Jordanian Student Nurses’ Attitudes towards the Care of Dying Patients

Abstract

The purpose of the current inquiry is to measure Jordanian student nurses’ attitudes towards the care of dying patients using a cross-sectional survey. The sample of this study comprises 300 nursing students. Data was collected using the Frommelt’s Attitude Toward Care of the Dying Form B (FATCOD–B). Most of the students were female (72%) in their second year (40.3%). The mean total score of all FATCD-B items was 95.8 out of 150 (SD 8.7). Student nurses had low mean scores for their attitude towards care of the dying. Two approaches could be taken to improve this situation. First, research is needed to fully understand and explain students’ attitudes towards the care of dying patients. It might be more appropriate to utilize mixed research methods. The second is to integrate end-of-life care courses within the curricula of nursing programmes, currently the mainstay in improving students’ knowledge and attitudes toward care of the dying.

Keywords

students Jordan end of life life-limiting disease education

Background

The proportion of the population older than 65 years and the number of people with life-limiting illness, such as cancer, heart failure, end-stage renal disease, and multiple sclerosis, is increasing (Grubb & Arthur, 2016; Jiang et al., 2019). These cohorts of patients need continuous care for longer periods, and the need for care of dying persons is becoming an integral part of daily nursing practice (Gillan et al., 2014). Add to this the increasing number of newly developed and implemented palliative care programmes within several healthcare systems around the world, designed to enhance patients' quality of life. This makes the knowledge and skills of care of dying persons a mandatory requirement for the new generation of nurses (Gillan et al., 2014).

Death and dying research are limited in Jordan. Death is one of the most fearful experiences for patients and their families. In Jordan, according to Islamic instructions, death is considered the door to the in-between life that lead to the afterlife after judgment day. So, based on the persons’ sins and good deeds that determine their final destination and immortal life either in heaven or hell would be decided. However, having a life limiting disease might be perceived as a chance for redemption and doing good such as praying and reading Quran. This might ease this fearful event and facilitate parents and family bereavement. Regarding place of death, Muslim usually would prefer to die at home with their families (Sheikh, 1998). However, legal consequences that impose forensic autopsy for patients who died at home to conclude the cause of death increased the percentage of patients who died in hospital to avoid autopsy. For instance, recent study in Jordan reported that 87.3% of cancer patients died in hospital (Alawneh & Anshasi, 2020). Further, being male, age 65 year or more and involved in home palliative care programmes increased likelihood of dying at home (Alawneh & Anshasi, 2020). A peaceful death remains the main outcome for a considerable number of patients with life-limiting disease; however, providing care for near-death patients is neither an easy nor a simple process (Henoch et al., 2017).

End-of-life care is complex and comprises physical, psychological, spiritual, and social components; it is not limited to treatment of disease. Thus, nurses should have adequate knowledge, skills and a positive attitude to enable them to provide high-quality and effective care for dying persons (Henoch et al., 2017). Positive attitudes may predict better compliance and commitment of nurses toward patient care (Gillan et al., 2014; Henoch et al., 2017). The best place for nurses to gain the required knowledge, skills, and attitudes is during their undergraduate study. Student nurses may encounter patient death or provide care for dying patients during their clinical training. Thus, instructors are required to facilitate this leaning experience and encourage students to actively participate in providing this care (Gillan et al., 2014; Jiang et al., 2019). In addition, nursing curricula should include content that enhances this experience, since most students find themselves initially unable to provide such care, especially in their first encounter with a patient’s death (Gillan et al., 2014).

Most studies exploring student nurses’ attitudes toward the care of dying persons m indicated either negative or neutral attitudes (Adesina et al., 2014; Jafari et al., 2015; Sharour et al., 2017). In a qualitative study that explored student nurses’ perception of providing care for patients in their last days, Österlind et al. (2016) concluded that student nurses found such care difficult. The authors concluded that students experienced complex feelings and processes that required knowledge and clinical experience to enable them to develop an acceptance of death as a normal life event (Österlind et al., 2016). A similar study was conducted in the UK to evaluate student nurses’ attitudes towards care of the dying, in which Frommelt's Attitude Toward Care of Dying Scale (FATCOD–B) was used to measure the attitudes of 567 students (Grubb & Arthur, 2016). The results showed that students had positive attitudes toward care of the dying (mean 75.9 SD 8.2), and that third-year students and those who had prepared a dead body had higher scores than first-year students and those who had not seen a dead body. Another study reported that students in Iran were afraid of providing care for dead patients and were more unwilling to provide care for a dying person than Swedish students (Iranmanesh et al., 2010). Hence, cultural and religious issues should be taken in considerations when developing end-of-life education and training pogrammes. Within this context, a study that was conducted in Palestine reported a low mean score on FATCOD–B and negative attitudes towards care of the dying (Abu-El-Noor & Abu-El-Noor, 2016). These results justify the need for further studies to be conducted in the region to fully explore this issue.

In Jordan only one study was found; it assessed student nurses’ attitudes toward care of dying cancer patients (Sharour et al., 2017). This was a single setting study with a small sample size (n = 100), and no mean attitude score was reported. It has also been reported that there was inadequate knowledge of palliative care in Jordan among students and licensed nurses in Jordan (Al Qadire, 2014a, 2014b). Further, the need for nurses with knowledge and skills in end-of-life care is increasing as Jordan, like other countries, is expanding the provision of palliative care services (Al-Qadire et al., 2014). Hence the purpose of this study is to measure Jordanian student nurses’ attitudes towards the care of dying patients.

Research Questions

This study aims to answer the following research questions:

What are the attitudes of Jordanian student nurses towards care of the dying?

Is there a difference in mean attitude scores by students’ gender, having previous education about end-of-life care, having witnessed patient death during clinical training, year of study, and university of study?

Methods

Design

A quantitative research method and a descriptive cross-sectional survey design were used.

Sample

The sample of this study comprises 300 students studying in three randomly selected Jordanian government universities. About 100 students were recruited through convenience sampling from each university, from different academic levels, agreed to participate.

Sample Size

The required sample size depends critically on the percentage of responses to the study questionnaire. For a percentage of 50%, knowing that the number of students within these universities is around 1,300, complete data from 297 students is needed. From http://www.raosoft.com/samplesize.html, this would allow the percentage of correct answers to be estimated with a 95% confidence interval and margin-of-error of at most ±2%. Thus, a total number of 300 students is an adequate sample size.

Settings

The current study involved three government universities, randomly selected from a computer-generated list of the five government universities that have nursing programmes in the north and middle of the country. Two of the three are located in the northern area of Jordan (A and B) and the third in the capital city of Amman (C). All these universities have about 1,300 undergraduate student nurses, and very similar programmes.

Instruments

Frommelt’s Attitude Toward Care of the Dying form B (FATCOD–B) scale was used (Frommelt, 2003). This scale consists of 30 statements to measure the respondent’s attitude towards care of the dying. There are 15 positively worded statements (i.e. 1, 2, 4, 10, 12, 16, 18, 20, 21, 22, 23, 24, 25, 27, and 30) and the other1 15 statements that are negatively worded statements, (i.e. 3, 5, 6, 7, 8, 9, 11, 13, 14, 15, 17, 19, 26, 28, 29) . Each statement is rated on a 5-point Likert scale. Before analysis, the negative statements were reverse scored. An overall score is then calculated, ranging from 30 to 150. A higher mean total score means a more positive attitude (Frommelt, 2003). Validity and reliability of the FATCOD–B scale have been tested extensively (Braun et al., 2010; Frommelt, 2003; Simon et al.,2009), and found to have a reliability coefficient ranging from 0.85 to 0.94 (Braun et al., 2010; Frommelt, 2003; Simon et al.,2009). The English version was used without translation since teaching and examination within nursing schools in Jordan is in English. Finally, information about students’ age, gender, year of study, university, and whether or not they had received end-of-life education and witnessed a death event was collected.

Procedure

The researcher obtained ethical approval of the universities’ research ethics committees. Data collection started in December 2019 and end on March 2020. Each university was visited to collect data from the classrooms, following permission from the dean of each school and the instructors. The researcher gave a brief introduction to the questionnaires and written information about the study background, purpose, and what is required from respondents. Once they agreed to participate, respondents were given the questionnaire to complete, and instructed to leave them on a table within each classroom for collection by the principal investigator.

Ethical Considerations

Ethical approval to conduct the study was obtained from the ethics committee of the author university. All the participants were given the right to participate or not in the study. However, completing the questionnaire was considered as implicit consent to take part in the study. Further, the identities of participants were not requested or revealed; only aggregate data was reported, and they were assured that their responses are confidential.

Data Analysis

Data was entered into the Statistical Package for the Social Sciences (SPSS) (version 22). Descriptive and inferential statistics were conducted (Creswell, 2008). Descriptive statistics such as percentages, frequencies, means, standard deviations were used to describe the sample characteristics and their responses on the FATCOD–B (Malim & Birch, 1997). Other inferential statistics such as the independent t-test and one-way ANOVA were applied to examine if there were any differences in the mean of the total score of FATCOD–B with regard to two or more categories of variables as appropriate (Field, 2009).

Results

Participants’ characteristics are presented in Table 1. The average age was 20.6 (SD 1.7) years, and the range 18 to 32. Most of the students were female (72%) in their second year (40.3%). Only 15 students reported having received previous teaching about end-of-life care.

Table 1.

Students Characteristics (n = 300).

Characteristic	Frequency (%)
Gender
Male	84 (28)
Female	216 (72)
Year of study
First	35(11.7)
Second	121(40.3)
Third	109(36.3)
Fourth	35 (11.7)
Have you been given an end of life care education?
Yes	15 (5)
No	285 (95)
Have you witnessed patient death in your clinical training?
Yes	158 (52.7)
No	142 (47.3)
University
University A	102 (34)
University B	100 (33)
University C	98 (32.7)

Students’ Attitudes Toward Care of the Dying

The mean total score of all FATCD-B items was 95.8 out of 150 (SD 8.7). In addition, the mean score for each item was calculated, presented in Table 2. The items with the highest mean scores were the following: item 21: It is beneficial for the dying person to verbalize his or her feelings (mean = 3.8 out of 5, SD = 1.2); 20: Families should maintain as normal an environment as possible for their dying member (mean = 3.7, SD = 1.1); and 16: Families need emotional support to accept the behavioural changes of the dying person (mean = 2.6, SD = 1.2). The items with the lowest mean scores were: 8: I would be upset when the dying person I was caring for gave up hope of getting better (mean = 2.6, SD = 1.2); 13: I would hope the person I’m caring for dies when I am not present (mean = 3.7, SD = 1.1); and er 26: I would be uncomfortable if I entered the room of a terminally ill person and found him or her crying (mean = 2.7, SD = 1.1).

Table 2.

Frommelt Attitudes Toward Care of the Dying Scale Items Mean Scores.

Item	Mean (SD)
1. Giving care to the dying person is a worthwhile experience.	3.6 (1.3)
2. Death is not the worst thing that can happen to a person.	3.2 (1.3)
3. I would be uncomfortable talking about impending death with the dying person.	2.8 (1.2)
4. Caring for the patient’s family should continue throughout the period of grief and bereavement.	3.5 (1.2)
5. I would not want to care for a dying person.	3.3 (1.3)
6. The non-family caregivers should not be the one to talk about death with the dying person.	2.9 (1.1)
7. The length of time required to give care to a dying person would frustrate me.	3.1 (1.2)
8. I would be upset when the dying person I was caring for gave up hope of getting better.	2.6 (1.2)
9. It is difficult to form a close relationship with the dying person.	2.9 (1.2)
10. There are times when death is welcomed by the dying person.	3.5 (1.1)
11. When a patient asks, “Am I dying?” I think it is best to change the subject to something cheerful.	2.9 (1.4)
12. The family should be involved in the physical care of the dying person.	3.6 (1.1)
13. I would hope the person I’m caring for dies when I am not present.	2.6 (1.2)
14. I am afraid to become friends with a dying person.	2.8 (1.2)
15. I would feel like running away when the person actually died.	3.0 (1.2)
16. Families need emotional support to accept the behavior changes of the dying person.	3.7 (1.2)
17. As a patient nears death, the non-family caregiver should withdraw from his or her involvement with the patient.	3.0 (1.1)
18. Families should be concerned about helping their dying member make the best of his or her remaining life.	3.6 (1.1)
19. The dying person should not be allowed to make decisions about his or her physical care.	3.2 (1.3)
20. Families should maintain as normal an environment as possible for their dying member.	3.7 (1.1)
21. It is beneficial for the dying person to verbalize his or her feelings.	3.8 (1.2)
22. Care should extend to the family of the dying person.	3.6 (1.1)
23. Caregivers should permit dying persons to have flexible visiting schedules.	3.6 (1.2)
24. The dying person and his or her family should be the in-charge decision makers.	3.3 (1.1)
25. Addiction to pain relieving medication should not be a concern when dealing with a dying person.	2.8 (1.3)
26. I would be uncomfortable if I entered the room of a terminally ill person and found him or her crying.	2.7 (1.1)
27. Dying persons should be given honest answers about their condition.	3.5 (1.2)
28. Educating families about death and dying is not a non-family caregiver’s responsibility.	2.8 (1.2)
29. Family members who stay close to a dying person often interfere with the professional’s job with the patient.	2.8 (1.0)
30. It is possible for non-family caregivers to help patients prepare for death.	3.5 (1.1)
Total scale score	95.8 (8.7)

Further, two-group analysis was conducted to examine for differences in the mean score by gender, receiving end-of-life education, and witnessing patient death during their clinical training. Since the FATCOD–B scores were normally distributed, the independent t-test was conducted. The results indicated no significant difference in the mean total score of FATCOD–B between male (mean = 95.3, SD = 9.2) and female students (mean = 96.0, SD = 8.6), or between students who had received education about end-of-life care (mean = 99.3, SD = 10.5) and those who had not (mean = 95.6, SD = 8.7), All p values were > .05. However, the results of the independent test show a statically significant difference in the mean total score between students who had witnessed patients’ death during their clinical training (mean = 94.9, SD = 8.8) and those who had not (mean = 97.8, SD = 8.6) (t = 1.87, df = 289, P = .032).

To examine the difference in the mean total FATCOD–B scores regarding student level (year of study) and place of study, the one-way ANOVA was conducted. The results show no significant difference in mean scores regarding year of study or university (p value > .05).

Discussion

The findings of this study provide important information about Arab Muslim student nurses’ attitudes towards care of the dying, especially as it is only the second within the Arab-Islamic culture, after the Palestinian study (Abu-El-Noor & Abu-El-Noor, 2016). It showed that students in Jordan had a low mean attitude score, lower than the Palestinian students (Abu-El-Noor & Abu-El-Noor, 2016) and even lower than that previously reported from other parts of the world using FATCOD–B (Berndtsson et al., 2019; Frommelt, 2003; Grubb & Arthur, 2016; Hagelin et al., 2016; Henoch et al., 2017; Iranmanesh et al., 2010). The main reason for this low mean score might be the lack of end-of-life care education within the curriculum of Jordanian nursing schools. In this survey, only 15 students out of the 300 who participated reported having received end-of-life care education. In addition, previous studies in Jordan show that both nurses and students nurses had insufficient knowledge about palliative care, reporting little palliative care content in their courses where most of end-of-life care teaching is usually delivered (Al Qadire, 2014a, 2014b). So, students lack the required theoretical background for caring for the dying, which may make it a fearful and stressful experience. End-of-life care education, regardless of its duration, was found to improve students’ attitudes towards care of the dying as evident from the increase in the FATCOD–B mean total score after education (Berndtsson et al., 2019; Dobbins, 2011; Henoch et al., 2017). For example, a study in Sweden evaluated the impact of a five-week palliative care course on student nurses’ attitudes towards care of dying (Berndtsson et al., 2019), using a quasi-experimental design. The sample consisted of 73 students who completed the FATCOD–B survey before and after the course. The results showed a significant improvement in the post-course total mean score (mean = 132.6) although it was already high at pre-course time (mean = 123). Students developed a comprehensive understanding of death and care of the dying (Berndtsson et al., 2019). There is increasing evidence for the need to incorporate palliative care education within nursing curricula (Chow & Dahlin, 2018; Ferrell et al., 2016; Kav et al., 2018) and Jordan seems to be in need of revisiting its nursing programme plans. This is needed to integrate palliative and end-of-life care within courses, to improve future nurses’ attitudes toward care of the dying and their ability to provide such care.

Regarding the factors that might affect students’ attitudes towards care of the dying, we only found one significant result: students who had witnessed patient death in clinical training had significantly lower mean scores on the attitude scale than students who had not. This might indicate students’ fear of the experience of seeing a dying patent. This fear could be explained by the lack of knowledge of death and end-of-life care, with students feeling worried and uncertain when they face a death. It was also indicated that when students face death events in their clinical training without being given the required theoretical background, they will develop negative attitudes toward death and the care of dying patients (Brajtman et al., 2007; Henoch et al., 2017; Kav et al., 2018). Hence, end-of-life care should be given in theory and practice, through either training in appropriate settings or simulation scenarios. This result contradicts the Palestinian study where no significant difference in the mean score was detected between students who had seen death and those who had not (Abu-El-Noor & Abu-El-Noor, 2016). Also, the Swedish study reported that previous exposure to death situations was correlated with more positive attitudes (Hagelin et al., 2016), the students seem to have better knowledge of end-of-life care than students in this study.

In this context, gender, previous end-of-life education, and year of study did not significantly affect the mean attitude scores. In the context of previous studies, our results with regard to gender are consistent with them (Abu-El-Noor & Abu-El-Noor, 2016; Hagelin et al., 2016; Henoch et al., 2017). However, most previous studies found that as students progress from year one toward their graduation their attitudes tend to become more positive (Abu-El-Noor & Abu-El-Noor, 2016; Berndtsson et al., 2019; Hagelin et al., 2016; Henoch et al., 2017; Jiang et al., 2019; Leombruni et al., 2014); in addition, the exposure to end-of-life education tends to improve students’ attitudes, with higher mean attitude scores. In our study this was not the case, perhaps because only 5% of the participants reported having received education about end-of-life care. So, without such education no difference is expected to be found. Thus, introducing end of life care education should be started as soon as possible. Further, Jordan is moving slowly but steadily towards integrating palliative care in its healthcare system (Al-Qadire et al., 2014; Doumit et al., 2015). It is therefore recommended to integrate palliative care education in undergraduate nursing programmes to boost students’ attitudes and equip them with the required skills to care for the dying. End-of-life care content can be merged within other courses or provided separately (i.e. palliative care), since their positive impact on students’ knowledge and attitudes toward care of the dying was found to be significant (Dobbins, 2011). With regard to clinical practice, the results of the study may indicate the need of currently practiced nurses to be educated about care of dying and its associated management. So, researches that aim to evaluate nurses’ attitudes and knowledge about care of dying are needed. Until this happened, frequent training and workshops are recommended to be delivered for nurses through the department of continuous medical education within each hospital.

The results of this study need to be read in the light of the following limitations: first, a convenience sampling approach was adopted, so students who did not have the chance to participate may have different attitudes. Second, this study was conducted in three government universities; no nursing schools from private universities were included. This may limit the generalization of the study’s result to similar settings. Finally, this study utilized the English version of the questionnaire since the language of teaching and examination within nursing schools in Jordan is English. However, students have various levels of reading and comprehending English, which may limit the internal validity of the results. Prospective studies are recommended to translate the questionnaire into Arabic.

Conclusions

This study demonstrated that student nurses from three government universities in Jordan had low mean scores for their attitude towards care of the dying. Witnessing a case of death in clinical training may lead students to develop a negative attitude to care of the dying in the absence of required knowledge and skills. This without doubt must affect the quality of the end-of-life care provided for patients. Investigation into the impact of witnessing death on attitudes towards care of the dying is therefore strongly recommended. Two approaches could be taken to improve this situation. First, research is needed to fully understand and explain students’ attitudes towards the care of dying patients. It might be more appropriate to utilize mixed research methods. The second is to integrate end-of-life care courses within the curricula of nursing programmes, currently the mainstay in improving students’ knowledge and attitudes toward care of the dying.

Footnotes

Acknowledgments

This work has been carried out during sabbatical leave granted to Dr Mohammad Al Qadire from Al Al-Bayt University during the academic year 2019/2020.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Al Al-Bayt University.

ORCID iD

Mohammad Al Qadire

Author Biography

Mohammad Al Qadire, RN, PhD, is an associate professor of Oncology and Palliative Care Nursing in the School of Nursing at Al AlBayt University, Mafraq, Jordan. He is currently spending his sabbatical leave in the College of Nursing at Sultan Qaboos University, Muscat, Oman. He has published more than 60 peer reviwe articles in the field of onclogy nursing.

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