Journal of Medical and Clinical Nursing Studies

Training in Palliative Care and its Relationship to Coping and Attitude to Death

Azahara Torres Santos

Department of Nursing, University of Leon, Spain

*Corresponding author
Azahara Torres Santos, Department of Nursing, University of Leon, Spain.

ABSTRACT
Abstract: The nursing staff is in permanent contact with death throughout their working life. In addition, attention in the process of dying, to family members and to the patient, is considered part of the nursing role. Patient care at the end of life generates in the nursing professionals feelings and an attitude to death, as well as a stage of coping with the fact of losing a patient, that are very different among professionals. Objective: To evaluate how a good training in palliative care and teaching techniques of coping with death to nurses, can help these health professionals to cope better with the death of patients and to have a healthier attitude to the patient dying process.

Material and Methods: this bibliographical review was achieved through the search of scientific evidence in the Pubmed, google academic, LILACs and Cochrane Library databases of articles in the last five years and the critical reading of them.

Results: The number of articles that relate training in palliative care and coping with death is insufficient to establish scientific evidence. However, articles found that the attitude and feelings to death by nurses are often negative or indifferent.Furthermore, the nurses participating in these studies state that the teaching of coping techniques and training in care palliatives could improve these results.

Conclusion: Training in palliative care for nurses during their university period as well as training throughout their professional career should be greater, so that nurses face better the death of patients and have an attitude that favors better care at the end of life.

Keywords: Education, Palliative Care, Attitude to Death, Nursing

Introduction and Justification
The nurses are the ones in the health sector who provide the majority of the palliative care to the dying person and support the patient’s family [1]. 

In addition, nurse professionals have the intrinsic responsibility in their nursing role, of providing an adequate care to dying patients so that they can have a good and dignified death. As it is mentioned by WHO “Nursing encompasses the autonomous and collaborative care provided to people of all ages, families, groups and communities, sick or not, and in all circumstances. It includes the promotion of health, the prevention of diseases and the care provided to the sick, disabled and terminally ill people” [2]. The Spanish Code of Nursing Ethics also includes within the nurse competences that “in the presence of a terminally ill patient, the nursing staff, aware of the high professional quality of palliative care, will endeavor to provide it until the end of their life, with competence and compassion, the necessary care to alleviate their sufferings. It will also provide the family with the necessary help so that it can face death, when it can no longer be avoided” [3]. Therefore, it can be assumed that nursing is expected not only to provide physical care and symptoms such as pain on a palliative patient, but also to satisfy the spiritual, mental and emotional needs of the patient and the family.

However, death and talking about it is a topic that in many societies is still considered a taboo. Talking about death or expressing the feelings that it generates is not common within the families and social relationships. The social values, the customs and the current biomedical conception, encourage the avoidance and rejection if everything related to death, which makes facing the dying process even more difficult. This fact being a nurse, leads professionals to experience negative emotions and in many cases they see the death as a professional failure. These two feelings can significantly influence the quality of care given to the palliative patient [4,5].

There are studies that support that nurses who deal with people at the end of life, must have the capacity to establish interpersonal relationships as well as training in end-of-life in order to change the preconceptions and negative attitudes to death and also reduce the anxiety levels that it may cause [6,7]. Professional skills which help to provide a quality and holistic palliative care. Nevertheless, according to one study of nurses working in a general hospitals in Korea the 70% of the professional who treated end-of-life patients hadn’t palliative care training [8].

Therefore, the objective of this literate review is to evaluate how a good training in palliative care and the teaching techniques to cope with the death may help nurses to have a better attitude towards the dying process and to cope with it.

Material and Methods
In reference to the methodology used in this literate review, an exhaustive search of the current scientific evidence on the subject was carried out. The research was done in the four internationally recognized databases Pubmed, Cochrane library, LILACS and scholar google. In order to meet the scientific criteria in this review, the key words utilized for the search are the ones recognized in the DECS (Heath Science Descriptors) in both English and Spanish, as shown in the below table.

These scientific terms were combined with each other through the Boolean operator of “AND”, also tested with the Boolean operator “OR” which was discarded because it greatly expanded the search.

The inclusion criteria applied to searches:
-    Scientific literature covering the period from 2012-2018.
-    Pertinent to the topic to be studied without limiting the methodology used or the design.
-    In English and Spanish.
-    Articles that include nurses or nursing students.
-    About coping with the death of humans.
-    Complete and free texts.

Once the inclusion criteria were established, the articles of utility for the review were selected, through the analysis of the title and the abstract and the critical reading of the articles. The selection in this first analysis was submitted to a methodological quality assessment tool called CASPE (Critical Appraisal Skills Program Spanish). As a result of this, the number of articles appropriate for the review was six.

Results 
Article 1
The first article reviewed is “Effect of end-of-life care education using humanistic approach in Korea” by Jo KH et al in 2015 [9]. It purpose was identify the effect of an end-of-life care course using an humanistic approach on nursing students’ attitudes toward death, death anxiety, and communication skills. On this article, the researchers had planned educational program with skills that are part of a palliative care training and they evaluated the improvement after course was finished.

The 20 students were assigned to the control group and 19 to the experimental. It was found that there were no significant differences between the groups related to the gender, age, religion, economic status, and having experienced the death of a loved one. 

Before the course took place there also were no significant differences between the groups for attitude towards death, death anxiety, and communication skills. After the course was implemented Tit was shown that the attitudes toward death (t = 2.299, p = .027) and communication skills (t = 2.813, p = .008) have significantly increased in the experimental group. However, death anxiety (t = 0.020, p = .984) did not significantly differ between the two groups.

Article 2
The second article reviewed has as a title “Attitudes in Chilean nursing professionals towards end-of-life care” was designed by Espinoza Venegas M et al in 2016 with the aid to evaluate the attitudes towards the end-of-life care of nurses in the Bío Bío region of Chile, and to determine the variables that exert the greatest influence on them [10]. It was a descriptive-correlational and predictive study in 308 nurses who worked in palliative care. They used several scales to evaluate the attitudes towards the end of life care of Frommelt, the emotional intelligence, the emotional work and bio-sociodemographic variables, but the one related with the purpose of our review is the FATCOD scale designed especially for measure nurses’ attitudes toward end-of-life patient care. The outcome from that study showed that the attitude toward end-of-life care (FATCOD scale) indicates that the older people has more favorable attitude to death than the younger. It also described that professionals who had postgraduate or post-graduate studies showed significantly higher mean differences in attitude towards end-of-life care (t = 2.55, gl: 305, p = 0 , 01). Furthermore, the study showed that professional experience in palliative care was also directly and significantly related to FATCOD (F = 5.2, gl = 3, p <0.002). Likewise, the number of hours the nurse has worked in palliative care (F = 3.56, df = 3, p = 0.015), joined with the higher number of patients treated, was related with an attitude scores towards care more favourable (F = 3 70, gl = 2, p = 0.026). The nurses with experience as palliative care trainers has more favorable attitudes toward palliative care (t = 4.78, gl = 302; p> 0.001). 

The perception of a greater emotional preparation in palliative care is associated with significantly higher averages in attitudes toward end-of-life care (F = 10.65, gl = 4, p <0.000). The average attitudes towards death tended to be located as attitudes of fear of death, avoidance and escape or neutral attitudes.

Article 3
The next article reviewed is titled “Coping of the nursing professional before the death of patients in palliative units and oncology” and was a observational, descriptive and cross-sectional study performed during the months of December 2014 and January 2015 in Spain [11]. This study pretended to assess the level of coping of the nursing staff with death in palliative and oncology care units.

The target population was the nurses and health care assistants of the Palliative Care and Oncology Units of 4 hospitals. The labor variables utilized in this study were: professional category, hospital where he works currently, years of work experience, professional training about death, perception of being trained in the subject of death coping and support systems of the institution. And also variables referred to coping and attitude towards death. It was used the Bugen’s death coping scale, a validated instrument in Spanish.

Regarding the number of subjects studied, 45 (63.4%) corresponded to nursing graduates compared to 26 (36.6%) who were health care assistants. The average number of years of experience was 17.14 years ± 8.41 (range 6-36 years). In relation with the professional the preparation about death, 59.1% expressed it was poor or regular, 26.8% (19) considered it satisfactory and a 14.1% said it was good. On the perception of being trained in the topic of coping with death, 60.6% said they did not feel trained. And the majority 83.1%, manifests that they do not have support systems from the Institution.

The results shown after the application of the Bugen Scale demonstrated a coping within a normal range. The competence of coping with death observed is deficient in 37% of the people interviewed. However, a 34%, expressed a good coping. Overall the professional who participated in the study seemed to be more confident with the facts related to communication and the worst score obtained was related with talking to children about death. Analyzed the marks about attitude to death, it is shown that the indecision or disagreement with the vision to death was expressed in almost 70% of professionals. Concerning about the topic of fear of death, 46% of people surveyed have negative thoughts and feelings about death whilst a 15% are undecided. According to the professional category, coping with death significantly differed between them two, with nurses showing a greater degree of coping with death. On the other hand, this study did not find differences. In this study, no differences between years of professional experience and their relation to training.

Article 4
The forth article analyzed is a Mater’s thesis by M Cárdenas Huanca and its title is “Attitude of the nursing professional in the process of death in terminally ill patients at the Hospital Hipólito Unanue Tacna-2016” in Peru [12]. The objective of this investigation is to determine the attitude of the nursing professional towards the process of death in terminally ill patients at that hospital. For this study the author examined the cognitive, affective and behavioral components of the professionals. The investigation utilized to collect the data a questionnaire made by them and endorsed by an instrument of reliability. It consists of six items referring to socio-demographic data of the population (age, gender, marital status, position held, time of practice of the profession and service) related with Death Attitudes and Self Reported Health / relevant Behaviors.

Once the questionnaire was answered by the 102 people involved on the study, it is observed that 38.24% of professionals are between 25-38 years old, while without reducing importance 36.27% have ages between 54-65 years and in a lower proportion with 25.49% among 39 -53 years. Regarding sex, the bulk majority of the nursing staff, a 91.18%, belongs to the female. Of 102 nurses, 70.59% have a negative attitude towards death while 29.41% have a positive attitude. In relation with the attitude and age of the nursing professional it is observed that, there are three age groups, in the first 25-38 years the negative attitude predominates with 71.79%. In the age group between 39 to 53 years, the negative attitude also predominates with 80.77% and finally in the group of 54 to 65 years the negative attitude predominates with 70.59%. Regarding the relationship between years of experience and attitude, it is shown that, professionals with 3 to 15 years of experience had a negative attitude with 71.43%. Professionals with 16 to 30 years of experience have even higher negative attitude (79.17%) and eventually the ones with 31 to 44 years of professional experience also predominate the negative attitude with 63.89%.

Article 5
The following articled reviewed was “Anxiety, coping, fear and knowledge in the face of the death of nursing students from the Yucatan peninsula” a master’s thesis presented in Spain in 2015 [13]. That investigation aimed to promote and develop knowledge to foster a comprehensive and quality care to terminal patients, and through a training program, change the attitudes to death and dying and reduce the confrontation that these situations cause in the personnel of nursing care of these patients. It was a descriptive and comparative study with a sample of 274 people (61 men and 213 women) where they selected 40 professional for the experimental group and 234 for the control. The variables included in this study were fear, coping and death anxiety and the tools used were the Bugen scale of death coping and the Collet-Lester death fear scale and the Revised Death Anxiety Scale.
 
Appling the scales to the people included in the study, there were no significant differences found between the two group before the program. The higher degree of coping was the one related to personal perception of enjoyment of life and talk about death.

After the implementation of the program 24 people increased on confronting the death and it could be found significant differences in coping with own death, spending time with the dying patients and communicating with them, the death process and talking with others about death. Once analysed and compared all data obtained, it was established that the differences between before and after the program were significant. The program has been shown to be effective in changing attitudes and has modified coping in the experimental group.

Article 6
The last article included in this literate review is the one by Schmidt Rio Valle J et al. called “Effects of a training program in palliative care on coping with death” in Spain in 2012 [16]. This article wants to evaluate the effect of a palliative care training program aimed at health sciences students, using the Bugen scale of coping with death. 

To achieve that objective they utilized a quasi-experimental study in which a training program was developed for future health professionals (nursing, medicine, psychology, occupational therapy and physiotherapy) who participated voluntarily and whose only selection criterion is that they had not had previous training in palliative care. The duration of the course was 45 hours from October 2008 to February 2009. Sociodemographic data were collected, as well as data related to the level of studies. At the beginning and at the end of the training, the “Bugen scale of coping with death” to the 87 participants to determine their degree of coping with death in each of the moments.

Of the 87 students, 75.9% are women and the rest are men. The majority of the participants are nursing students (64%) and 26.4% are enrolled in first year. Before the intervention, the average score in the Bugen scale was 121.46 ± 19, 7 and after the 15-week period, the score was 158.16 ± 20.6. This means there were significant differences regarding the coping of death after the training program (p = 0.000) and hence It could be said that the training program had served to improve the competence with coping with the death to the participants. From the outcomes of that study they determined that the development of the experiential program has contributed to increase awareness of personal attitudes towards death, to create an atmosphere that has allowed the group to encourage, share and accept these attitudes. Participants report an increase in perceived competence; so that they express feeling more prepared and able to work with patients in end-of-life processes.

Discussion
The amount of articles that relate training in palliative care and coping with death is insufficient to establish scientific evidence. However, articles were found that establish that the attitude and feelings towards death on the part of the nursing staff are usually negative M Cárdenas Huanca at 70.59%, Espinoza Venegas M, et al. in 2016 that establishes that most of the nurses have feelings of fear of death and avoidance and escape, Marchán Espinosa S, et al. that in addition to negative feelings also manifest indecision [10-12].

Referring to Espinoza Venegas M, et al. in 2016 it is established that attitudes towards death are positive and improve with the level of postgraduate training, with training and involvement in the dissemination of palliative care and with work experience in palliative care. In M Cárdenas Huanca as opposed to Marchán Espinosa S, et al. says that the attitude towards death is always negative regardless of the years of experience, but not if training in palliative care had been given [10-12].

In the Jo KH, et al. in 2015, after a palliative care training program in this case, nursing students had a better attitude towards death and increased communication skills according to what was said in Linares Manrique M, Marchán Espinosa S, et al. who agrees on the improvement of communication and points out that the worst coping occurs when dealing with children [9,13]. And in the Schmidt Rio Valle J that says that the improvement of the coping with the programs leads to an improvement of the competence of the professionals that the nurses participating in the studies show that the teaching of coping techniques and training in Palliative care could improve these results [14].

Conclusion
During the search of scientific literature, I found a lot of current bibliography that evaluated or described the coping to death and / or the attitude towards the death of nursing staff and others that evaluated the effectiveness of a training or palliative care programs at the time procure the patient a good death and provide quality care. However, there have been few studies evaluating the role that training in palliative care contributed to improve the attitude towards death, to cope better with it and therefore to give quality care to the dying.

Despite the lack of sufficient scientific evidence and the need for more research on the subject. It can be inferred that training in palliative care helps nursing to better face death and to improve attitudes towards death. Therefore, training in palliative care for nurses during their university period as well as training throughout their professional career should be greater, so that nurses face better the death of patients and have an attitude that favors better care at the end of life.

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