The effects of occurrence and frequency of nursing students ’ confrontation of death on their attitudes towards death

This study was conducted as a descriptive study aiming at determining the effects of the facing death situation and frequency of nursing students on their attitudes towards death.The research was carried out between October 10 and October 21, 2016 with the participation of 233 students who were currently studying in the nursing department of the Faculty of Health Sciences. The data were collected by the 25question questionnaire form prepared by the researchers and determined the demographic characteristics of the students and their attitudes towards death using the Death Attitude Profile-Revised (DAP-R) Scale. As the total scores obtained on the scale increased, it is considered that a more negative attitude is developed towards death. For the data assessment, percentile estimation, Levine test, One Way ANOVA, Tukey test, Mann Whitney U test, and Kruskall Wallis test were used. The present study demonstrated that of the students, 46.4% loved their profession, 59.7% preferred their profession willingly, 36.5% lost a first-degree relative previously, 65.7% faced death situation during clinical practices, 60.1% avoided from facing with the relatives of the deceased individual, and only 21.5% found herself/himself sufficient for understanding the patients’ relatives. The median score of DAP-161.00), the median score the -72), the median score of the Escape Acceptance subdimension -32), and tha relationship was found amongthe DAP-R scores of the students and their sociodemographic and occupational characteristics and facing death situations (p <0.05). Considering that a negative attitude toward death was developed as the total score of the scale increased, this study revealed that the students did not develop any negative attitudes towards death.


Introduction
Death is a universal incident.Death is the truth and a part of life (Oz, 2004).The concept of death bearing in the minds of people affects the behaviors and lifestyles of individuals religiously, philosophically, morally and legally, and the person, who is always in touch with death, can develop an attitude towards death by considering the concept of death (Bilge et al., 2013).The individual's perception of death and his/her attitude can be influenced by many factors such as religion, culture, social values, beliefs, and traditions (Ozdemir and Ekinci, 2014).People can develop a positive or negative attitude toward death in line with their experiences about the deaths of individiuals around them (Inci ve Oz, 2009) and the attitudes and reactions towards death may differ on individual basis (Ozdemir and Ekinci, 2014).Even though the attitude developed towards death is defined as a reaction against the experience of death, this reaction is defined as a threat, fear, and a sense of discomfort (Rooda et al., 1999).
The personality, emotions, and behaviors of a nurse, who is taught of being responsible for sustaining life during her education period, can also affect her attitude towards death.In the face of the loss of a patient, the nurse who is in charge of his/her treatment and care may feel the emotions of fear, anxiety, denial, anger, guilt, depression, helplessness, and grief (Oz, 2004, Asti andKaradag, 2013).When nurses have conceptual complexity about death and when they can not develop a positive attitude, it becomes more difficult for them to work with dying patients (Tanhan and Ari, 2006) the attitude developed towards death negatively affects the quality of care and may prevent the peaceful and comfortable death deserved by the patient (Ay and Oz, 2013).In this respect, it is of great importance for a nurse to be aware of her feelings towards death, to be able to manage these feelings properly and to develop an appropriate attitude (Oz, 2004, Asti andKaradag, 2013).
As stated in the literature, nursing students are given the responsibility of sustaining life during their education.Accordingly, the inability to prevent death may cause the emergence of different feelings and thoughts in the nursing students, who feel the responsibility of sustaining the life of the individual (Oz, 2004).Some studies on nursing students abroad revealed that students confronted with the death situation during clinical practice, that they had fears about caring a patient with approaching death, and that their training programs failed to prepare them for this situation (Cooper and Barnett, 2005;Shih et al Loftus, 1998).Therefore, as also stated in the literature, the feelings and opinions of nurses about death should be examined from the beginning of their school years, and students should be allowed for being able to express these feelings and develop themselves (Duke, 1997, Macleod et al., 2003, Hurtig and Stewin, 1990).Nursing students are observed to have the feelings of fear, anger, helplessness, guilt, and incompetency while caring for the patients with approaching death and their families (Koc and Saglam, 2008), and it is considered that this situation may reduce the quality of care by affecting the care given to the patient and his or her family negatively.In this respect, in order to provide effective care and psychosocial support for the patient with approaching death in his or her family by nursing students, there is need for determining the effect of the facing death situation and frequency on their attitudes toward death and developing appropriate strategies in line with the findings obtained.We suggest that the results to be obtained from this research will be useful in the configuration of nursing education curriculum programs.

Objective of the Study
This study was conducted as a descriptive study aiming at identifying the effects of the facing death situation and frequency of nursing students, studying in the nursing department of the Faculty of Health Sciences, on their attitudes towards death.This research inquires answers to following questions:  What is the facing death frequency of nursing students?
 How are the attitudes of nursing students towards death?
 What are the sociodemographic and occupational characteristics affecting the attitudes of nursing students towards death?

Place and Time of the Research
This research was conducted as a descriptive study in order to determine the effect of the facing death situation and frequency of the nursing students, who were studying in the second, third, and fourth grades of the nursing department of Health Sciences Faculty, on their attitudes towards death between October 10 and October 21, 2016.

Population and Sample of the Research
In the research, the sampling method was not employed and we aimed to reach the entire population (n = 389).However, a total of 233 students (59.9%) who filled in the questionnaire completely and volunteered to participate in the study constituted the study group since the students who did not agree to participate in the study during the data collection process (n = 96), who were not present at school on the days when the questionnaire was filled in (n = 47) and who did not fill in the questionnaire completely (n = 13) were excluded.

Tools of data collection
The data of the research were collected by an introductory questionnaire using the Death Attitude Profile-Revised (DAP-R) Scale.The questionnaire form consisted a total of 25 questions describing the socio-demographic characteristics (age, grade, gender, marital status, family type, place of residence, where they live now, income status, social security, family structure, intrafamilial communication status, how she describes her relations with friends and social environment) and occupational characteristics (enjoying the profession of nursing, whether pursuing the profession of nursing willingly or not, facing death during clinical practice, death cases confronted, escaping death, presence of health problem, losing a first-degree relative, hesitating from facing with the relatives of the deceased person, feeling herself sufficient about understanding and approaching the patients in a proper manner, frequency of thinking of death, what she feels when she faces death situation, etc.) of the students.

Death Attitude Profile-Revised (DAP-R) Scale
The Death Attitude Profile-Revised (DAP-R) Scale is a scale developed by Wong et al. (1994) to assess the attitudes of individuals toward death and adapted to Turkish by Isik et al. (2009).It is a seven-point Likert type scale based on the notion of the presence of death and consists of 26 items.The Scale is composed of three subdimensions namely, "Neutral Acceptance and Approach Acceptance" (items 4, 6, 8, 12, 13, 14, 15, 19, 21, 22, 23, and 25), "Escape Acceptance" (items 5, 9, 11, 20, and 24 ), and "Fear of death and avoidance of death" (items 1, 2, 3, 7, 10, 16, 17, 18, 26) and measures the individual's attitudes towards death.In addition to obtaining a score on each subdimension, the total score of the scale can be obtained as well.The high total score obtained on the scale is considered as the development of negative attitude towards death (Isik et al., 2009).
"Neutral Acceptance" is believing that death is a part of life.In this way, no one is afraid of death nor accepts it.The person only accepts it as one of the facts of life that cannot be changed.She or he tries to make the most of limited life."Approach Acceptance" is believing in a happy afterlife by considering the death as being transferred to the other life."Escape Acceptance" is believing that death provides relief from physical or psychological pain and the distress of life.It is to believe that life is full of suffering and misery and death may be a welcomed acceptable alternative."Fear of death" is the fear felt when someone confronts death."Death avoidance" is to avoid thinking of and talking about death with the hope of reducing the anxiety of death.Therefore, death avoidance is a defense mechanism that someone uses to keep death away from herself or himself.(Wong et al., 1994).The Cronbach Alpha value of the scale was found to be0.081 in this research.

Data Collection
The questionnaire and the scale were initially tested on a group of five individuals.The items which could not be understood or which were missing were identified and corrected.After this pilot study, the last touches were put on the final version of the draft.This research was in accordance with the ethical standards of the Helsinki Declaration.The data were collected from the students by the researchers through face-to-face interviews and informed consents were obtained from the students.After making an explanation about the study to the participating students, the Death Attitude Profile-Revised (DAP-R) Scale was administered via the questionnaire form.It was expressed to the students that the decision of participating or not participating in the research was completely their own choice, that their names would not be written in the questionnaire form and that the data to be collected from this study would only be used within the scope of the research.The data collection period was completed approximately in 6-7 minutes.

Data Assessment
The statistical analysis of the data of the students included in the scope of the research was analyzed in a computer environment using the SPSS v15.0 package program.Percentage estimation, Levine test, One Way ANOVA, Tukey test, Mann Whitney U test and Kruskall Wallis test were used for the assessment of the data.The results were expressed as percentages, means, and standard deviations.Statistical significance level was accepted as p<0.05.

Results
A total of 233 nursing students participated in this research.In this study, 36.5% of the students were in the second grade, 34.8% of them were in the third grade and 28.7% of them were in the fourth grade.Of them, 70.4% were girls, 29.6% were males, 97.9% were single, 73.4% had a nuclear family structure, 46.4% lived in the city center.The income of 67% students was equal to their expense.Of the students, 89.7% had social security, 56.2% defined their family structure as protective, 54.1% defined their intrafamilial communication status as good, 46.8% were living in a dorm and 54.1% defined their relationships with their family and social environment as good (Table 1).
Of the students, 46.4% liked their profession, 59.7% preferred their profession willingly, 65.7% confronted with death during clinical practice, 18.9% escaped a serious death risk, 7.7% had a serious health problem,16.7% had a first-degree relative with high death risk, 36.5% experienced the death of a first-degree relative, 60.1% hesitated over facing with the relatives of the deceased individual, 71.2% felt themselves sufficient for understanding their patients and relatives and 50.6% thought of death occasionally (Table 2).
The median score of the Death Attitude Profile-Revised Scale was found to be 110.00(26.00-161.00), the median score of the Neutral Acceptance and Approach Acceptance subdimension was 57 (12-72), the median score of the Escape Acceptance subdimension was 19 (5-32), and that of the Fear of Death and Death Avoidance subdimension was 34.12 8.49.In this study, a statistically significant relationship was found among the Death Attitude Profile-Revised Scale scores of the students and their sociodemographic and occupational characteristics and facing death situations (p <0.05).The students who confronted with death during clinical practice (U = 4979, p = 0.019) who liked his or her profession (F = 3.885, p = 0.022), who never found himself or herself sufficient for understanding patients ( = 9.955, p = 0.007), who defined his or her intrafamilial communication as very good ( = 7.013, p = 0.03), who thought of death occasionally = 11.692,p = 0.009), who lived alone at home (U = 2074, p = 0.164), who were married (t = 2.677, p= 0.008) and who did not have social security (U = 2074, p = 0.164) were observed to develop a more positive attitude towards death.(Table 3).

Discussion
In this study, which aimed to determine the effect of the facing death situation and frequency of nursing students on their attitudes towards death, it is identified that the students were not developing a negative attitude towards death.The median score of the Death Attitude Profile-Revised Scale was found to be 110.00(26.00-161.00), the median score of the Neutral Acceptance and Approach Acceptance subdimensions was 57 (12-72), the median score of the Escape Acceptance subdimension was 19 (5-32), and that of the Fear of Death and Death Avoidance subdimension was found to be 34.128.49.
After the study by Bilge, Embel, and Kaya (2013) which was conducted to determine the attitudes of the students towards death, its relationship with death anxiety and the variables affecting them, the mean score of the Fear of Death and Death Avoidance subdimension of the nursing students was 34.94 ± 9.93, the mean score of the Neutral Acceptance and Approach Acceptance subdimension was 58.87 ± 13.52 and that of the Escape Acceptance subdimension was found to be 19.57± 5.85.The mean score of the Neutral Acceptance and Approach Acceptance subdimension was reported to be higher compared to the other subdimensions.Another study by Selcuk and Avci (2015) revealed thatthe mean of the total score obtained on the Death Attitude Profile-Revised Scale was 117.62± 17.86 , that the scores of Fear of Death, Death Avoidance, Death Acceptance subdimensions and the total score of the students were above the average, the scores of Neutral Acceptance were below the average, while the scores of Acceptance Approach were determined to be at a moderate level.Although the mean score of the Death Attitude Profile-Revised Scale of the students differs depending on the research conducted, it is considered that this difference may be influenced by the sociodemographic and occupational preference characteristics of the students.
In this study, the students who faced death situation during clinical practice, who liked their profession, who did not find themselves sufficient for understanding patients, who defined their intrafamilial communication as very good, who thought of death occasionally, who lived alone at home, who were married and who did not have social security were observed to develop a more positive attitude.
The study conducted by Selcuk and Avci (2015) demonstrated that the variables of age, gender, marital status, grade, religious belief, facing death in close environment, proximity degree of the death experience, willingness for caring the patients in the terminal period were found to be significantly associated with the total score of death attitude and the mean scores of its sub-dimensions.As a result of the study by Saad, Demirkiran, and Adana (2016) on nursing students to identify death anxiety, willingness for caring a dying patient and the affecting factors, they found that more than half of the nursing students confronted with death during any period of their lives, that experiencing loss due to death increased their death anxiety further, that female students had higher death anxiety compared to male students, that male students were more willing for caring a dying patient and that the students with higher death anxiety did not want to care a dying patient.Another study conducted by Bilge, Embel and Kaya (2013) reported that the mean score of the Neutral Acceptance and Approach subdimension was found to be higher in females when the death anxiety, attitude toward death and gender were compared.Even though the factors affecting the mean scores of the Death Attitude Profile-Revised Scale of the students differ depending on the studies, it is considered that this situation may be influenced by the personal and occupational preference characteristics of the students, values given to life and death by them, and the approaches of educators.

Conclusion
This study revealed that the students who faced death during clinical practice, who liked their profession, who never found themselves sufficient for understanding patients, who defined their intrafamilial communication as very good, who thought of death occasionally, who lived at home alone, who were married, who did not have social security developed a more positive attitude towards death.In line with the results obtained, it is suggested that death education programs should take place in the training programs of nursing.Students should be encouraged to speak about their feelings in respect to death.Students should be there while talking with the patient with approaching death and his or her family.They should have the right to choose if the student is not ready to give the antemortem and postmortem care or not ready to talk with the patient or family.Enough time should be given and experiences should be shared with students.

Limitations of the Research
 Inability to make long-term observations to assess the correctness of the statements within the answers given regarding the face-to-face interviews carried out with the sample group is a limitation of this research.