Death-coping self-efficacy and its influencing factors among Chinese nurses: A cross-sectional study.

BACKGROUND: Nurses are the main caregivers of dying patients. Facing or dealing with death-related events is inevitable. Death-coping self-efficacy (DCS) is very important, as it can reduce the risk of nursing staff to adverse emotional distress, help them participate in end-of-life care and improve the quality of care of patients.
METHODS: Using the convenient sampling method, this study included a total of 572 nurses from a tertiary hospital in Hangzhou, China. The status and influencing factors of the DCS of nurses were explored using a general information questionnaire and DCS scale.
RESULTS: The scores of each parameter, ranging from low to high, were in the order of coping with grief, preparation for death and hospice care. Factors influencing nurses' DCS included attendance in hospice care education courses within the previous year, experience of accompanying the family members of the deceased and attitude towards death.
CONCLUSIONS: The overall self-efficacy of nurses in palliative care was at a medium level. Moreover, their self-efficacy in coping with grief and preparation for death should be strengthened. Managers of medical institutions can assess the death-coping ability of nurses, which helps provide corresponding support and training for nurses at an early stage. Nurses should receive guidance in grief adjustment and emotion regulation. Medical units should provide nurses with a platform for continuous training and education, use of death-related theoretical models and frameworks to guide nurses in dealing with death-related events, reduce nurses' negative mood and jointly promote their mental health.

Introduction

Death-coping self-efficacy (DCS) refers to whether a nurse has the confidence to provide palliative care timely to dying patients and assist their family members, which include the confidence to evaluate needs, dealing with care problems, managing symptoms and providing information, coping with the death of a loved one and planning and preparation for burial [1]. It has always been the core goal of palliative care to allow patients to treat death with the best mentality, optimism and happiness at the end of life, and to achieve a "good death" [2]. When caring for terminally ill patients and dealing with death-related events, it often brings different degrees of anxiety, fear, fatigue, helplessness, guilt and other negative moods to nurses, which affect nurses’ daily life and even work quality [2, 3]. Managers of medical institutions and patients generally believe that dealing with death-related events is a special mission that medical staff should undertake, and often ignore the psychological stress and trauma brought to medical staff, especially front-line nurses, in the process. DCS can assist nurses to better participate in the development of palliative care strategies, the arrangement of end-of-life care programs, death preparation and planning, and death dialogue, and are essential skills for nursing professionals. Whether nursing students are on clinical traineeships, internships, or entering clinical positions after graduation, if nurses have insufficient understanding and preparation for death, they may increase the risk of negative attitudes such as burnout. Nurses’ frequent exposure to patient death-related events can also lead to compassion fatigue and burnout [4, 5]. Even among the medical personnel who know about palliative care, they still equate palliative care with ‘giving up’ or shortening of their life span [6] and saving the lives of patients with terminal illness ‘at all costs’ [7]. This indicates that China lacks professional palliative care personnel who can provide palliative care services.

Zheng et al. [2] investigated the palliative care behaviour and self-efficacy of 338 nurses and found that the number of patients cared for did not affect the self-efficacy of nurses; however, the willingness and emotions of patients directly affected the self-efficacy and work execution of nurses. Yang et al. [8], scholars from Taiwan, investigated the relationship between nurses’ emotional distress and self-efficacy in coping with death while taking care of dying patients. The results showed that young and junior nurses exhibited higher emotional distress, which negatively correlated with their self-efficacy in coping with death. A previous study reported that knowledge and nursing experience in palliative care are key factors in improving self-efficacy [9]. The literature has also pointed out that most of the nurses are aware of the insufficient education and training in death-related and end-of-life care. Specifically, the new staff in the intensive care unit, who take care of patients with complex diseases, often feel that they are unable to care for patients at the end of their lives, resulting in physical and mental exhaustion, poor working ability and increased staff turnover rate [10, 11]. The emergency medical staff generally considers that patients are exposed to the emergency unit for a short period; therefore, there are practical difficulties in providing end-stage care to them [11]. The main obstacles for nurses in caring for patients at the end of their lives include their low awareness of palliative care guidance, lack of education and training for palliative care by hospitals and most of the nurses do not participate in palliative care education courses, thereby affecting their nursing guidance ability [12]. According to Zheng et al. [13], working years, behavioural experience of end-stage nursing and perceived importance of nurses are positively correlated with the self-efficacy of palliative care. However, Pfister et al. [14] found that the palliative care knowledge and self-efficacy were positively and negatively correlated with work experience, respectively. Other studies have shown that nurses with relevant work experience, aged >36 years, were female and had formal training in palliative care scored higher in communication self-efficacy evaluation [15]. Based on the above literature, age, sex, work experience, work unit, willingness and attitude of nurses to care for patients, knowledge and attitude to palliative care and other factors might affect their self-efficacy, but the correlation between some variables remains different.

Improving the self-efficacy of nurses to cope with the death of patients is important. Lien et al. [16] concluded that dying patients can feel care and satisfaction from the patience, care and comfort of nurses. Hospital clinical nurses’ nursing ability and attitude to care for terminally-ill patients directly affect the nursing quality of terminally-ill patients [17]. However, studies have shown that Chinese nurses have low levels of attitudes and cognitions towards death [2]. At present, most studies on death focus on the attitude level of nurses, while a few empirical studies have evaluated the self-efficacy of nurses. Therefore, this study intended to analyse the status quo of the self-efficacy of nurses to cope with patient’s death and discussed its influencing factors. The findings of this study will serve as a reference for human resource management, utilisation of medical institutions and search for the stability of nurses’ manpower and will contribute to the improvement of the quality of nurses’ work and palliative care.

Methods

Study design and participants

The Epidemiological Observational Study Report guidelines and methodologies were used in the reporting of the results of this study.

A cross-sectional survey was conducted using a questionnaire survey among registered nurses in a tertiary hospital in Hangzhou, China, from August to September of 2020 through convenience sampling. First, participants were briefed on the purpose of the study, and their verbal consent was obtained. Notably, nurses have cared for patients with terminal illness. The authors obtained information that could identify individual participants after data collection.

Inclusion criteria: ①Nurses who have cared for terminally ill patients; ②Informed consent and willing to cooperate with the investigator; ③Clinical nurses who hold a nurse qualification certificate and are registered on the job.

Exclusion criteria: ①Clinical nurses on shifts, advanced studies or going out; ②Nurses on sick leave, maternity leave or vacation

The G-Power 3.1 statistical software was used to estimate the sample size, with two-tailed tests, effect size of 0.3, power of 0.95 and α value of 0.05, which was calculated to be 134. Considering the possibility for dropped or missed out cases during the study, an additional 10% of the study participants were selected, and the total number of participants selected as a sample was 250. To reduce the sampling error and make the conclusions more reliable, the sample size was set to 600. After excluding 28 incomplete responses, a total of 572 questionnaires were included in the analysis.

Instruments

General information questionnaire

A total of 10 parameters were investigated, which included sex, age, educational background, department, marital status, religious belief, duration of clinical work, attendance in palliative care education courses within the previous year, experience of accompanying the family members of the deceased and attitude towards death. Participation in the palliative care education course was defined as taking part in online or offline training on palliative care-related content, in which nurses participated in each training session for not less than 40 min.

Death-coping self-efficacy scale (DCSS)

The DCSS was originally developed by Robbins [18], an American scholar, for hospice wards in 1992. It had good reliability and validity. In 2006, Professor Zhang [19], a Taiwanese scholar, compiled the DCSS in hospice wards and formed its Taiwanese version, which has been used widely as a measurement tool to study DCS in Taiwanese nurses [5].

The DCSS has 29 questions and three dimensions, including 12 questions on hospice care. It evaluates nurses’ confidence in providing physical and spiritual care of dying patients and their families. Nine questions are on grief management, which assesses nurses’ confidence in dealing with their grief when facing the death of other people. There were eight questions on the preparation for death, which assess the caregivers’ confidence in planning their death preparation. In this study, the expert validity test value of DCSS was 0.97, and the scores for the three subscales ranged from 0.857 to 0.893. Cronbach’s α value of the total scale was 0.905. A 5-point Likert scale was adopted, in which 1 point indicates surely not and 5 points mean surely yes; the total score was 29–145 points. The scores for the questions in each dimension were added and taken as the score of the nurses’ ability to cope with patients’ death. The higher the score, the more self-efficacy they had in coping with death and vice versa. In this study, the Taiwanese version of DCSS was used to evaluate nurses’ DCSS score.

Data collection

For this study and relevant literature, the questionnaire survey was adopted as the method for data collection. The investigator and two nurses conducted a field investigation in each department to distribute the questionnaires and explained the study purpose and method of questionnaire collection for the data collection. Participation is voluntary, and all responses are anonymous. In the course of the study, all relevant data and questionnaire contents were first coded and then recorded by a computer. The answer time was 8–15 min. After the questionnaires were collected, the answers were reviewed and sorted. Valid questionnaires were then coded, and data were processed using a quantitative method.

Ethical consideration

This study was approved by the Research Ethics Committee of the Sir Run Shaw Hospital, College of Medicine, Zhejiang University (No. 20201029–31). Written informed consent was obtained from all participants in this study, the data were strictly limited, and they were also assured that these questionnaires were used for research purposes only.

Quality control

To avoid bias in responses, data about the training purpose of the researchers, issues that needed attention and methods of questionnaire collection were determined before the questionnaires were distributed.

The integrity of the returned questionnaires was checked, and invalid ones were excluded. The exclusion criteria of the questionnaires were as follows: all or basic questions had the same answers, >10% of the answers were missing and obvious logical errors were noted in the responses. After the questionnaire was collected on the spot, the integrity and logicality of the questionnaire were checked, and the missing answers <10% were corrected in time.

Data analysis

After the collection of questionnaires, data were imported to EpiData3.1, and the IBM SPSS Statistics 26.0 (IBM Corp., Armonk, NY, USA) was used as the main statistical analysis tool. The analysis methods were as follows: general information of the nurses and DCSS scores were described as mean, percentage and standard deviation. The Chi-square test, independent sample t-test, one-way analysis of variance and multiple post-mortem comparison tests were used to analyse differences in sex, age group, titles, departments and other demographic data. The multiple linear stepwise regression analysis was used to analyse factors influencing nurses’ DCS. All tests were conducted on both sides. The test level α = 0.05 and P<0.05 indicated significant differences.

Results

A total of 600 questionnaires were sent, and 594 were recovered. Incomplete and invalid questionnaires were removed, leaving 572 valid questionnaires with a valid questionnaire rate of 95.3%.

Sociodemographic and work characteristics of the participants

Of the 572 nurses, 569 (99.5%) were women, and 57.2% were married. The mean age of the nurses was 32.4 ± 7.1 (range, 23–54) years. Most of the nurses (73.1%) had clinical working experience of ≤10 years. Moreover, 518 (90.6%) nurses had a bachelor’s degree, 43 (7.5%) had a master’s degree, 94.8% had no religious affiliations, 38.5% did not attend palliative care education courses within the previous year, 35.3% had experienced accompanying the family members of the deceased and 59.4% said they would accept death. Details are shown in Table 1.

Table 1

Sociodemographic and work characteristics of the participants (N = 572).

Variable	Subgroup	Frequency (N)	Percentage (%)
Age	≤30	348	60.8
	31~40	187	32.7
	≥41	37	6.5
Gender
	Male	3	0.5
	Female	569	99.5
Marital status
	Single	238	41.6
	Married	326	57.0
	Divorced	8	1.2
Length of service (yrs.)
	≤10	418	73.1
	>10	154	26.9
Department
	Surgical	213	37.2
	Medicine	245	42.8
	ICU	28	4.9
	Oncology ward	52	9.2
	Emergency	34	5.9
Educational background
	Associate (College)	11	1.9
	Bachelors (University)	518	90.6
	Masters	43	7.5
Religious affiliation
	Yes	30	5.2
	None	542	94.8
Attended palliative care education courses within one year
	Yes	352	61.5
	No	220	38.5
Personal bereavement experience
	Yes	202	35.3
	No	370	64.7
Attitude in talking about death
	Feeling uncomfortable	158	27.6
	Trying to avoid	74	12.9
	Quite open	34	59.4

Note: DCSS, Death Coping Self-Efficacy Scale; ICU, intensive care unit.

Status quo of the DCSS of nurses

Among the three dimensions of DCSS, hospice care ability recorded the highest score, while coping with grief had the lowest score. The scores of each dimension and parameter are presented in Table 2.

Table 2

Mean death-coping self-efficacy scale scores of the nurses (N = 572).

Variable	Total mean score	Mean parameter score
Hospice care	47.43±5.81	3.95 ±0.48
Coping with grief	27.14±4.50	3.39± 0.56
Preparation for death	28.01±5.58	3.11±0.62
Total DCSS score	102.58±12.07	3.48±0.42

Table 3 presents the descriptive statistics of DCSS and its subscales, namely, hospice care, coping with grief, preparation for death and other parameters. The average DCSS score was 10.46 (SD 1.27), while that for the subscales were 3.95 (SD 0.48) for hospice care, 3.11 (SD 0.62) for coping with grief and 3.39 (SD 0.56) for preparation for death. Among the 11 parameters, ‘allow a patient to communicate fully’ showed the highest mean (4.30), while ‘coping with the death of your child’ (parameter 22) presented the lowest mean (2.41).

Table 3

Descriptive statistics of DCSS and its subscales, namely hospice care, coping with grief, preparation for death and other parameters.

Item No	Subdomain	Item	Mean (SD)
4	Hospice Care	Listen to the family of a dying patient	4.15(0.623)
11	Hospice Care	Allow a patient to communicate fully	4.30(0.593)
16	Hospice Care	Visit a dying friend	4.16(0.653)
25	Hospice Care	Tolerate spiritual and religious differences	4.25(0.571)
3	Hospice Care	Listen to the concerns of a dying patient	4.21(0.575)
5	Hospice Care	Identify the concerns of a dying patient and his/her family	3.91(0.665)
17	Hospice Care	Provide emotional support for the patient’s family	3.96(0.643)
27	Hospice Care	Care for me if I am experiencing stress in caring for a dying patient	3.90(0.636)
28	Hospice Care	Be with a person at the time of death	3.79(0.717)
10	Hospice Care	Ask to know if someone close to you has a terminal illness	3.83(0.803)
20	Hospice Care	Attend a funeral or wake where the casket is open	3.59(0.939)
1	Hospice Care	Be sensitive to the needs of the patient	3.48(0.716)
21	Coping with Grief	Understand bereavement and grief	4.01(0.724)
6	Coping with Grief	Handle the illness of your child	3.89(0.712)
26	Coping with Grief	Cope with the death of a pet	3.56(0.821)
7	Coping with Grief	Handle knowing that a family member has a fatal condition	3.29(0.801)
24	Coping with Grief	Cope with the death of a friend the same age as you	3.21(0.805)
15	Coping with Grief	Cope with the death of your father	2.64(1.024)
22	Coping with Grief	Cope with the death of your child	2.41(1.012)
23	Coping with Grief	Handle the death of your spouse	2.47(1.022)
13	Coping with Grief	Cope with the death of your mother	2.53(1.034)
2	Preparation for Death	Buy life insurance	3.62(0.900)
9	Preparation for Death	Listen to a news report of multiple deaths	3.78(0.753)
18	Preparation for Death	Write a living will	3.47(0.858)
14	Preparation for Death	Ask to know if you have a terminal illness	3.83(0.803)
8	Preparation for Death	Prepare your will	3.51(0.844)
19	Preparation for Death	Plan your funeral service	3.03(0.869)
29	Preparation for Death	Prepay your funeral	2.92(0.818)
12	Preparation for Death	Purchase your cemetery plot	2.98(0.869)

Note: DCSS, Death-coping Self-efficacy Scale.

Factors affecting DCSS

The DCSS scores of nurses were taken as the dependent variable, and factors showing significance in general data were taken as independent variables. Multiple stepwise regression analysis was conducted according to the levels of α = 0.05 in the entry model and α = 0.10 in the exit model. After the final entry into the equation, the factors were analysed for attendance in palliative care education courses within the previous year, personal bereavement experience and attitudes about death (Table 4).

Table 4

Regression analysis of the DCS of nurses.

Independent variables	B	SE	β	t	P
Constant	68.565	4.130	-	16.600	<0.001
Attending palliative care education courses within one year	-2.980	0.901	-0.136	-3.749	<0.001
Personal bereavement experience	2.380	0.921	-0.118	-3.237	<0.001
Attitude in talking about death	3.182	0.504	0.145	3.966	<0.001

Factors affecting hospice care

The scores of nurses on the hospice care subscale were taken as the dependent variable, and factors with significance in general data were taken as independent variables. Multiple stepwise regression analysis was conducted according to the levels of α = 0.05 in the entry model and α = 0.10 in the exit model. After the final entry into the equation, the factors were analysed for educational background, attendance in hospice care education courses within the previous year and attitudes about death (Table 5).

Table 5

Regression analysis of the DCS of nurses.

Independent variables	B	SE	β	t	P
Constant	4.346	0.156	-	27.826	<0.001
educational background	-0.153	0.065	-0.095	-2.334	0.020
attended palliative care education courses within one year	-0.170	0.041	-0.171	-4.196	<0.001
Attitude in talking about death	0.068	0.023	0.122	2.998	0.003

Factors affecting coping with grief

The scores of nurses on the coping with grief subscale were taken as the dependent variable, and factors with significance in general data were taken as independent variables. Multiple stepwise regression analysis was conducted with α = 0.05 and α = 0.10 in the entry and exit models, respectively. After the final entry into the equation, the factors were respectively analysed for age, attendance in palliative care education courses within the previous year and attitudes about death (Table 6).

Table 6

Regression analysis of the DCS of nurses.

Independent variables	B	SE	β	t	P
Constant	2.674	0.151	-	17.720	<0.001
Age	0.259	0.102	0.103	2.535	0.012
attended palliative care education courses within one year	-0.129	0.052	-0.101	-2.483	0.013
Attitude in talking about death	0.147	0.029	0.208	5.118	<0.001

Factors affecting preparation for death

The scores of nurses in the preparation for death subscale were taken as the dependent variable, and factors with significance in general data were taken as independent variables. Multiple stepwise regression analysis was conducted with α = 0.05 and α = 0.10 in the entry and exit models, respectively. After the final entry into the equation, the factors were analysed for the score of the length of service (Table 7).

Table 7

Regression analysis of the DCS of nurses.

Independent variables	B	SE	β	t	P
Constant	3.249	0.071	-	45.709	<0.001
length of service	0.113	0.053	0.089	2.131	0.033

Discussion

The results of this study revealed that the score of each parameter in the DCSS was 3.48 ± 0.42, with the mean score of 3 as an intermediate criterion. This finding indicates that the overall DCSS score of the nurses was at a moderate level. With a higher average score for hospice care and the lowest score for coping with grief. Nurses, who have attended palliative care education courses within the previous year, have experienced accompanying the family members of the deceased, have an open attitude towards death, have higher self-efficacy in coping with death.

In this study, the score on the coping with grief subscale was the lowest and consistent with the results of a previous study [5], which indicated that their ability to cope with the death of their loved ones should improve. Most studies have supported that older people are more receptive to death than younger people, which was related to the clinical work experience of the study sample [2, 5, 20]. A study of nurses in palliative care units revealed that as nurses grew older and had more work experience, their self-efficacy in coping with hospice care, grief and death increases [19]. Kapoor et al. [21] found that some nurses believed that professionals must cover up the sadness and that the expression of sadness might be regarded as ‘unprofessional’ and ‘weak’. Nurses want formal support; otherwise, they could not deal with their work emotionally and would rely on the informal networks of colleagues and friends outside the unit to talk about work. Bandura’s self-care theory [22] suggested that nurses should clarify the influence of self-loss or death experience on themselves, adjust their self-identity, find the meaning of events through the death experience and accept social support from others. Moreover, nurses’ sense of life, psychological distress, job burnout and low negative emotions [23] suggest that clinical nurses, in addition to focusing on solving patients’ problem, should form a group or end-of-life care facility for life and death issues, which should assist with emotional relief and signify their existence and value.

The main factors influencing the DCS of nurses were attendance in palliative care education courses within the previous year, experience of accompanying the family members of the deceased and attitude towards death.

In this study, age and clinical experience did not show independent significance after the adjustment for the basic attributes by multiple linear regression analysis. Possible reasons were as follows: our study participants were mostly young and junior nurses and the hospital investigated provided hospice joint nursing in 2019 and gave great importance to the palliative care training of nurses of various professional titles and levels. A study [24] also found that the nurses, working in intensive care units, with religious beliefs had better abilities of near-death management, death thinking and expression and life examination. However, this study found that religious affiliations had no effects on the DCS; the possible reason is that 94.2% of the participants in this study had no religious affiliations. Therefore, age, clinical work experience, religious beliefs and other factors had little influence on the DCS of nurses, which should be confirmed in studies with a large number of participants.

The nurses, who attended palliative care education courses within the last year, had higher DCSS scores, which was consistent with the results of Kim et al. [25] and Evenblij et al. [15]. This finding suggests that palliative care education courses could be an effective strategy to improve the DCS of nurses. Yang et al. [8] reported that the higher the number of end-of-life care courses the nurses received, the more they could understand the course and stages of death, recognise the emotions and needs of patients who are dying and positively think about death-related facts. Dehghani et al. [26] conducted a palliative care training programme in Iran, in which 40 nurses were randomly selected and trained four times. Each session lasted for 45 min. Through the questionnaire data analysis, they proved that the training significantly improved the nurses’ sense of self-efficacy. White et al. [27] supported and trained nurses remotely using video conferencing, a network communication platform, and group discussions, for 6 months of 2-h palliative care teaching, and case discussion and suggested that nurses’ knowledge and self-efficacy of palliative care were significantly improved after training. Hospitals should conduct practical education and training on topics where nurses have low knowledge levels, such as symptom management and spiritual care, to improve nursing knowledge and self-efficacy [28]. Education and training related to end-of-life care should be held regularly, especially regarding death counselling, stress management, self-affirmation and other related courses [26, 29] to help nurses understand and deal with their feelings of death when facing patients with terminal illness and prevent negative emotions such as fear and anxiety [30].

The experience of accompanying the family members of the deceased is one of the factors influencing the DCS scores of nurses, which was consistent with the results of Cheung et al. [4] and Ay et al. [31]. This might be because nurses could project their rich experience of end-of-life care to the patients, thereby showing their caring behaviour with empathy. Some studies [20] have also shown that contact with the palliative care team and experience in accompanying the family members of the deceased can provide more care to dying patients in the aspect of their psychology and spirituality, discussion of non-resuscitation (DNR) and palliative care [12].

The results of this study indicate that attitude towards death is an important factor that affects the DCS of nurses. Among them, the nurses scored the highest for open acceptance and the lowest for fear of death. The possible reason was that nurses felt frustrated in diagnosing and treating the dying patients and felt that it was not easy to establish a relationship with the family members of the deceased, thereby hoping that they could not face the death of patients [12]. A relevant study [32] revealed that nurses’ fears included the fear of losing close people, sadness upon seeing their relatives and friends became sick, uncertainty about the time of death of their patients and subsequent treatment of death events (fear of body care, funeral planning, etc.). The open acceptance of nurses’ attitudes towards death was positively correlated with their attitude towards dying patients and work engagement [2]. The fear of death and escape were negatively correlated with the meaning of nurses’ life and tended to cause negative emotions [33]. In addition, clinical departments often faced the powerlessness of dying patients, and the inability to treat disease could result in emotional distress among nurses and thus job burnout feelings [2]. Burnout feelings among nurses could directly affect the quality of care and professional academic performance [34] and resulted in low DCS and demand. Moreover, the positive attitude towards end-of-life care was positively correlated with the ability to solve end-of-life-related problems [35].

According to the findings from our study, factors correlated with the level of educational background, attendance in palliative care education courses within the previous year and attitude towards death. Among the values of each subscale, hospice care recorded the highest average score, with 3.95 ± 0.48 points. Effective care can promote health, and the art of nursing is mainly expressed through caring [36]. A study showed that nursing care is positively correlated with satisfaction; the higher the frequency of nurses with caring behaviour, the higher would be the satisfaction of patients receiving nursing care [13]. Ling et al. [37] suggested that the priority of palliative care was to provide patients and their families comfort, satisfaction of needs, healthy environment, emotional support and protection of privacy and respect. Moreover, nursing itself is a representative group of the helping industry; therefore, a therapeutic environment with a caring atmosphere should be created. Through the characteristics of respect, focus, and care, the patients and their families can be assisted to resolve negative emotional reactions and respect the needs of the patients [38].

We found that the length of service (years), namely, ≤10 and >10, were the only significant independent variables with a significant association (p<0.05) with the preparation for death. The possible cause was that Chinese cultural background tends to avoid conversations about death. Therefore, nurses were reluctant to face this issue and were less prepared about their death, such as wills or plans for their future funerals [37]. Moreover, studies have shown that nurses rarely talk about death and lack knowledge and skills about death communication [39, 40]. China and Taiwan amended the palliative care medical regulations in 2013 and implemented the Patient Autonomy Rights Law in 2019, making the concept of palliative care, not performing non-cardiopulmonary resuscitation and gradually paying attention to the concept of pre-existing medical decisions. Patients can pre-sign and choose not to receive life-saving medical treatment or remove ineffective ones. Patients can think about not accepting invalid medical treatments at the end of their lives as early as possible, and in clinical practice, the medical staff can discuss with the patients and their families about shortening the suffering of patients at the end of their lives.

Based on social learning theory, Bandura developed self-efficacy, and proposed self-coordinated motivation, thinking strategies and behavioral paths to reflect appropriate behaviors and accomplish goals [22]. Medical staff’s self-assessment of self-strength and performance shows that when they have low self-efficacy, they are more likely to compromise when confronted with adversity and obstacles, and often feel anxious, worried and frustrated. People with high self-efficacy are willing to face difficulties and setbacks. And find out the appropriate method [41]. Studies [42, 43] have shown that high self-efficacy can improve the quality of care and ultimately improve individual and organizational performance. Scholars [44] found that during the coronavirus disease-2019 (COVID-19) pandemic, an assessment by nurses found that the ward nurses experienced higher than normal levels of despair, social isolation, and physical symptoms due to grief. Japanese scholars found that only 27% of nurses performed palliative care family psychological support care [45]. Dahlin [46] also pointed out that nurses in oncology wards lacked effective nursing methods to solve the psychological problems and negative emotions of end-stage patients, as well as lack of coping methods to alleviate the suffering of patients. In the three dimensions of death coping self-efficacy, the scores from high to low are Hospice Care, Preparation for Death, and Coping with Grief, which indicates that in clinical practice nurses pay more attention to the physical symptoms of patients, while the psychological needs of patients and caregivers often overlooked. This suggests that nurses’ psychological and spiritual nursing self-efficacy needs to be strengthened urgently. Therefore, this paper can fully tap the potential of nurses, improve the efficiency and quality of nursing work, and promote the development of human health by understanding the self-efficacy level of nurses’ death coping and discussing its influencing factors, and adopting targeted and effective methods.

Limitations

Among the limitations of this study, a self-assessment questionnaire was adopted, which could be affected by personal cognition and social and cultural expectations or limitations. Future studies should conduct long-term in-depth interviews for qualitative analysis or retrospective research, and individual differences in mortality should be considered to achieve impeccable results. International studies are mostly cross-sectional studies that cannot dynamically observe the changes in death-coping ability and determine the causal relationship between death-coping ability and influencing factors. More scholars are expected to pay attention to the death-coping ability of nurses.

In terms of participants, some of the healthcare workers who currently belong to the selected setting were less numerous, for example: male nurses, nurses older than 40 years, non-religious nurses, etc. They may also have issues with Death-coping self-efficacy. However, in China, the absolute majority of hospital nurses are women, and only 2% of non-religious nurses are male. In addition, older nurses are generally not clinical, so in this study, we aimed to include only those only those clinical females, young and non-religious nurses, which suggests that this study cannot infer the current status of DCS for all clinical nurses.

International studies are mostly cross-sectional studies, which cannot dynamically observe the changes of death coping ability and determine the causal relationship between death coping ability and influencing factors. It is expected that more scholars will pay attention to the death coping ability of nurses.

Conclusions

Studies [12, 37] show that when nurses perform palliative care, they often focus on physical care, but ignore the psychological and spiritual care of patients and their families. Nursing researchers should attach importance to nurses’ palliative care self-efficacy, pay attention to psychological support, and improve nurses’ psychological quality; set up relevant palliative care courses to promote nursing students to have a positive understanding of death; improve nurses’ social support and strengthen palliative care psychology Nursing awareness, so as to improve nurses’ palliative care self-efficacy and palliative care quality, thereby improving the comfort of dying patients, and promoting the development of palliative care.

The dataset from which the results of the study were produced (SPSS file).

(ZIP)

Click here for additional data file.

5 Jul 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mohanad Mousa Taha Odeh

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following financial disclosure:

“The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

At this time, please address the following queries:

a)        Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b)        State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c)        If any authors received a salary from any of your funders, please state which authors and which funders.

d)        If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

5. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: As a reviewer, I believe the study met all of the journal's publication criteria. However, I do have some concerns and suggestions for the manuscript.

1. In general it is a clear, well-written manuscript, The researcher's goal was to analyze the current state of clinical nurses' self-efficacy to cope with patients death and discuss it is influencing factors, but the sample was limited to almost females, young and non-religious nurses, Nurses with hospice care education, family accompanying experience, and an open attitude toward death have higher self-efficacy in coping with death, according to the findings.

2. in my opinion generalizing the findings to "clinical nurses" is an overestimation.

I believe that these limitations might be changed as a strength point that distinguishes those results from the current literature.

3. No distinction was made between palliative and hospice care, which are two distinct terms.

4. Excluding questionnaires that contained >10% missing data can lead to some bias, additionally, it was not mentioned how it was dealt with questionnaires that contained less than 10% of missing data.

5. What does "anonymous method" in line 190 mean?

6. it is stated that Parameter 25 has the highest mean (4.30) in line 250, whereas in Table 3, parameter 11 has a mean of (4.30) and parameter 25 has a mean of (4.30).

What impact did this have on the calculations and the outcomes?

7. On line 173, it is stated that there are eight questions regarding death preparation, and above that, it is stated that there are 29 parameters, but parameter 14 is missing in the death preparation section!

What impact did this have on the calculations and the outcomes?

8. The mean of parameter 25 is higher than the average, according to lines 383-385. Why is this parameter specifically mentioned in the paragraph while other parameters mean are higher than the average value but aren't mentioned in the paragraph?

9. finally, please Supply professional title for each author.

Regards

Reviewer #2: Thank you for allowing me the opportunity to review this journal submission and to provide feedback. This article to investigate death-coping Self-efficacy and its influencing factors among Chinese Nurses: A cross-sectional study.

This journal submission is about a topic that requires additional investigation. Nonetheless, some issues need to be addressed as follow:

Feedback:

Introduction:

The authors need to restructure the literature review to better make the case for why the data they are gathering is useful. Though there may be relatively little data collected about participants in the studied area. also few studies were addressed in this section

Methods:

1. Were there any exclusion criteria?

2. Sample and setting - more information on the context of sample collection would be helpful so that the reader can determine if the study applies to their population of interest. This is especially true since not all readers will be familiar with the demographic characteristics or hospital settings of China.

3. Please say more about the privacy and confidentiality procedures that were used

4. Study measures – please say more about what modifications were made to instruments

Discussion

1. The discussion's structure should be updated. Instead than repeating specific data and results, the authors should focus on larger themes. This will be easier to accomplish if the material they reference in the discussion is reviewed first in the literature review section.

2. many statements in the discussion section should be moved to a separate section named study implication

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ahmad Alazzam

Reviewer #2: Yes: Manar M AlAzzam

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

21 Aug 2022

Dear Reviewers,

On behalf of my co-authors, I thank you very much for giving us an opportunity to revise our manuscript entitled “Death-coping Self-efficacy and its influencing factors among Chinese Nurses: A cross-sectional study” (PONE-D-22-10472R1). We appreciate you very much for your positive and constructive comments and suggestions. Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches.

We have carefully considered all issues mentioned in the reviewers' comments, outlined every change made point by point. We have made correction which we hope meet with approval. Revised portion are marked in red in the paper. The main corrections in the paper and the responds to the reviewer’s comments are as flowing:

Responds to the academic editor comments:

Journal requirements:

1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We appreciate the reviewer very much for his positive comments and suggestions on our manuscript. We have revised the manuscript to conform to PLOS ONE's style requirements, including file naming.

2. Thank you for stating the following financial disclosure:

“The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Response: We have added financial disclosures at the end of the article and cover letter. ( line 517-518, pages 23)

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found.

Response: We have expressed the data as Supporting information at the end of the article and uploaded it to Supporting information.

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Response: We have removed ethical statements written outside of methods.

Reviewers' comments:

Response #1:

1. In general it is a clear, well-written manuscript, The researcher's goal was to analyze the current state of clinical nurses' self-efficacy to cope with patients death and discuss it is influencing factors, but the sample was limited to almost females, young and non-religious nurses, Nurses with hospice care education, family accompanying experience, and an open attitude toward death have higher self-efficacy in coping with death, according to the findings.

Response: We appreciate the reviewer very much for his positive comments and suggestions on our manuscript. In terms of participants, the selected setting had fewer healthcare workers, such as: male nurses, nurses older than 40, non-religious nurses, etc. They may also have issues with Death-coping self-efficacy. However, in China, the absolute majority of hospital nurses are women, and only 2% of non-religious nurses are male. In addition, older nurses are generally not clinical, so in this study, we aimed to include only those clinical females, young and non-religious nurses. This limit has been added to Limitations. ( line 453-457, pages 21)

2. In my opinion generalizing the findings to "clinical nurses" is an overestimation.

I believe that these limitations might be changed as a strength point that distinguishes those results from the current literature.

Response: Thank you very much for this helpful suggestion. We have changed "clinical nurses" to “nurses” and added a description at Limitations. ( line 453-457, pages 21)

3. No distinction was made between palliative and hospice care, which are two distinct terms.

Response: Thank you very much for this helpful suggestion. We have made changes in the article.

4. Excluding questionnaires that contained >10% missing data can lead to some bias, additionally, it was not mentioned how it was dealt with questionnaires that contained less than 10% of missing data.

Response: We are very sorry for the expression is not very clear in this paper. We excluded data that contained >10% missing data because the questionnaire lacked too many participants' attitudes, and the questionnaire had little reference value. After the questionnaire was collected on the spot, the completeness and logic of the questionnaire were tested. For <10% of the missing answers, they should be corrected in time. An explanation has been added in the Quality control. We excluded >10% of the missing data because the questionnaire was missing too many participants. The attitude of the respondents is not serious, and the reference value of the questionnaire is not large. After the questionnaire is collected on the spot, the completeness and logic of the questionnaire will be tested. If the answers are missing <10%, they should be corrected in time. An explanation has been added in Quality control. (line 208-210, pages 8)

5.What does "anonymous method" in line 190 mean?

Response: We are very sorry for the expression is not very clear in this paper，and we have removed the expression we have removed the expression.

6. it is stated that Parameter 25 has the highest mean (4.30) in line 250, whereas in Table 3, parameter 11 has a mean of (4.30) and parameter 25 has a mean of (4.30).

What impact did this have on the calculations and the outcomes?

Response: We are very sorry, due to the author's negligence, the average value of parameter 11 in line 252 should be (4.30), and the average value of parameter 25 is the highest (4.25), which has been modified at the table. This has no effect on the rest of the article, just in the article A typo in the form. (line 252-253, pages 12)

7. On line 173, it is stated that there are eight questions regarding death preparation, and above that, it is stated that there are 29 parameters, but parameter 14 is missing in the death preparation section!

Response: We are very sorry for the expression is not very clear in this paper，and we have supplemented parameter 14 in the table. There is parameter 14 in the original data, but we forgot to write it on the table. (Pages 13)

8. The mean of parameter 25 is higher than the average, according to lines 383-385. Why is this parameter specifically mentioned in the paragraph while other parameters mean are higher than the average value but aren't mentioned in the paragraph?

Response: We appreciate this suggestion, and We have removed this sentence from the article.

9. Finally, please Supply professional title for each author.

Response: Under your advice, we have added at Author contributions.

Reviewer #2:

1.he authors need to restructure the literature review to better make the case for why the data they are gathering is useful. Though there may be relatively little data collected about participants in the studied area. also few studies were addressed in this section

Response: We appreciate the reviewer very much for his positive comments and suggestions on our manuscript. We have restructured literature reviews to better illustrate why the data they collected are useful. (line 252-253, pages 12)

2.Methods:. Were there any exclusion criteria?

Response: We appreciate this suggestion. Exclusion criteria: ①Clinical nurses on shifts, advanced studies or going out; ②Nurses on sick leave, maternity leave or vacation. (line 144-145, pages 6)

3. Sample and setting - more information on the context of sample collection would be helpful so that the reader can determine if the study applies to their population of interest. This is especially true since not all readers will be familiar with the demographic characteristics or hospital settings of China.

Response: Under your advice, we have added inclusion criteria. (line 141-143, pages 6)

4. Please say more about the privacy and confidentiality procedures that were used.

Response: We are very sorry for the expression is not very clear in this paper. Confidentiality: After completing the questionnaire, the questionnaire and the subject's consent shall be sealed in an envelope and returned by the researcher himself. In order to protect the privacy of the case, in addition to filling in the questionnaire anonymously, the data collected will be numbered. The coding table and the questionnaire data will be stored separately, and the coding table will be properly kept, which is not accessible to others except researchers and professors. This study is subject to the personal Data Protection Act and the relevant laws and regulations, and will be carefully protected by the privacy of researchers. The research materials will only be used for the purpose of writing papers and publishing academic journals. They will not be linked to other institutions and will not be provided to the public. The completed questionnaires will be destroyed by shredder two years after the publication of the papers, and the destruction process will be witnessed by a third party other than this study.

5. Study measures – please say more about what modifications were made to instruments.

Response: We are very sorry for the expression is not very clear in this paper. he original scale includes 44 items: ① daily life and work (13 items); ② coping with the death of others (9 items); ③ death preparation behavior (8 items); ④ caring for terminally ill patients and family members (10 items); ⑤Near-death and post-death physical care (4 items). The revised scale includes three subscales: "hospice" (12 items), "grief coping" (9 items), and "death preparation" (8 items).

Discussion

6. The discussion's structure should be updated. Instead than repeating specific data and results, the authors should focus on larger themes. This will be easier to accomplish if the material they reference in the discussion is reviewed first in the literature review section.

Response: This is a very valuable recommendation, we didn’t think about it before. We have updated the discussion structure, with changes highlighted in red. (line 418-442, pages 20)

7. many statements in the discussion section should be moved to a separate section named study implication

Response: We appreciate this suggestion. Due to word limit, this part of the statement has been incorporated into the conclusion. (line 466-474, pages 20)

We tried our best to improve the manuscript and made some changes in the manuscript. These changes will not influence the content and framework of the paper. And here we did not list the changes but marked in red in revised paper. We appreciate for Reviewers’ warm work earnestly, and hope that the correction will meet with approval.

Once again, thank you very much for your comments and suggestions.

Looking forward to hearing from you.

Thank you and best regards.

Yours sincerely,

Xi Lin

30 Aug 2022

Death-coping Self-efficacy and its influencing factors among Chinese Nurses: A cross-sectional study

PONE-D-22-10472R1

Dear Dr. Liu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Mohanad Mousa Taha Odeh

Academic Editor

PLOS ONE

2 Sep 2022

PONE-D-22-10472R1

Death-coping Self-efficacy and its influencing factors among Chinese Nurses: A cross-sectional study

Dear Dr. Liu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Mohanad Mousa Taha Odeh

Academic Editor

PLOS ONE