Death education for undergraduate nursing students in the China Midwest region: An exploratory analysis

Abstract

Aim

The purpose of this study was to comprehend the need for incorporating death education within the curriculum of undergraduate nursing students and to assess the factors that impact the desire for such education.

Design

We enlisted undergraduate nursing students from several nursing colleges located in the central and west region of China. Undergraduate students who fulfilled the eligibility criteria between January and February 2021 were chosen to participate. Data were collected via an online platform called Questionnaire Star. The survey encompassed a general information questionnaire and a scale for assessing the need for education on the topic of death. Descriptive statistical analysis was performed using the SPSS 20.0 software, while multivariate stepwise regression was employed for more complex analysis. Statistical significance was indicated when the p-value was below 0.05, and high statistical significance was noted when the p-value fell below 0.01.

Methods

We designed a descriptive quantitative approach to investigate the need for death education and its associated factors. The research involved 907 undergraduate nursing students from the central and west region of China. The data collection was done through the Questionnaire Star platform.

Results

Following the collection of completed surveys, individuals displaying contradictory responses were omitted. Out of 911 surveys disseminated, 907 were successfully collected, resulting in a recovery rate of 99.6%. Among the participants, 769 identified as female, constituting 84.8% of the total, while 138 identified as male, making up 15.2%. The survey findings indicated that factors such as residency, parental educational history and exposure to hospice care education significantly impacted the need for death education among undergraduate nurses (p < 0.05).

Conclusions

Among students pursuing a nursing degree at the undergraduate level, there was a pronounced need for education related to the topic of death. Offering such education to these students is essential, as it helps cultivate a proper understanding of death. This, in turn, contributes to enhancing the overall quality of patient care throughout their life journey.

Patient or Public Contribution

A total of 907 nursing undergraduates from central and western China participated in the questionnaire.

INTRODUCTION

Can nursing students be effectively guided towards a balanced understanding of death? Death is an unavoidable aspect of life, especially apparent when dealing with seriously ill patients. Nurses frequently encounter the passing of patients, making end-of-life care a crucial skill. Scholars like Mahan et al. (2019) advocate its inclusion in the nursing curriculum. Therefore, instilling knowledge about death is essential for undergraduates studying nursing. Death education aids individuals in grappling with mortality and has its origins in US colleges (Doka, 2015; Kelly et al., 2018; Zhao et al., 2022). Unfortunately, insufficient instruction often leads students to perceive the curriculum as inadequate. Consequently, they may feel unprepared, anxious and apprehensive when tending to dying patients and their families (Heise & Gilpin, 2016; Mastroianni et al., 2021). In this study, we investigated the extent of the need for death education among undergraduate nursing students. The aim was to analyse and provide a conceptual framework for integrating death education into nursing programmes at this level.

Research questions

Is the inclusion of death education essential for undergraduate students in the China Midwest region?

What were the influencing factors for death education among undergraduates in the China Midwest region?

BACKGROUND

Lately, there has been a notable integration of death education with subjects such as hospice care and end-of-life care. Research has predominantly focussed on educating and preparing healthcare professionals to assist individuals who are terminally ill (Gelegjamts et al., 2020; Mahan et al., 2019; Mak, 2013). Nurses play a direct role in providing end-of-life care, offering palliative and hospice care during a patient's final moments. They also provide vital support to family members, although this responsibility can be emotionally taxing for nursing students (Byrne et al., 2020).

The primary goal of death education is to equip nursing students with the ability to confront patient mortality with a receptive outlook. This involves furnishing them with suitable psychological tools to assist the families of the deceased (Testoni et al., 2023). Clinical work exposes students to patients at various stages of illness, thereby presenting a challenge in adapting to the unique requirements of each patient (Da Silva et al., 2015). During these instances, death education takes on significant importance not only for ensuring proper care for the dying and their families but also for the emotional well-being of the nurses themselves (Ling et al., 2020).

Originating in the United States, death education has been integrated into the educational curricula of colleges, universities, hospitals and society at large as a professional programme (Ronconi et al., 2023). The Association of Death Education and Counseling (ADEC) serves as the primary professional body for death education in the United States (Balk et al., 2011). This has led to the establishment of a system of death educators and consultants, furthering the advancement of death education (Bakan & Arli, 2018). Many countries view death education as pragmatic learning, conveying its essence through clinical practice, hospice volunteer service, near-death experiences and other hands-on activities (Charys et al., 2016; Dame & Hoebeke, 2016). In China, death education is currently in the exploratory phase of transitioning from theoretical research to practical implementation, facing challenges in terms of a lack of scientific standards and educational content (Li et al., 2019; Shen et al., 2022).

DESIGN Sample collection

We employed convenience sampling to select a total of 911 college students from six different universities in China mainland, mainly from nursing colleges in the Midwest region of China. The universities included Jilin Medical University, Henan University of Traditional Chinese Medicine, Shanxi Medical University, Hunan University of Traditional Chinese Medicine, Guizhou Medical University and Guizhou University of Traditional Chinese Medicine. These universities represented a diverse geographical range from north to south and encompassed both western medicine and traditional Chinese medicine institutions. The selection process focussed on undergraduate nursing students who fulfilled specific inclusion criteria during the period from January to February 2021. The criteria encompassed being full-time undergraduates in nursing, aged 18 years or older, providing informed consent and expressing a willingness to partake in the study. Research Ethics Committee approval for the survey was obtained from the institutional review boards of the respective universities and was determined to be exempt.

Methods Survey method

The survey was conducted over the winter break, facilitated by Questionnaire Star, an internet-based survey tool. In each college, a single teacher–researcher provided consistent instructions for the questionnaire on online class groups such as QQ and WeChat. Subsequently, the questionnaire link was shared. Respondents participated willingly in this anonymous survey, which restricted submissions to one per individual. All questionnaire fields were mandatory to uphold data quality. Out of the 911 questionnaires distributed, 907 were successfully collected, resulting in a retrieval rate of 99.6%.

Ethical considerations

The online survey data were accessible only to the two researchers responsible for conducting statistical analysis. These researchers were not involved in questionnaire distribution. Participants received assurance that the collected data would exclusively serve this study. The researchers were unable to access details about individual respondents or nonrespondents, ensuring the voluntary nature of student participation and safeguarding their rights against undue pressure or manipulation.

Survey content

(1) General information questionnaire: after an examination of the existing literature and factors that have an impact in previous research, we developed a general information questionnaire for this study. The questionnaire encompassed the following inquiries: gender, ethnicity, place of residence, birth order, school grade, religious affiliation, current health status of family members, parental educational attainment, any past instances of severe illnesses (both acute and chronic) personally experienced, any past instances of severe illnesses (both acute and chronic) among family members, was the decision to pursue nursing as a career a personal decision, attending a funeral, prior exposure to education about hospice care and personal involvement in the care of terminally ill patients or family members.

(2) Death education needs scale: the Death Education Needs Scale, as adapted by Shu-Huei Yen, a Chinese Taiwanese researcher, was primarily employed to assess the need for death education among university students (Yan, 2002; Zhang & Liu, 2020). It comprises of 10 statements: (1) I believe it is important to educate undergraduates about death; (2) I am convinced that receiving death education will greatly benefit my future personal and professional life; (3) I think teaching students how to cope with emotional challenges stemming from death is advantageous for their mental well-being; (4) educators can utilize pertinent teaching materials to encourage students to contemplate and discuss death, as well as express their own sentiments; (5) I consider death education valuable in forming a correct perception of death; (6) I hold the view that introducing death education can alleviate people's apprehensions and apprehensiveness about death, enhancing the significance of life; (7) I feel that society should place importance on death education; (8) I believe educational institutions should incorporate death education into their curriculum; (9) I am interested in obtaining more information about death education; and (10) I think it is essential for everyone to receive education about death. Participants rated these statements using a 5-point Likert scale: 1—strongly disagree, 2—disagree, 3—neutral, 4—agree and 5—strongly agree. The total achievable score was 50, with higher scores indicating a greater need for death education. The validity and reliability of this assessment tool have been established, as evidenced by a Cronbach's α coefficient of 0.81, indicating robust internal consistency.

Statistical method

Questionnaires that had identical answers or displayed clear disorderly patterns were excluded from the analysis. The valid questionnaires that remained were assigned numbers, and two investigators entered the collected data into a computer. Descriptive statistical analysis was carried out using the SPSS 20.0 software. For multivariate analysis, a multivariate stepwise regression approach was employed. Demographic variables and participants' responses to the Death Education Needs scale were subjected to descriptive statistical analysis. The scores of death needs based on different characteristics were compared using independent sample t-tests and analysis of variance. To assess the influence of the five factors on Death Education Needs as the dependent variable, a multivariate linear regression model was utilized. Prior to the linear regression, all variables were standardized. Statistical significance was determined at p-values less than 0.05, and high significance at p-values less than 0.01. The study's design was well-considered, considering sample size and statistical analysis requirements.

RESULTS

We found that the scores of death education need among undergraduate nursing students were elevated, registering a mean score of 43 ± 7.37 points. This score surpassed the mean score of 38.43 ± 6.35 points identified in the study by Peng et al. (2017) regarding the death education needs of nursing students. Among the 907 participants, 138 surveys (15.2%) were completed by male students, while 769 surveys (84.8%) were completed by female students. Notably, there were no statistically significant differences in scores between the genders (p > 0.05). These results are shown in Table 1. Univariate analysis identified five factors of statistical significance:

1. Students from rural backgrounds exhibited lower need for death education compared with their nonrural counterparts (t = −4.301, p < 0.05).
2. The surveyed students included 250 freshmen (27.6%), 275 sophomores (30.3%), 244 juniors (26.9%) and 138 seniors (15.2%). As students progressed in grade and as the education level of their parents increased, there was a gradual rise in the need score for death education (p < 0.05).
3. Students who had cared for terminally ill patients or family members with terminal illnesses exhibited higher death education need scores (p < 0.05).
4. Nursing students who had taken specialized courses on hospice and death displayed a relatively higher need for death education compared to those who had encountered related content in other courses or had no exposure to hospice and death knowledge (p < 0.05).

TABLE 1 Comparison of the general demographic information and scores of death education need among 907 undergraduate nursing students $\left(\overline{x}\pm \mathrm{S}\right)$.

[Table omitted. See PDF]

Considering these findings, it is evident that there exists a pronounced need for death education among undergraduate nursing students. To elucidate the elements that impact the need for instruction on the topic of death, we employed the total score denoting the requirement for death education across 907 nursing undergraduates as the outcome variable. The independent variables included the place of residence, academic year, parental education level, prior exposure to hospice care education and involvement in tending to either a critically ill patient or a family member in such a condition. These independent variables exhibited statistical differences during the univariate analysis. By employing a multiple regression approach, we constructed a multivariate regression model. The allocation of these variables is illustrated in Table 2.

TABLE 2 Assignment of the influencing factors of death education need among the general information in 907postgraduate nursing students.

Variable	Assignment
Place of residence	1—Rural area, 2—Urban
Grade	1—College freshman, 2—Sophomore, 3—The third year in university, 4—The fourth year in university
Parental educational background	1—Without, 2—Preliminary school, 3—Junior high school, 4—Senior high school, 5—Junior college, 6—College and above
The experience of having hospice care education	1—Having learned courses specialized in hospice care and death, 2—Not having learned courses specialized in hospice care and death, but with the learning of other courses concerning relevant contents, 3—Never have contact with the knowledge concerning hospice care and death
The experience of caring for a terminally ill patient or a terminally ill family member	1—Yes, 2—No

Based on the findings, three variables were ultimately incorporated into the model (with a significance level of p < 0.05). These variables include the place of residence, the educational background of parents and prior exposure to hospice care education. These factors were identified as the primary influencers of the need for death education among students pursuing a bachelor's degree in nursing. Further information can be found in Table 3, where details are provided.

TABLE 3 Linear regression analysis of the death education need in 907 undergraduate nursing students.

Variable	Unstandardized coefficient		Standardization coefficient		95% confidence interval
	B	S.E.	B	t	S	Lower limit	Upper limit
Constant	41.165	1.060		38.825	0.000	39.084	43.246
Place of residence	1.600	0.572	0.103	2.796	0.005	0.477	2.723
Parental educational background	0.536	0.246	0.080	2.176	0.030	0.053	1.019
The experience of having hospice care education	−1.182	0.357	−0.108	−3.307	0.001	−1.883	−0.480

DISCUSSION

Based on the findings, there are significant variations in the death education needs of undergraduate nursing students. These differences were based on factors such as their place of residence, the educational background of their parents and their prior exposure to hospice education.

Place of residence

Residential location showed a connection with the need for education about death. The need for death education was most pronounced among nursing students living in urban areas. This observation aligns with the findings of Park and Yeom (2014), who proposed that nursing students in urban settings would likely possess positive attitudes towards death. Urban students may find it easier to engage in conversations about topics related to death due to favourable circumstances related to economics, culture and society. Moreover, their advantageous educational backgrounds and access to quality education may enable them to have a more comprehensive grasp of the concept of death, allowing them to confront and embrace it more openly. The reduced interest in death education among students hailing from rural regions could be connected to their limited willingness to embrace the topic. This reluctance might stem from their subconscious tendency to avoid such discussions, likely influenced by the prevalent traditional culture during their upbringing.

Parental educational background

A study conducted by Chen (2018) revealed that students who had been exposed to death education and engaged in discussions about death at home exhibited lower levels of anxiety related to death when compared to those who had not received death education or never talked about death. This trend can be attributed to the impact of traditional culture, wherein parents with higher levels of education tend to possess a more enlightened perspective on death, underscoring the importance of death education for their children. As primary role models, parents significantly influence their children through subtle actions and thoughts within the upbringing environment. Therefore, it is crucial to consider the upbringing context of nursing students, emphasizing the need for both family and school settings to facilitate opportunities for these students to embrace a scientific understanding of death.

Previous hospice care education

Nursing students who had previously received education about hospice care and the concept of death tended to exhibit a stronger inclination towards seeking positive education related to death. These students demonstrated a need for the establishment of both internal and external reinforcement programmes aimed at enhancing their ability to provide person-centred care. The ultimate goal was to equip them with the capacity to come to terms with the passing of others in a peaceful manner. As these nursing students transition into becoming future nurses, it becomes imperative to educate them across diverse clinical scenarios, including the care of terminally ill patients and their families (Cheon & You, 2022).

In nursing education, a particular emphasis should be placed on essential components such as the fundamental nursing curriculum, comprehensive understanding of death theory and practice, and the principles of hospice care. The incorporation of hospice care education can effectively transform nursing students' attitudes towards death, alleviating their fear and thereby enhancing the quality of hospice care (Cerit, 2019; Fernández-Martínez et al., 2021; Zahran et al., 2022).

It is noteworthy that an individual's perception of death can be influenced by cultural, socioeconomic and personal factors. Online courses focussing on the education of life and death have been identified as effective educational tools (Park et al., 2022).

In a study conducted in Switzerland concerning the inclusion of death education components within palliative care, it was observed that while universities offered palliative care education to varying degrees, topics related to life and death were challenging both to teach and to comprehend. The predominant form of education was theoretical. Therefore, there is a pressing need for substantial palliative care education not only at the university level but also at a national scale to prioritize the advancement of palliative care. Teachers should aim to enhance their comprehension of students' needs and employ innovative teaching strategies to expand the scope of palliative care education (Hagelin et al., 2022).

The limitation of this study lies in the predominant concentration of students within the central and western regions. Additionally, the simplicity of the questionnaire items falls short of fully capturing the attitudes and needs of nursing students concerning death education. Thus, there is room for improvement in future research endeavours.

Effective death education is essential for nursing students to approach patient deaths in a rational manner, enabling them to provide composed patient care and console grieving families. To establish a comprehensive and efficient death education system, universities should integrate physical, mental and professional aspects in independent courses or incorporate them into hospice care programmes. This approach will aid in fostering both the emotional resilience and professional competence of nursing students. It will facilitate a seamless transition from theoretical learning to practical clinical experience, preparing students for successful nursing careers and attracting promising individuals to the field of hospice care.

CONCLUSION

Death education is crucial for undergraduate nursing students, as they exhibit a significant need for the same. Offering such education and cultivating a proper understanding of death are essential steps to enhance the overall nursing care quality across all stages of a patient's life.

AUTHOR CONTRIBUTIONS

Fen-Ju Su was involved in conception and design of the research. Hai-Yan Zhao was involved in acquisition of data. Tian-Lan and Wang were involved in analysis and interpretation of the data. Lu-Jiao Zhang was involved in statistical analysis. Yuan Li was involved in obtaining financing. Fen-Ju Su was involved in writing of the manuscript. Fen-Ju Su and Guo-Feng Shi were involved in the critical revision of the manuscript for intellectual content. All authors read and approved the final draft.

ACKNOWLEDGEMENTS

We would like to acknowledge the hard and dedicated work of all the staff who implemented the intervention and evaluation components of the study.

FUNDING INFORMATION

2020 Undergraduate Teaching Engineering Construction Project-04 (Provincial Project of Guizhou Province (No. 3411-41100008307).

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no competing interests.

DATA AVAILABILITY STATEMENT

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

ETHICS STATEMENT

Research Ethics Committee approval for the survey was obtained from the institutional review boards of Jilin Medical University, Henan University of Traditional Chinese Medicine, Shanxi Medical University, Hunan University of Traditional Chinese Medicine, Guizhou Medical University and Guizhou University of Traditional Chinese Medicine and was determined to be exempt.