Nursing Students ’ Attitudes towards Caring for Dying Patients

Background: Dying is a normal human phenomenon that requires a holistic care approach. Nurses’ attitudes towards the care for dying patients need to be explored, understood, and analyzed to improve the quality of care in palliative setting, including in nursing students. Purpose: This study explored the nursing students’ attitude and its relationship with the students’ demographic profile in caring for the dying patients in Indonesia. Methods: This study used a quantitative descriptive cross-sectional research design. The samples were 192 nursing students from Universitas Jember, Indonesia, who were recruited by using simple random sampling. Data were collected using the Frommelt Attitudes towards the Care of the Dying Care Form B Indonesian version (FATCODBI). The reliability test of FATCOD-BI showed a Cronbach’s alpha of 0.68, and the result of validity test using correlation coefficient showed the range of -0.278 to 0.544. Data were analyzed using frequency distribution, and mean differences test using t-test and One-Way Analysis of Variance (ANOVA). Results: Results showed that the mean of nursing students’ attitudes in caring for dying patients was 93.83±5.96 (range 30-120). Gender and training experiences had no relationship with students’ attitudes in caring for dying patients (p=0.22 and p=0.943). There was a relationship between the experiences and student academic level and the students’ attitudes in caring for dying patients (p=0.023 and p=0.036). The students’ experiences and academic level become a primary factor in the attitudes toward caring for dying patients. Conclusion: Findings revealed that student nurses’ attitudes in caring for dying patients was in low category and there was no significant relationship between gender and training experience and students’ attitudes towards caring for the dying patients. In contrast, experiences in caring for dying patients and academic level were associated with students’ attitudes. Further studies in the development of curriculum on dying patient care emphasizing on socio-demographic status are recommended.

Palliative care is an approach to deal with the end of life process.Palliative care improves the quality of life of both patients and families in the face of life-threatening diseases from the first diagnosis until death through psycho, socio, cultural and spiritual approach (Macleod et al., 2012).Previous studies agreed that one form of palliative nursing implementation is the care of dying persons (Barrere, Durkin, & Lacoursiere, 2008;Lynn, 2003).Higgs (2010) indicates that end of life care (EOLC) can be defined in caring for the patients in clinical setting and in strengthening the family support system.Over the two decades, the attention of the EOLC is raised (Payne et al. 2008).EOLC needs to be applied for the response of increasing of chronic diseases (Todaro-Franceschi & Spellmann, 2012).The goals of palliative nursing are increasing the patients' quality of life especially in patients with chronic diseases (Lynn, 2003).To increase the quality of life, strengthening the patients' physical and psychological aspect is needed.Positive attitudes in the caring process can bring more power to patients which can influence the patients' physical and psychological aspects (Gallagher et al., 2015).Thus, nurses should have positive attitudes toward caring activity, especially in the dying process.
Nurses are the health workers who stay nearly 24 hours with patients, and thus they know the patients' needs appropriately (Smeltzer & Bare, 2010).Patients with total care are usually very dependent on the care given by the health care team including nurses.The patients may observe the whole nursing activities so that nurses' attitudes become very important.A previous study reported that negative attitudes from nurses, such as the feeling of fear and anxiety in nursing care, could decrease the quality of care in dying patients (Grubb & Arthur, 2016).Furthermore, another previous study also reported that negative responses of nurses facing a dying process were evoked such as anxieties, fears, and the helplessness that influence the quality of care (Gillan, van der Riet, Jeong, Riet, & Jeong, 2014).Beck, Tornquist, Brostrom, and Edberg (2012) stated that nurses need to describe their feeling through pained expression when caring for the dying patients.These studies figure out that the patients may have an unmet need since nurses may not always deliver convenient care to dying patients.
Nursing students should have positive attitudes towards dying patients in order to give excellent care.However, recent studies reported that nursing students feel unprepared Nurse Media Journal of Nursing, 8(1), 2018, when they should face patients and family within dying care (Gillan et al., 2014;Wallace et al., 2009).Grubb and Arthur (2016) emphasized that positive students' attitudes in caring for dying patients can be used as an indicator of effective therapeutic relationship with dying patients.Positive attitudes towards dying patients become a central role in developing EOLC curricula (Jeffers, 2014), and thus should be explored for the development of appropriate curricula in EOLC education.Developing nursing students' attitudes in an academic setting is more convenient and more effective than that in a clinical setting (Mutto, Cantoni, Rabhansl, & Villar, 2012).
Recent studies showed that the attitudes towards caring for dying patients have been investigated in Asia, Europe, and US.All of these studies used the Frommelt Attitudes toward the Care of the Dying Care Form B (FATCOD-B) to explore the attitudes (Frommelt, 2003;Henoch et al., 2014;Iranmanesh, Savenstedt, & Abbaszadeh, 2008;Nakai, Miyashita, & Sasahara, 2006;Wang, Li, Yan, & Li, 2016).The Death Attitude Profile-Revised (DAP-R) was also added and utilized in one of the studies (Iranmanesh et al., 2008).Other studies added information about the correlation between the characteristics of nursing students and FATCOD-B Score in the aims of study (Arslan et al., 2014;Iranmanesh, Axelsson, Häggström, & Sävenstedt, 2010).However, there is no evidence of studies which explore attitudes toward caring in dying patients in Indonesia.Therefore, investigating attitudes toward caring for dying patients and its influencing factors is needed.

PURPOSE
This study aimed to explore nursing students' attitude towards caring for dying patients using FATCOB-B of Indonesian version and its correlation with the characteristics of students which include gender, experience in caring for dying patients, experience in attending training programs, and academic levels.

METHODS
This study utilized a quantitative descriptive cross-sectional research design.The samples were students of School of Nursing, Universitas Jember, who were recruited using simple random sampling.The inclusion criteria were the students who have completed basic nursing courses and willing to participate in this study.The number of respondents was calculated using G*power analysis.The result showed that the power was 0.80, the effect size was 0.30 and the significance level was 0.05.As a result, 84 respondents are required (Faul, Erdfelder, Lang, & Buchner, 2007).In this study, the number of participants was 192.
Questionnaires about the characteristics of respondents and the Frommelt Attitudes toward the Care of the Dying Care Form B of Indonesian version (FATCOD-BI) were administered.The questionnaire of respondent characteristics consisted of gender, experience in caring for dying patients, experience in training programs, and academic levels.The FATCOD-BI is the adoption of the questionnaire the Frommelt Attitudes toward the Care of the Dying Care Form B (FATCOD-B) developed in the United States (Frommelt, 2003).The FATCOD-B questionnaire of Indonesian version was adopted by A'la (2016).The back-translation for FATCOD-BI was done by two experts Nurse Media Journal of Nursing, 8(1), 2018, in medical-surgical nursing and palliative nursing from Universitas Jember and Universitas Gadjah mada.
The FATCOD-BI has been tested for its validity and reliability in 127 nursing students.All items in FATCOD-BI were valid in the range of -0.278 up to 0,544.The reliability test was 0.68, indicating that FATCOD-BI was valid and reliable for the study.The FATCOD-BI consisted of 30 items and statements using five Likert scales.This questionnaire aimed to identify the respondents' attitudes towards caring for dying patients and consists of favorable and unfavorable statements.The favorable statements were items 1, 2, 4, 16, 18, 20, 21, 22, 23, 24, 25, 27 and 30.They were given a score of 1 for strongly disagree and 5 for strongly agree, and vise versa for the unfavorable statements.The total score ranged from 30-150.Higher scores indicate more positive attitudes in caring for dying patients.
The data analysis in this study was performed using descriptive and analytical approach.The descriptive approach sought the frequency distribution with a mean and standard deviation of the attitudes toward caring for dying patients.Meanwhile, the analytical approach used an independent t-test and one way ANOVA to see the correlation between the characteristics of respondents and the FATCOD-BI score.
This study obtained approval from the Ethical Committee Review Board of the Division of Research Centers in Universitas Jember.This study was conducted in January-February 2016.

RESULT
Table 1 shows the characteristics of respondents.The majority of respondents were women (76%).Students having no experience in caring for dying patients were higher in number than the experienced ones (54.7%).Furthermore, 84.9% of students did not have experience in the training of caring for dying patients.Based on the academic level, most respondents were students in the third year with 33.9%.Table 3 shows the correlation between the characteristics of respondents and FATCOD-B-I overall score.In gender, the score FATCOD-B-I did not contrast significantly between women and men (94.55±5.77vs. 94.733±5.23; p=0.223).Moreover, the experience of training in caring for dying patients showed no significant difference (93.85±6.17 vs. 93.77±5.59;p=0.94).Meanwhile, the experience of caring for dying patients contrasted significantly (94.85±5.39 vs. 92.99±5.77;p= 0.022).The students' academic level also showed significant difference with p=0.036.

DISCUSSION
The result showed that the FATCOD-BI score was 93.88±5.66.When compared with other countries, the score was in the low category.The score in this study is lower than that in the United States (126.75), in Palestine (96.96), and in Sweden (125.5) (Abu-El-Noor & Abu-El-Noor, 2015;Dobbins, 2011;Henoch et al., 2014).However, the result of this study is higher than that in the UK (80.86) (De Witt Jansen, Weckmann, Nguyen, Parsons, & Hughes, 2013).The attitudes toward the end of life care still low because in Indonesia, there has been no comprehensive curriculum regarding the end of life care.
The result of each item of FATCOD-BI showed that the item of "Care should extend to the family of the dying person" is higher than other items.It interprets that family involvement influences the students' perceptions and attitudes toward the end of life care.Sudore, Casarett, Smith, Richardson, and Ersek (2014) mention that family involvement in palliative care increases the patients' quality of life.Nevertheless, the lowest score is item "Families need emotional support to accept the behavior changes of the dying person".It describes that the curriculum also needs to emphasize the treatment for the family in palliative care settings.
In this study, it was indicated that there is no gender-related difference in attitudes in caring for dying patients.It is in accordance with the study of Abu Hasheesh, Al-Sayed AboZeid, Goda El-Said, and Alhujaili (2013) in Jordan.There is no difference between attitudes in caring dying patients and gender factor.Another study in Spain showed that there was no relationship between attitudes in caring dying patients and gender factor (Edo-Gual, Tomás-Sábado, Gómez-Benito, Monforte-Royo, & Aradilla-Herrero, 2017).However, Dunn, Otten, and Stephens (2005) explains that feminism influences the attitudes of caring for dying patients.
The results in this study also indicated no relationship between attitudes and previous training programs in caring dying patients.It is in contrast with Barrere, Durkin, and Lacoursiere (2008) who reported that the end of life training program affects the attitude in caring for dying patients.The training program explained in the previous study is a comprehensive program and formed in a formal curriculum, while in Indonesia according to Rochmawati, Wiechula, and Cameron (2016), there is no evidence about palliative care module for nursing education in Indonesia.
This present study shows a relationship between the students' experience and attitudes of caring dying person.This is in accordance with a study by Arslan et al. (2014) stating that the experience of college students in caring for dying patients affects the attitudes in caring for dying patients.The experience in caring for a patient before death can develop a positive attitude in caring for dying patients.This experience can influence students' perceptions and develop an attitude in caring for the dying patients (Lange, Thom, & Kline, 2008).
The academic level in this study is also indicated to have a relationship with the attitudes in caring for dying patients.The level of academic is related to student age.The results of studies in Jordan and Sweden also show that age affects the attitudes in caring for dying patients (Abu Hasheesh et al., 2013;Henoch et al., 2014).In contrast to Nurse Media Journal of Nursing, 8(1), 2018, a study in Turkey, there is no relationship between age and attitude of students in caring for dying patients (Arslan et al., 2014).Senior students in nursing have a better ability and high confidence in caring for dying patients (Colley, 2016).Understanding the knowledge of nursing will influence the formation of attitudes.The higher the academic level, the higher the attitude that the students have.

CONCLUSION
The attitude of caring dying patient in nursing students in Indonesia is in a low category.The factors of the experience of caring for dying patients and level of academic affects the students' attitudes in caring for dying patients.Further studies need to explore the development of palliative care curriculum in nursing program in Indonesia

Table 1 .
Socio-demographic characteristics of the nursing students (n=192)Table2shows the mean and standard deviation in overall score and each of items of FATCOD-BI.The average of FATCOD-BI in the nursing student was 93.88±5.66.The item with the highest score was item 22 "Care should extend to the family of the dying

Table 3 .
The correlation between the characteristics of nursing students and the mean scores of Frommelt Attitudes toward Care of the DyingScale (n=192)