The Factors Influencing Terminal Care Performance among Eriatric Hospital
Mi-jung Kim1, Jung-hyun Choi*2
1 Nurse, Gaon nursing hospital, 797 Namdong-gu, Incheon Metropolitan City, 21555, South Korea.
*2Professor, Dept. of Nursing, Namseoul University, 91 Daehakro, Seonghwan-eup, Seobuk-gu, Chonan-Si, Chungnam, 31020, South korea.
Abstract
This study investigated a relationship between terminal care performance and attitude toward death and death anxiety among geriatric hospital nurses.The subjects of this study were 145 nurses who are working more than a year in geriatric hospital located in Gyeonggi-do and Incheon Metropolitan City.In correlation analysis, nurses’ terminal care performance was positively associated with terminal care attitude (r =.25, p=.002), but didn’t associated with attitude toward death and death anxiety. Nurses’ attitude toward death and terminal care attitude were negatively associated with death anxiety (r =-.57, p<.001, r =-.29, p<.001). As a result of analyzing the factors influencing terminal care performance through multiple regression analysis, it was showed that working career (β=.203, p=.020) in nursing homes and terminal care attitude (β=.238, p=.005) had significant effect on terminal care performance. The model explained 16.5% of the variables. It was thought that terminal care attitude had a great effect on terminal care performance.It was found that the terminal care attitude had a significant effect on the terminal care performance. This study was limited in that it only studied nurses working in nursing hospitals. However, it is meaningful in that the basic data for a terminal care education program were provided by identifying the correlations between terminal care attitude and the terminal care performance, and finding factors affecting the degree of terminal care performance.It will be necessary to establish a certain sense of values for death by providing a program for terminal care education.
Keywords: terminal care performance;the attitude toward death; death anxiety; terminal care attitude; nurses; Korea
* Corresponding Author Name: Jung-hyun Choi Email: [email protected]
Fax: +82-415802931
Date of Submission: 05-10-2020 Introduction
Death is a natural and normal course of life in which all humans are inevitably faced with, and no one can escape death (Kim, 1997). But death is the object of fear and panicto man, and man has continued to strive to escape death (Nam, 1999). With the aging population, change in family structure, accidents, increase in death from disease, and change in the traditional consciousness of preferring death at home, more and more people are dying in medical institutions (Kim, 2003). In the situation delegated by family and relatives to experts, terminal care is urgently needed among many factors of nursing work (Choi, 1991).
The attitude toward death refers to a multi-dimensional concept that several factors such as concern about death, anxiety, understanding and meaning of death are mixed(Thorson J A et al., 1988), meaning individual feelings, perceptions and personal beliefs about death (Kim J H., 2008). However, while acknowledging the universality of death that "every human being dies."(Han M K., 1994), man has contradictory attitude toward death that humans instinctively try to ignore painful problems(Mun Y S., 2010). Especially in modern society, attention is paid to prolonging life and negative attitudes toward death are prevalent throughout society (National Cancer Center Hospice Relief Medical Center, 2018).
Death anxiety is an anxiety about the inevitable end and suspension of empirical life in the recognition of human finitude(Kubler-Ross E., 2008), and a psychological process that causes negative feelings like fear, disgust, destruction, rejection, and injustice that humans show about the events of death and dying processes (Jeon Y G., 2000). The nurses, who are anxious about death, react emotionally to the situation associated with death, including anxiety and unpleasant feelings (Cha Y R., 2005), unconsciously suppressing the problem of death, and beingunconsciously afraid of death (Jeon M H., 2008). Death affects our lives a lot, and depending on how we view it, we can make life motivated or full of anxiety and fear (Ryu H O., 2004; Son J Y., 2007). If nurses understand their fear of death and accept it as a part of their life, they will be able to understand and relieve the fear and anxiety of the patient who is about to die and his family (Choi H J., 1975).
The terminal care attitude affects physical, psychological, social and spiritual aspects of patients and their families, and is an important factor to improve their health and quality of life and face a dignified death by providing holistic care (Kim K H., 2016). Experienced terminal care as a nurse who closely watches patient's deathbed and acts as a mediator between the patient,
family and other medical staff is very important (Kim Y H., 2001). However, nurses feel burden, panic, frustration, and depression when faced with the situation to care for their dying patients (Lee M S., 2003), and feel helpless at the thought of being unable to do anything for their patients (KangB H et al.,2001). So, terminal care is something they want to avoid meaninglessly and finally they have some psychological burden (Cho H J et al.,2005).The more positive feelings and perceptions a nurse may have in caring for a terminally ill patient, the better quality care can be provided to the patient (Yang S A., 2015). Therefore, it is possible to perform qualitative terminal care depending on whether terminal care attitude is positive or negative, and in turn, it is necessary for nurses to have a positive terminal care attitude.
The elderly population in Korea is increasing rapidly, and the number of elderly people who die in geriatric hospitals is also increasing. As a result, more and more nurses working in nursing hospitals are exposed to death, which increases death anxiety and has a negative impact on those subjects of terminal care.This study investigated a relationship between terminal care performance and attitude toward death and death anxiety and provided basic data for terminal care education program for geriatric hospital nurses.
Materials and Methods
Participants
This research is a descriptive survey to find out the correlation between the attitude toward death, death anxiety, or terminal care attitude and terminal care performance. The participants were 145 nurses who are working more than a year in geriatric hospital located in Gyeonggi-do and Incheon Metropolitan City and the data were collected from July 15, 2019 to July 31, 2019.
Measurement
Attitude toward death
Attitude toward death scale developed by Thorson & Powell (1988) and translated by Park (1992)was used. It consisted 25 items which were scored using a Likert scale: 1 = “not at all”, 2
= “almost no”, 3 = “almost yes” and 4 = “exactly yes”. If the score of an item is higher, it means that the attitude toward death is more positive. The Cronbach’s alpha coefficient was .83 in the study of Park (1992) and .85 in this study.
Death Anxiety
In this study, death anxiety was measured using Fear of Death Scale developed by Collet &
Lester (1969) and revised by Shim (2001). It is composed of 20 items which were scored using a Likert scale: 1 = “not at all”, 2 = “almost no”, 3 = “almost yes” and 4 = “exactly yes”. Nine items were reversely scored. If the score of an item is higher, it means that the death anxiety is higher. The Cronbach’s alpha coefficient was .96 in the study of Shim (2001) and .78 in this study.
Terminal care attitude
In this study, terminal care attitude was measured using Frommelt’s Attitudes(Frommelt K H M., 1991) toward Nursing Care of the Dying Scale(FATCOD) developed by Frommelt and translated by Cho& Kim(2005). It is composed of 30 items which were scored using a Likert scale: 1 = “not at all”, 2 = “almost no”, 3 = “almost yes” and 4 = “exactly yes”. Fifteen items were reversely scored. If the score of an item is higher, it means that the terminal care attitude is more positive. The Cronbach’s alpha coefficient was .90 in the Cho’s study and .81 in this study.
Terminal care performance
Terminal care performance scale developed by Park & Choi (1996)was used. It consisted 22 items which were scored using a Likert scale: 1 = “not at all”, 2 = “a little bit”, 3 = “almost” and 4 = “always”. If the score of an item is higher, it means that the terminal care performance is better implemented. The Cronbach’s alpha coefficient was .96 when it was developed and .95 in this study
Data analysis
The collected data were analyzed with a program called SPSS 23.0 by using frequency analysis, descriptive statistics, t-test, one-way ANOVA test and Scheffe's test, Pearson's correlation coefficient, multiple regression analysis
Ethical Consideration
This study was approved by the center for research ethics information of Namseoul University(1041479-HR-201905-008), and the data was collected during two weeks from July 15 to July 31, 2019.
Results and Discussion General Characteristics
Table 1 showed the characteristics of the participants. Participants were 145 nurses: 11 males (7.6%) and 134 females (92.4%). Ages were from 23 to 70 years old (M = 45.7; SD = 10.7). The participants who experienced terminal care performance education were 67 nurses (46.2%).
Working career in nursing homes was mostly for less than five years (47.6%). Working position of participants was mostly staff nurses (75.2%). The number of nurses who took education about patient death was 129 (89.0%).
Table 1.General characteristics (N=145)
Variable Categoty n(%), Mean±SD
Age
23-29 15(10.3)
30-39 24(16.6)
40-49 48(33.1)
50-59 46 (31.7)
12 (8.3)
≥60
45.7±10.7
Gender Male
Female
11 (7.6) 134 (92.4)
Marital status Single 35 (24.1)
Married 110(75.9)
Religion
Christian 49(33.8)
Catholicism 26(17.9)
Buddhism 16(11.0%)
Others 54(37.2)
Education
Diplom 82 (56.6)
Bachelor 58(40.0)
Master 5(3.4)
Experience of receiving terminal care performance education
Yes 67(46.2)
No 78(53.8)
A place of terminal care performance education
Supplementary education 40(27.6)
Education in hospital 8(5.5)
Buddhism 19(13.1)
Working career in nursing homes(year)
<5 69(47.6)
5-10 47(32.4)
10-15 26(17.9)
15-20 3(2.1)
Working position
Staff 109(75.2)
Charge 9(6.2)
More than Heal 27(18.6)
Experience of patient death Yes 129(89.0)
No 16(11.0)
Dye experience of family or acquaintance
Yes No
110(75.9) 35(24.1)
Descriptive statistics for variables
Descriptive statistics for the attitude toward death, death anxiety, terminal care attitude, and terminal care performance are shown in Table 2. The level of the attitude toward death, death anxiety, terminal care attitude, and terminal care performance of nurses was 2.78±.35, 2.50±.29, 2.95±.24, 2.79±.58 point each.
Table 2.Descriptive statistics for variables
Variable Mean±SD
Attitude toward death 2.78±.35
Death Anxiety 2.50±.29
Terminal care attitude 2.95±.24
Terminal care performance 2.79±.58
The analysis of terminal care performance by general characteristics
The analysis of terminal care performance by general characteristics are shown in Table 3.Terminal care performance was significantly different according to general characteristics such as gender(t=-2.147, p=.033), marital status(t=-2.782, p=.006), experience of receiving terminal care performance education(t=2.506, p=.013), working career in nursing homes(F=4.909, p=.003), working position(F=6.517, p=.002), the dying experience of a family or close acquaintance(t=2.502, p=.013). As a result of Scheffe's test, there was a significant difference in working career in nursing homes, working position. The result of the test showed that terminal care performance was performed better under these condition; more than 10 years less than 15 years and more than 5 years less than 10 years on working career in nursing home, more than head in working position.
Table 3. The Analysis of Terminal Care Performance by General Characteristics(N=145) Characteristics Categories n Terminal Care Performance
M±SD F/t(p) scheffe
Age(year)
23-29 15 2.54±0.38
2.084 (.086)
30-39 24 2.66±0.48
40-49 48 2.89±0.57
50-59 46 2.84±0.45
≥60 12 2.92±0.50
Gender Male 11 2.49±0.60 -2.147
Female 134 2.83±0.49 (.033)
Marital status Single 35 2.60±0.49 -2.782
Married 110 2.87±0.49 (.006)
Religion Christian 49 2.80±0.52 0.069
(.977) Catholicism 26 2.82±0.56
Buddhism 16 2.83±0.61 others 54 2.78±0.44 Education
Diploma 82 2.77±0.48
1.780 (.072) Bachelor 58 2.81±0.53
Master 5 3.21±0.52
Experience of receiving terminal care performance
education
Yes 67 2.91±0.43
2.506 (.013)
No 78 2.71±0.54
A place of terminal care performance
education
supplementary
education 40 2.85±0.43
2.660 (.051) Education in hospital 8 2.90±0.23
Hospice education
19 3.04±0.50
Working career in nursing homes(year)
<5a 69 2.64±0.50
4.909
(.003) a<b,c
5-10b 47 2.91±0.46
10-15c 26 3.00±0.52
15-20 3 3.03±0.32
Working position
Staffa 109 2.72±0.48
6.517
(.002) a<c
Chargeb 9 2.94±0.63
more than Headc 27 3.09±0.46 Experience of
patient death
Yes 129 2.80±0.48
-0.324 (.746) 16 2.84±0.67
No dying experience of a family
or close acquaintance
Yes 110 2.86±0.48
2.502 (.013)
No 35 2.62±0.55
Correlation between main variables
Correlations are shown in Table 4. Nurses’ terminal care performance was positively associated with terminal care attitude (r =.25, p=.002), didn’t associated with attitude toward death and death anxiety. Nurses’ attitude toward death and terminal care attitude were negatively associated with death anxiety (r =-.57, p<.001, r =-.29, p<.001).
Table 4. Correlation between main variables Terminal care
performance Attitude toward death Death anxiety Terminal care attitude Terminal care
performance 1 . .
Attitude toward death .01 1 .
Death anxiety .04 -.57*** 1 .
Terminal care attitude . .25** . .26*** -.29*** 1
**p<.01, ***p<.001
Results of the analysis of factors affecting terminal care performance
As a result of analyzing the factors influencing terminal care performance through multiple regression analysis in Table 5, it was showed that working career in nursing homes and terminal care attitude had significant effect on terminal care performance. In other words, the more working career(β=.203, p=.020) and terminal care attitude(β=.238, p=.005), the higher terminal care performance was. It was thought that terminal care attitude had a greater effect on terminal care performance. The model explained 16.5% of the variables.
Table 5. Results of the Analysis of Factors Affecting Terminal Care Performance (N=145) Factor
Terminal Care Performance
B SE β t p
Constant -.114 .908 -.126 .900
Gender .120 .170 .063 .707 .481
marital status .157 .113 .134 1.388 .167
Education .130 .074 .146 1.761 .081
Working position .123 .101 .105 1.217 .226
Working career in nursing homes .124 .053 .203 2.352 .020
The attitude toward death -.036 .136 -.025 -.261 .794
Death anxiety .200 .168 .115 1.188 .237
Terminal care attitude .491 .172 .238 2.863 .005
F=4.567 p<.05 R²=.212 Adj R²=.165 Durbin-Watson=1.847
Discussion
This study was conducted to investigate the factors influencing terminal care performance among geriatric hospital nurses. Terminal care performance was significantly different according to general characteristics such as gender(t=-2.147, p=.033), marital status(t=-2.782, p=.006), experience of receiving terminal care performance education(t=2.506, p=.013), working career in nursing homes(F=4.909, p=.003), working position(F=6.517, p=.002), and the dying experience of a family or close acquaintance(t=2.502, p=.013). This finding was partially consistent with previous studies (Noh H S et al., 2016; Yu R K, 2004). In the study (Noh H S et al., 2016), age, religion, marital status, final educational background and working position in the hospital showed significant differences on the terminal care performance, somewhat similar to the results of this study. In the study by Yu (2004), there were significant differences in the terminal care performance, depending on marital status, working career at hospitals, working
position in the hospital, and the dying experience of a family or close acquaintance, somewhat different results from this study.
In correlation analysis, nurses’ terminal care performance was positively associated with terminal care attitude (r =.25, p=.002), butdidn’t associated with attitude toward death and death anxiety. Nurses’ attitude toward death and terminal care attitude were negatively associated with death anxiety (r =-.57, p<.001, r =-.29, p<.001). This finding was consistent with previous studies underscoring the importance of the terminal care attitude (Kim S H., 2017; Ahn S M., 2017). In the study by Kim (2017), there was a significant static correlation between the terminal care attitude and the entire area of terminal care performance, which is the same result as Ahn's(2017) study showed a significant correlation. Comparing with the study by Lee and Park (2017), it was the similar result that there was no significant difference in the correlation between death anxiety and the terminal care performance. These results suggest that a positive terminal care attitude is important to perform a high-quality terminal care, and a positive terminal care attitude requires a reduction in anxiety about death by clearly establishing a positive attitude and concept of death.
As a result of analyzing the factors influencing terminal care performance through multiple regression analysis, it was showed that working career in nursing homes and terminal care attitude had significant effect on terminal care performance. This result is similar to previous studies (Noh SSet al., 2016;Lee L J et al., 2017; Kim S E., 2011; Kim M J., 2019). In the study by Lee and Park (2017) for nurses working in the hospice ward and the study by Kim (2019) for nurses in intensive care units, it was found that the more working career, the higher the level of terminal care performance. In the study by Noh(2016) for nurses caring of cancer patients, it was found that terminal care attitude had a significant effect on terminal care performance. As the number of elderly people increases and the frequency of death at geriatric hospital increases, nurses can reduce death anxiety by having positive attitude toward death. Thus, it is necessary to find out the correlation between the attitude toward death, death anxiety or terminal care attitude and terminal care performance through continuous and repeated study. By doing so, it will be necessary to establish a certain sense of values for death by providing a program for terminal care education. Considering factors influencing terminal care performance, it can be found that the more working career is and the higher terminal care attitude is, the higher terminal care performance is (Kim, 2019).
Conclusion
In this study, we conducted a survey to examine a relationship between terminal care performance and attitude toward death and death anxiety of geriatric nurses in Korea. The number of participants was 145 nurses who are working more than a year in geriatric hospital. In correlation analysis, nurses’ terminal care performance was positively associated with terminal care attitude, but wasn’t associated with attitude toward death and death anxiety. Nurses’ attitude toward death and terminal care attitude were negatively associated with death .As a result of analyzing the factors influencing terminal care performance through multiple regression analysis, it was showed that working career (β=.203, p=.020) in nursing homes and terminal care attitude (β=.238, p=.005) had significant effect on terminal care performance. It was thought that terminal care attitude had a greater effect on terminal care performance. It was found that terminal care attitude had a significant effect on terminal care performance. This study was limited in that it only studied nurses working in nursing hospitals. However, it is meaningful in that the basic data for a terminal care education program were provided by identifying the correlations between terminal care attitude and terminal care performance, and finding factors affecting the degree of terminal care performance.
Acknowledgments
Funding for this paper was provided by Namseoul university
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