives meaningfully. Provision of death preparation education is especially important for nursing students because it helps them change their negative attitudes stemming from fear and negative perceptions of death, making them more positive,which is an essential tenet of caring for dying patients. Accordingly, through the development and implementation of the Heal-Dying Program, this study’s aim was to promote comprehension of the meaning and value of life and help in the formation of positive attitudes toward death in nursing students. Based on the results, the meaning of life and life satisfaction were significantly improved in the experimental group. These findings are consistent with a study conducted in Taiwan (Hwang H L et al., 2005)in which nursing students showed improvement in their perceptions of the meaningfulness of life after participating in a death study course. Further, Lee and Kim’s (Kim E H et al., 2009) studyreported that the

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meaning of life was better comprehended after death education. Byun and Park (Byun D H et al., 2019) reported the same results. Therefore, death education programs are thought to be the driving force to live positively, helping establish the right values to live by, and sending the message that life is precious. After the Heal-Dying Program, death anxiety in the experimental group was significantly reduced. In the studies by Lee and Lyu (Lee N Y et al., 2019) and Kim and Song (Kim S H et al., 2013),which implemented well-dying programs for the elderly and college students, respectively, death anxiety was reduced. In addition, Kim, Cho, and Yoo (Kim H G et al., 2016) demonstrated significantly reduced fear of death in patients with breast cancer after death-related programs. However, Coleman’s (Coleman W T, 1983) study as an emergency room medical technician did not show any reduction in death anxiety.

Death is inevitable, but the related fear and anxiety can be alleviated through preparation.

However, if anyone is not specifically prepared for death, it may further increase death anxiety.

Death- education programs can be conducted not only for the elderly but across age groups, such as in Coleman’s (Coleman W T, 1983) study and the results can differ based on participants’ exposure to environments where death is common and on the basis of prior knowledge. In other words, since the effects of death preparation education vary by participants, periods, and methods, such programs must be tailored to individual characteristics. College is a turning point, and in the context of nursing students, gaining an understanding of the meaning of life and the realities of death before clinical practice is essential, given that, generally, nursing students face the death of patients without reflecting on their own lives. Therefore, it is believed that the Heal-Dying Program will not only help nursing students recognize the value of life and their present situation, but also have a positive impact on establishing a correct view of death and overcoming life crises. The findings of the present study confirmed that the Heal-Dying Program can improve nursing students’

understanding of the meaning of life and reduce their death-related anxiety. This program not only helps individuals recognize the value of life, but also establishes the value of death as a part of life.

By doing so, it greatly reduces fear, anxiety, and emotional burden related to death and promotes nurses’ active participation in providing end-of-life care.

Despite its strengths, this study has certain limitations. Owing to the small sample size, the fact that participants were selected from the nursing program of a single university, and the single educational experience provided, the results are not generalizable. Therefore, further studies using larger sample sizes and various modalities are needed to evaluate the effects of the Heal-Dying Program on the variables in question for a longer period of time.

Conclusion

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The Heal-Dying program was an effective intervention that resulted in positive changes such as improving nursing students’ perceptions of the meaning of life and reducing their death-related anxiety. Therefore, it is hoped that this program can be applied to a wider range of university students to help them recognize the value of their own lives and selves, and positively influence them to live diligently enthusiasticallyin the present. Based on the results, it is deemed necessary to study the effectiveness of the Heal-Dying Program and the development of death preparation programs in relation to the problems of the youth, which have emerged as a social problem in South Korea. The majority of the college students in South Korea are either in their late teens or early 20s.

Providing a death experience like the Heal-Dying Program did to these students may be a good strategy to improve life satisfaction by helping them recognize the meaning of life.

Acknowledgment

This study was supported by the Faculty Research Program funded by the semyung University in 2017.

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