Nurses' Attitude Toward Caring for Dying Patients in a Nigerian Teaching Hospital.

INTRODUCTION: Death and the dying experience are common phenomena in all clinical settings. Death and the dying presents physical and emotional strain on the dying patient, his relations and professional caregivers.
OBJECTIVE: The study therefore assessed the sociodemographic determinants of nurses' attitudes towards death and caring for dying patient.
METHOD: A cross-sectional design was used to study 213 randomly selected nurses, working in one of the tier one teaching hospital in Nigeria. Attitude towards death and the dying was collected with Frommelt Attitude Care of the Dying and Death Attitude Profit-Revised questionnaire. The data collected was analysed with SPSS version 20 and inferential analyses were considered statistically significant at p < 0.05.
RESULTS: The study revealed that most of the nurses had negative attitudes toward the concept of death (76.5%) and caring for dying patient (68%). Furthermore, a chi-square test revealed significant associations between the nurses' years of working experience (χ2 = 24.57, p <.00) and current unit of practice (χ2 = 21.464; p = .002) and their attitude towards caring for the dying patient. Also, nurses' age (χ2 = 13.77, p = .032), professional qualifications (χ2 = 13.774, p = .008), and current ward of practice (χ2 = 16.505, p = .011) were significantly associated with their attitudes to death. Furthermore, the study observed a significant association between nurses' attitudes to death and caring for the dying patient (χ2 = 11.26, p < 0.01).
CONCLUSION: This study concluded that nurses had negative attitudes towards death and dying and therefore prescribes, as part of continuing professional development strategy, the need for requisite positive value - laden, ethnoreligious specific education regarding end of life care.

Death and the dying experience, as an integral and inevitable aspect of human existence, over the years, has been a subject of concern among all and sundry. Although, death has been defined as the state of non — being, the termination of biological life (Tomasini, 2017), the experience of dying remains an enigma to all and even the individual going through it (O’Connor, 2016) thus evoking a series of emotional experiences, varying from positive to negative ones. Such experiences include uncertainty, fear anguish and sometimes anger and depression (Kübler-Ross, 1969; Kübler-Ross & Kessler, 2005). Professional caregivers in the clinical settings particularly nurses, take responsibility of caring for patients in varying stages of disease process with the hope of preserving life and functioning (Shamain, 2014). However, death is a reality within the health care setting (Adegoke & Ajuluchukwu, 2019) thus these professionals are prone to witness and experience first-hand, the associated strong emotional experiences and perhaps lead the patient through the experience to attain a peaceful death (Cardoso et al., 2019).

Nurses in particular, command the rare privilege of witness both the beginning and the end of extra — uterine human existence and esteem these as truly a wonderful experience; however, evidence suggest that caring for patients at the tail end of their sojourn on this part of existence constitutes the most stressful facets of nursing (Kudubes et al., 2019). This is partly because, when compared to other health care team members, nurses spend more time interacting with and attending to the complex and dynamic care demands of dying patients (Buttler et al., 2018; Thacker, 2008; Westbrook et al., 2011) and as such, make them more vulnerable to negative emotional and traumatic experiences including a sense of loss and grief which could eventually lead to secondary traumatization and isolation (Coetzee & Laschinger, 2018; Figley, 2001; Stamm, 2010). The possible attendant effect is the likelihood of compromised quality of nursing care accorded to the dying and by extension, other care recipients, including other patients as well as grieving family members, who also require a fair deal of support to enable them deal with the impending loss.

Dying patients, particularly those with terminal diseases may generally express a bleak hope at life or of recovery and often may feel powerless in the final phase of their lives therefore requiring comfort and care. This unique field of nursing is often associated with interplay of strong emotional responses between the dying patient and the relatives as well as the nurse (Kübler-Ross, 1969; Noome et al., 2016). How well the nurse manages these complex emotion — laden interactions is a natural offshoot of the individual nurse’s attitude towards the concept of death and particularly, the dying process.

While meeting the care of this cohort, patient – centered, value – laden and culturally – based care is required especially while upholding the patient’s right to die in peace and with dignity (Henderson, 2015). It therefore, takes adequately prepared nurses to effectively deal with the immense stress, associated with the care needs of the dying patient otherwise, many nurses in this circumstance, will likely feel uncomfortable and put – up behaviours that may create a safe emotional distance from their patients (Coetzee & Laschinger, 2018).

Many studies have documented that attitudes of nurses are sacrosanct in the management of the dying patient (Chang & Iskandar, 2018; Cheong et al., 2020; Tranter et al., 2016; Wang et al., 2018), however none has been documented about this concept in Nigeria where in-hospital mortality has been documented to be one of the highest in the world (Adegoke & Ajuluchukwu, 2019; Akinmokun et al., 2019; Ilesanmi et al., 2019; Ilyasu et al., 2010). The study therefore examined the sociodemographic determinants of the attitude of nurses working in a Nigerian Teaching Hospitals towards the concept of death as well as caring for dying patients. The findings of the study will contribute to ongoing efforts to promote excellence in the area of palliative and end of life care as it relates to meeting physical, social, spiritual and cultural needs of the dying patients without compromising the nurses’ wellbeing.

Methodology

Research Design

A cross sectional design was used to study the determinants of the attitude of nurses working in a tertiary healthcare facility in Nigeria towards caring for dying patient.

Research Setting

The study was conducted in a Teaching Hospitals Complex in Nigeria. The facility provides service, research and teaching. In view of its vast specialization capacity, it receives referrals from most hospitals in South West Nigeria. Also, being one of the foremost tertiary healthcare facilities in Nigeria, it admits terminally – ill patients into various wards of its units therefore, it is not uncommon to find dying patients in the hospitals, hence its choice for this study.

Target Population

Nurses working in the convalescent facilities of the hospital who had interacted with terminally ill and/or dying patients.

Sample Size

The nurses’ sample size for the study was determined using Taro Yammane formula for calculating sample size (Yamane, 1967); n = N/1+N(e)2, Where; n = desired sample size, N = the total number of nurses working in the convalescent units of the study setting. This, according to the administrative office of the nursing unit as at the time of the study was 455 nurses. e = margin of error (0.05). Therefore, n = 455/1 + 455(0.05)2, n = 212.86. approx. 213 nurses

Sampling Technique

Sample for the study was selected using a simple random sampling technique. The nurses’ duty roaster was used as the sampling frame and half of the nurses in each unit was selected. A total of 213 nurses were selected from the overall 455 nurses working in the selected units of the hospital as at the time of the study.

Research Instrument

Data was collected with a structured questionnaire comprising the Frommelt Attitude Care of the Dying (FATCOD) scale (Frommelt, 1991) which collected data on nurses’ attitude towards caring for dying patients. It contained 30 items using a 5-point Likert scale with Strongly Agree, Agree, Indifferent, Disagree, and Strongly Disagree corresponding to scores of 1– 5. Nurses’ attitude towards death was measured using Death Attitude Profit-Revised questionnaire DAP-R (Wong et al., 1994). It is also a 25-item instrument on a using a 5-point Likert scale with Strongly Agree, Agree, Indifferent, Disagree, and Strongly Disagree corresponding to scores of 1– 5. The items in the two sections are summed to give a total score. The score for Frommelt Attitude Care of the Dying (FATCOD) scale ranged from 30 (minimum) to 150 (maximum), while the score for Death Attitude Profit-Revised questionnaire DAP-R ranged from 25 (minimum) to 125 (maximum). Scores above the median score was regarded as positive attitude while any score below the median score was regarded as negative attitude for the two instruments. High scores indicate positive attitudes while low scores indicate poor attitude. Thus, Attitude towards Care of the Dying was graded as Negative (0–60) or Positive (61–150) while Attitude towards Death was graded as Negative (0–55) or Positive (56–125).

The FATCOD and DAP-R has been repeatedly field tested and reported to be reliable in a number of studies (Abu Hasheesh et al., 2013; Cevik & Kav, 2013; Dimoula et al., 2019; Miyashita et al., 2007). The questionnaire was pilot tested using 20 nurses which were recruited from the medical – surgical units of Seventh Day Adventist Hospital, Ile – Ife. The Cronbach’s alpha correlation coefficients of FATCOD and DAP-R components of the questionnaire were determined to be 0.83 and 0.94 respectively, therefore the questionnaire was adjudged to be fit for use in this study.

Method of Data Collection

Prior collecting data, the study setting was visited and due permission was obtained from the Director of Nursing Services of the hospital and the managers of each wards. The nurses were then met individually and a written consent was collected. This was after the purpose of the study, and their roles in the study were explained to them. Afterwards the questionnaire was administered to each consenting nurse.

Method of Data Analysis

Data obtained was coded and imputed into SPSS version 20. The data was cleaned and sorted. Descriptive statistics were presented with frequency distribution tables and percentages. The association between the nurses’ years of experience and their attitude towards caring for dying patients was tested with Pearson’s chi – square technique. The inferential analyses were considered to be significant at p value less than 0.05.

Ethical Consideration

Approval for this study was obtained by the Ethics Research Committee of the hospital. In addition, A permission to collect data was obtained from the Director of Nursing Services. Each eligible nurse provided a written informed consent before they were recruited into the study and were instructed to complete the questionnaire anonymously.

Results

The demographic characteristics of the respondents is presented in Table 1. The age of the nurses ranged from 20 to 60 years with a mean age of 35.78 ± 10.00 years. The distribution showed that more than one-third (33.3%) were within the age of 30–39 years of age. Also, majority of the nurses (83.1%) were female and married (80.3%) and more than two thirds (78.4%) of the nurses were Christian. Similarly, more than a quarter belonged to the Nursing Officers’ cadre (26.3%), and 28.6% had less than five years of working experience (Table 1).

Table 1.

Sociodemographic Characteristics of the Respondents.

Variables	Frequency (N = 213)	Percentage (100%)
Age (years)
20–29	62	29.1
30–39	71	33.3
40–49	39	18.3
50–59	28	13.1
60 and more	13	6.1
Sex
Male	36	16.9
Female	177	83.1
Marital status
Single	42	19.7
Married	171	80.3
Religion
Christian	167	78.4
Islamic	38	17.8
Traditional	8	3.8
Professional qualification
RN only	32	15.0
RN plus RM	87	40.9
RN plus RM and RPHN	58	27.2
RN plus BNSc	36	16.9
Designation or rank
Assistant Director of  Nursing Services	15	7.0
Chief Nursing Officer	20	9.4
Principal Nursing Officer	32	15.0
Senior Nursing Officer	48	22.5
Nursing Officer I	42	19.7
Nursing Officer II	56	26.3
Years of professional experience
1–5	61	28.6
6–10	58	27.2
11–15	37	17.4
15–20	28	13.1
21–25	20	9.4
26–30	9	4.2
Convalescent units
Medical Unit	40	18.8
Surgical Unit	36	16.9
Intensive Care Unit	24	11.3
Adult Emergency unit	25	11.7
Children Emergency unit	15	7.0
Orthopedic Unit	38	17.8
ENT/Ophthalmology Unit	37	17.4

Note. RN = Registered Nurse; RM = Registered Midwife; RPHN = Registered Public Health; BNSc = Bachelor of Nursing Science.

Figure 1 revealed that majority of the nurses (67.6%, n = 144,) had negative attitude towards caring for dying patients. Similarly, 75.6% (n = 161) of the nurses had negative attitude towards the concept of death (Figure 2).

Figure 1.

Attitude Towards Caring for Dying Patients.

Figure 2.

Attitude Towards Death.

Furthermore, a chi-square test of association between the nurses’ sociodemographic variables and attitudes towards caring for dying patients was presented in Table 2. A significant association was observed between nurses’ attitudes towards caring for dying patients and their years of working experience (χ2 = 24.577, df = 5, p < 0.001) and current ward/unit of practice (χ2 = 21.464, df = 6, p < 0.001). In the same vein, the nurses’ Age (χ2 = 13.77, df = 3, p < 0.001), and current ward/unit of practice (χ2 = 16.505, df = 6, p = 0.01) were significantly associated with nurses’ attitude towards death. Lastly, Table 3 revealed a statistically significant association between the nurses’ attitudes toward death and caring for the dying (χ2 = 11.26, df = 1, p < 0.001)

Table 2.

Association Between Nurses’ Sociodemographic Variables and Attitude Towards Caring for Death and Dying Patients.

Sociodemographic variables	Attitude towards dying patients				Attitude towards death
	Positive (n = 69)	Negative (n = 144)	χ2	p	Positive (n = 52)	Negative (n = 161)	χ2	p
Age (years)
20–29	20	42	0.03	0.99	10	52	13.77
30–39	23	48			12	59
40–49	13	26			12	27		0.03
50–59	13	28			11	17
Gender
Male	8	28	2.05	0.15	12	24	1.86
Female	61	116			40	137		0.17
Marital status
Single	12	30	0.35	0.56	14	28
Married	57	114			38	133
Religion
Christian	51	116	2.09	0.35	39	128	0.92
Islamic	16	22			10	28		0.63
Traditional	2	6			3	5
Professional qualification
RN only	14	18			5	27
RN plus RM	27	60	2.86	0.41	21	66	5.87	0.11
RN, plus RM & RPHN	19	39			12	46
RN plus BNSc	9	27			14	22
Designation or rank
Assistant Director of Nursing Services	6	9	7.13	0.21	7	8	10.02
Chief Nursing Officer	8	12			8	12
Principal Nursing Officer	10	22			5	27
Senior Nursing Officer	9	39			10	38		0.07
Nursing Officer I	18	24			12	30
Nursing Officer II	18	38			10	46
Years of working experience
1–5	10	51	24.58	<.001	19	42	9.7
6–10	32	26			10	48
11–15	14	23			6	31		0.08
15–20	5	23			5	23
21–25	5	15			8	12
26–30	3	6			4	5
Current ward/unit of practice
Medical ward	9	31	21.46	<.001	12	28
Surgical ward	11	20			9	22	16.50
Intensive care unit	13	11			6	18		0.01
Adult Emergency unit	7	18			5	20
Children Emergency ward	10	5			9	6
Orthopedic ward	14	27			7	34
ENT/Ophthalmology ward	5	32			4	33

Note. RN = Registered Nurse; RM = Registered Midwife; RPHN = Registered Public Health; BNSc = Bachelor of Nursing Science. Bold values significant at p< .05.

Table 3.

Association Between Nurses’ Attitude Towards Death and the Dying Patient.

	Attitude towards the dying patient
Attitude towards death	Positive	Negative	Total	χ2	df	p
Positive	7	45	52	11.260	1	<0.001
Negative	62	99	161
Total	69	144	213

Discussion

Nurses in the course of practicing their noble calling frequently encounter terminally – ill patients and by obligation, care for them whenever they are dying (Kongsuwan et al., 2016; Ranse et al., 2018; Roman et al., 2001). Dealing with death and dying patients poses a serious challenge to the nurse and therefore has aroused special interest in the recent years (Abu Hasheesh et al., 2013) especially because it can influence the quality of care rendered. The quality of care rendered, according to Cevik and Kav (2013) is hinged on the individual nurses’ attitude towards attending to the complex care needs of the dying patient and death itself. The foregoing is capable of being altered by nurses’ demographic and experiential characteristics (Khader et al., 2010).

The study revealed that most of the nurses had a negative attitude towards death which in turn influenced the feelings they are likely to display in the event of caring for dying patient. This observation supports the findings in previous similar enquiries (Abate et al., 2019; Abu Hasheesh et al., 2013; Cevik & Kav, 2013; Wang et al., 2018). Furthermore, the study established that nurses’ years of experience and their current ward/unit of practice influenced their attitudes towards caring for dying patients. Literature have been divergent on this; while more recent similar studies have observed a congruent result (Abate et al., 2019; Hagelin et al., 2016; Jafari et al., 2015; Ozcelik et al., 2018) observed the contrary. Similarly, the study revealed that nurses’ attitude towards death was significantly associated with nurses age and their current ward/unit of practice. Previous studies are replete on this (Abu Hasheesh et al., 2013; Akpan-Idiok, 2009; Hagelin et al., 2016; Jafari et al., 2015; Ozcelik et al., 2018). In this regard, Benner (1984) posited that nurses’ personal and work – derived attributes such as practical knowledge from professional experience can potently influence their attitude towards the care accorded to their patients. Furthermore, in concord with the finding of the study which observed a significant association between nurses’ years of experience and their attitude concerning caring for dying patient, Miyashita et al. (2007) established a positive correlation between attitude toward caring for the dying patient and nurses’ years of clinical experience as well as number of actual experiences of caring for dying patients. This probably is because more matured nurses have learnt by experience, the art of establishing better relationship and communication with the terminally ill patients which may serve as impetus for better coping with the requisite emotional demands of interacting with death and dying (Ingebretsen & Sagbakken, 2016). Also, many studies recorded that the more experienced RNs were more likely to sustain a more comfortable perspective about death when compared to the fear – laden conception of less experienced RNs (Abu Hasheesh et al., 2013; Dunn et al., 2005; Ek et al., 2014). However, findings from this study observed that older nurses were less likely to demonstrate better attitude when dealing with dying patients than their younger colleagues. This finding is contrary to those observed in similar studies (Abu Hasheesh et al., 2013; Khader et al., 2010) which observed that older RNs perceived death as a conduit to a blissful state of existence thus providing an escape from painful experience as we know it.

Another important finding of the study, which may explain the foregoing is the observed association between nurses’ religion and their attitude towards death. Religious and cultural beliefs are factors which have been observed to powerfully influence how nurses define death and by extension, their attitudes towards caring for the dying patient (Cevik & Kav, 2013; Tranter et al., 2016; Wang et al., 2018). All religious thinking fosters transcendent living and a hope for a blissful afterlife hence its strong propensity to foster positive attitudes to death and caring for dying patient. In reality however, the lack of enough confidence particularly with nurses’ ability to provide existential and spiritual care may precipitate adverse feelings of inadequacy and insecurity (Kudubes et al., 2019; Tornøe et al., 2014). The foregoing is a requisite for stressors and adverse emotional experiences such as burnout which will further compromise care quality accorded to the dying patient and their significant others.

This study therefore, supports other scholars that advocated for incorporating a detailed, clinical – based end of life educational program into clinical nursing practice with a view to improving nurses’ attitude towards death and caring for the dying (Ay & Öz, 2019; Chang & Iskandar, 2018; Cheong et al., 2020), we propose that a value – laden, ethnoreligious based – educational package should be incorporated into nurses’ curriculum and continuing professional development program. This form of education should have its foundation on the rich bank of professional expertise of and delivered by experienced clinical nurses within the context of mentoring. This is necessary to nurture the nurses to develop the requisite skills necessary for handling the dynamically – complex care demands of dying patients within real practice context.

Conclusion

This study concluded that nurses have negative attitude towards death and caring for the dying patients. This negative attitude is associated with their years of working experience and current unit of practice while their age and current ward of practice all significantly affected their attitudes to death.