The effect of death education and experience on nursing students' attitude towards death

Journal of adVanced Nursing, 1990, 15, 29-34 The effect of death education and experience on nursing students'attitude towards death Wendy austin Hurtig BScN MEd RN Assistant Professor, Faculty of Nursing and Len Stewin BSc MEd PhD Professor, Faculty of Educaton, Unupersty of Alberta, Edmonton, canada Accepted for publication 1 February 1989 HURTIG W A&STEWIN L(1990) Jourmal of Advanced Nursing 15, 29-34 Effect of death educaton Nurses face their own fear of death whenever they come to the bedsIde of a dying patient Thus fear must be confronted and reconciled before they can help others meet death with dignty Examunung ones attitude towards death is a difhcult task that needs to begin in the student years, when attitudes towards working with the dying are formed Nurse educators recognize that bref but effective ways of promoting this knd of personal awareness need to be found An experimental study is described that investigated the effect of death ducaton programmes and personal experience wth death on the attitudes of nursing students It was found that the death attitudes of inexpenenced students who were In an experiential programme were more positive than simular students who received a didactic or placebo programme Experienced students, however, were negatively affected by the expenential approach The implications of these fndings for nursing education are outlined INTRODUCTION evidence that teaching nurses to face personal death con- cems increases the lkelhood that they will relate in a often experience great dthculty in coping with such a Nurses do need to recognize and confront their own responsblty The results of a survey of over 15 000 reactions to death before they can help their patents to do nurses suggest that nurses'anxiety in caring for the dying so It is diffcult, however, to develop this type of self- Is strongly related to fear of ther own death(Popoff 1975) awareness Thus process needs to begin in the student years Cumulative nursing expenence has not been found to be a when attitudes towards working with the dying areformed signuhcant factor in dealing with such a fear In fact, the (Caty Tamblyn 1984, Quint 1967, Wise 1974) opposte has been indicated uneasiness associated wth Interactions wth dying persons has increased with nursing experence(Stoller 1980) THE PROBLEM Those interested in improving the care of the terminally have concluded that, until nurses learn to cope with the How can nurse educators help students to face death spectre of death, they wll be inclined to put physical and related fears before they come to the bedside of the dying social distance between themselves and the dying There is patent? Death educaton is a potental means OutsIde orrespondence Wendy Hurt 400 Gameau Professomal Comte 11044-82 Amemw of nursing death education(thantology) courses have evolved in North Amencan colleges since the seventies

Joumal of Advanced Nursing, 1990,15, 29-34 The effect of death education and experience on nursing students' attitude towards death Wendy Austin Hurtig BScN MEd RN Asststant Professor, Faculty of Nursing and Len Stewm BSc MEd PhD Professor, Faculty of Educaliin, Universtty of Alberta, Edmonton, Canada Accepted for publicahon 1 Febmary 1989 HURTIG W A & STE WIN L (1990) Journal of Advanced Nursmg 15, 29-34 Effect of death education Nurses face their own fear of death whenever they come to the bedside of a dying patient This fear must be confronted and reconciled before they can help others meet death with dignity Exammmg one's attitude towards death is a difficult task that needs to begm m the student years, when athtudes towards workmg with the dymg are formed Nurse educators recognize that bnef but efiFective ways of promoting this kind of personal awareness need to be found An experimental study is descnbed that mvestigated the effect of death education programmes and personal expenence with death on the attitudes of nursing students It was found that the death attitudes of lnexpenenced students who were in an expenenhal programme were more positive than similar students who received a didactic or placebo programme Expenenced students, however, were negatively affected by the expenential approach The implications of these findings for nursing education are outlmed INTRODUCTION evidence that teadung nurses to face personal death con￾cems mcreases the likelihood that they will relate m a Canng for those facing death is not an easy task Nurses j^^jp^j ^^^ ^^ ^^^^^ p^^.^^^^^ (^^33 J97g) often experience great diffiailty m coping with such a ^^^^^ ^^ ^^^^ ^^ recognize and confront their own responsibility The results of a survey of over 15 000 reactions to death before they can help their patients to do nurses suggest that nurses' anxiety m canng for the dymg ^^ j ^ ^^ diffiailt, however, to develop this type of self￾is sh-ongly related to fear of theu- own death (Popoff 1975) a^g^eness This process needs to begm m the shident years Cumulahve nursmg expenence has not been found to be a ^j^^^^ athtudes towards worbng with the dying are fonned significant factor m dealmg with such a fear In fact, the ^^^^ ^ Tamblyn 1984, Qumt 1967, Wise 1974) opposite has been mdicated uneasiness assoaated with interactions with dymg persons has mcreased with nursing expenence (StoUer 1980) THE PROBLEM Those interested in improvmg the care of the termiruilly ill have conduded that, until nurses leam to cope with the How can nurse educators help students to face death￾specfre of death, they will be mclmed to put physical and related fears before they come to the bedside of the dymg social distance between themselves and the dymg There is pahent? Death education is a potential means Outside „ , of nursmg death educahon (thantology) courses have Comspondence WendyHi^g 400GameauProfessimialCer^ U044r-82Aveme i • » , LL A II LL. Edmonim, Alberta. Canada T6C0T2 evolved m North Amencan colleges smce the sevenhes 29

A Hurte and L Stewin There is no conclusive evdence as to the effectiveness of Kitson 1986)A survey of Amencan nursing schools death educahon however, nor is there data avallable as to (Thrush et a! 1979)ndicates only 5% requred a death and the optimal approach to this kind of learming process dying course, with an additonal 39 5% having an elective Empuncal evaluation is needed there Is Ittle time within a course available The majonty of Amencan schools inte- nursing cumculum to prepare students to care for the grated concepts and issues related to death and dying patent for whom there is no cure The time must be used into vanous nursing courses, a trend followed as well n CanadIan baccalaureate nursing educaton Caty Approaches to death education can be placed on a Downe-Wamboldt 1984)Of note is that a companson of dndachIc-expenental continuum(Bugen 1979), and it is the integrated and specihc course approaches found the Implied by many educators that teaching methods mvolv- latter more effective in lessening students' death anxiety ing a personal, affective approach to the topIc of death are Degner 1985) more effective than those that focus on giving information ( Durlack 1978)ThIs expermental study compared the persona experience with death effect of programmes from ether end of thus continuum wIth a placebo approach The programmes were bnef, Quint(1967)in her landmark work on the nurse and the being 7 hours n length and presented n a I-day workshop dying patient impled that personal experence with death had a positive effect on one's ablity to cope in related Although professional expenence wnth death has not nursing sItuations She noted nurse educators who skill- been shown as a significant, postive influence on death fully guided students in their care of the terminally ll had attitude, personal expenence with death may be an mport. learned to do so 'usually through personal expenence wIth ant factor Thus kind of expenence may affect the impact of death The effect of personal expenence on death attitude a death education programme, and so the personal ex ds to be examined further In the studies reviewed ence of the students in this study was consIdered death of a friend or famly member was not found to be anable signifcant factor(Caty Tamblyn 1984, Denton Wisenbaker 1977), except by Hopping(1977), who found a relatve s death to be associated with less positive death REVIEW OF THE LITERATURE attutude. whule a fnend's death had no measured effect Death education Schultz(1978), in a crtical review of the hterature, noted that no study has shown that contact wnth death or with early studies of death education in the nursing cumcula hugh-nsk situations nfluences death anxiety in a positiver ere descriptive and used subjective evaluation to measure negative way It may mpact, however, one's reaction to their effect on the student All such studes reviewed vanous death educaton learmng experences eported postive results(drummond Blumberg 1962, Folck& Nie 1959, Robinson 1974, Wagner 1964, Watson 1968, Wise 1974)A common recommendaton was that Death attitude measurement students be given the opportunty to examine personal A mayor diffculty m comparng the effectiveness of pro- grammes is the wide vanety of death atitude constructs Research un thus area occurred prumanly in the seventies and measures used in the research Death attitude has bee Hoppung(1977)and Taylor(1979)measured the effect of operationalized in terms of death fear(Sarnoff & Corwin specihc courses on student nurses' death anxiety and found 1959, Lester 1967, Collett Lester 1969), death anxiety no change Studies usung longtudmal measurement found (Dickstein Blatt 1966, Templar 1970), death concern a delayed positive effect after death educaton(Caty & (Dickstein 1972), death acceptance( Ray Najam 1974, Tamblyn 1984, Laube 1977, Murray 1974)Death att- Hardt 1979, Kurlychek 1978), and reconcliation wth deatH tudes may change only gradually over tume Investigators (Klug 1976)Death fear, anxiety and concern research has examining the effect of nunn educaton in general have been unable to distinguish between those who harbour yet found death anxiety to decrease as the level of nursing deny a fear of death and those who maintain a sense of educahon ncreases (Lester et al 1974, Yeaworth et al acceptance yet exhibit some death fear Reconciliation with 1974) death, defined as 'the deliberate intellectual acknowledge In the Unted KIngdom, the hours spent on 'teaching ment of the prospect of one s own inevitable death and the death and dymg' average between 6 and 14 hours, using positve emotional assumilahon of the consequences(Klug predominantly traditonal (didactic)methods(Field 1976)may be a more sensitive measure, as feelings of den

WA HurttgandL Stewm There is no conclusive evidence as to the effectiveness of death educahon, however, nor is there data available as to the optimal approach to this kmd of leammg process Empincal evaluation is needed there is little time withm a nursmg cumculum to prepare students to care for the pahent for whom there is no cure The time must be used well Approaches to death educahon can be placed on a didactic-expenenhal contmuum (Bugen 1979), and it is implied by many educators that teachmg methods involv￾ing a personal, affechve approach to the topic of death are more effective than those that focus on giving information (Durlack 1978) This expenmental study compared the effect of programmes from either end of this contmuum with a placebo approach The programmes were bnef, being 7 hours m length and presented m a 1-day workshop format Although professional expenence with death has not been shown as a significant, positive irJluence on death athtude, personal expenence with death may be an import￾ant factor This fand of expenence may affed the impact of a death educahon programme, and so the personal expen￾ence of the students m this study was considered as a vanable REVIEW OF THE LITERATURE Death education Early studies of death educahon in the nursmg cumcula were descnptive and used subjedive evaluahon to measure their effect on the student All such studies reviewed reported positive results (Drummond & Blumberg 1962, Folck & Nie 1959, Robmson 1974, Wagner 1964, Watson 1968, Wise 1974) A common recommendation was that students be given the opporturuty to examme personal views and reachons Research m this area occurred pnmanly m the seventies Hoppmg (1977) and Taylor (1979) measured the effect of specific courses on student nurses' death aruaety and found no diimge Studies usmg longitudinal measurement found a delayed positive effect after death educahon (Caty & Tamblyn 1984, Uube 1977, Murray 1974) Death ath￾tudes may change only gradually over time Investigators exammmg the effect of nurmg educahon m general have found death anxiety to decrease as the level of nursmg educahon mcreases (Lester et al 1974, Yeaworth et al 1974) fai the United Kingdom, the hours spent on 'teadung death and d3rmg' average between 6 and 14 hours, usmg predominantly fradihonal (didactic) methods (Field & Kitson 1986) A survey of Amencan nursmg schools (Thrush et al 1979) indicates only 5% required a death and dying course, with an addihonal 39 5% havmg an eledive course available The majonty of Amencan schools inte￾grated concepts and issues related to death and dying mto vanous nursing courses, a trend followed as well m Canadian baccalaureate nursing educahon (Caty & Downe-Wamboldt 1984) Of note is that a companson of the mtegrated and speafic course approaches found the latter more effechve m lesserung students' death anxiety (Degner 1985) Personal experience with death Qumt (1967) m her landmark work on the nurse and the dying pahent unplied that personal expenence with death had a positive effect on one's ability to cope m related nursing situations She noted nurse educators who skill￾fully guided students m their care of the terminally ill had leamed to do so 'usually through personal expenence with death' The effed of personal expenence on death attitude needs to be exammed further In the studies reviewed, death of a fnend or family member was not found to be a significant factor (Caty & Tamblyn 1984, Denton & Wisenbaker 1977), except by Hoppmg (1977), who found a relahve's death to be assoaated with less posihve death athtude, while a fnend's death had no measured effect Schultz (1978), m a cntical review of the literature, noted that no study has shown that contact with death or with high-nsk situahons mfluences death anxiety in a posihve or negative way It may impact, however, one's reaction to vanous death educahon leammg expenences Death attitude measurement A major difficulty m companng the effediveness of pro￾grammes IS the wide vanety of death athtude constructs and measures used m the research Death attitude has been operahonalized m terms of death fear (Samoff & Corwm 1959, Lester 1967, Collett & Lester 1969), death anxiety (Dickstem & Blatt 1966, Templar 1970), death concem (Dickstein 1972), death acceptance (Ray & Najam 1974, Hardt 1979, Kurlychek 1978), and reconciliahon with death (Klug 1976) Death fear, anxiety and concem research has been unable to dishnguish between those who harbour yet deny a fear of death and those who maintain a sense of acceptance yet exhibit scwne death fear Reconciliahon with death, defined as 'the deliberate intellectual acknowledge￾ment of the prospect of one's own inevitable dearti and ttie [x>sihve emohonal assmuiation of the consequences' (Klug 1976) may be a more sensihve measure, as feelmgs of denial

Efect of death educaton or anxiety are not excluded It is the construct used n thus (eg What dd you lke best, least about the programmer) was used to gain descriptive data of subjects reactions to the programmes and their assessment of personal change n death awareness METHOD Subjects Programmes The subjects were a frst level class(no clinical experence) Didactic a format of lectures, hlms and group discussion 106 diploma nursing students Self-selection into the was used to present topIcs death In our society, a develop- study was controlled by incorporating the treatment pro- mental view of death, the dying process, tasks of the dying grammes into the adult development section of a required and the value of death psychology course Informed that they were taking part in al focus was taken using death a study of teaching approaches, subjects consent was awareness exercises, music, drawing and dyad obtained, and they were randomly assigned to one of three encounters between students groups expenential, didactic and control Some subjects did Placebo a simulaton game, BrooksIde Manor(Coons not attend an entre treatment session(for reasons such BykowskI 1980), dealing wth independence in the aging medicaland dentalappointments, anexamunation in another adult and a lecture/discussion on adult development course)and others dd not complete the Confrontation- compnsed the control pronn mosen with the standards for Integration of Death Scale in full Their data were omitted Programme leaders were cho he sample size then consisted of n=23 in the expenential, death educators as proposed by Levton(1977)as a guIde n=27 in the dIdactic group and n= 26 in the control group He believes that such educators should have come to terms wIth their own death feelings and be aware of their Measures influence on the total personalty, be knowledgeable about the subject matter, be able to use the of death Reconciliation with death was measured naturally, be familiar wIth psycho-thantologIcal develop- Confrontatlon-Integration of Death Scale mental events throughout lfe, and be cognisant of the Developed by Klug(1976)and adapted by Impact of social changes on the attitudes, practices, laws (1980)for an investigation of the relationship of d nsttutons concerned wth death students'personalty type and their death attitude, the CIDS Is a Likert-type response option questionnaire It Procedure measures the two components of the reconcilation with death construct, death confrontation(the conscious con- To avold the sensitization effect of a pre-test, a post-test templaton of one one death)and death integration(the only design with randomized subjects was used Subjects positive emotional assimlahon of the consequence of made a commitment not to discuss the expenence with any death confrontaton) The CiDS has 18 tems with a total student outside their group untl noted The evaluation score range of 0-72 The score range for the death confron- forms were completed by subjects, anonymously except taton factor s 0-32, for the death integraton factor, 0-40 for group membership, at the end of the programme 's A hugh score indicates that the subject possesses a high 7-hour class day Seven days later, dunng a regularly degree of the factor measured There Is evidence for the scheduled psychology class, the CIDS was administered valdty of the reconahation with death construct and ts The instruments were coded wIth group and attendance measurement of the CIDS in ts low negative correlation mformation A death education programme was provided wIth Templar's Death Anxiety Scale (Templar 1970) for the control subjects at the conclusion of the study Research indicates that the CiDS is a rehable instrument (Klug 1976, Klug &Sinha 1987) It has recently evolved RESULTS to a 16-1tem questionnaire renamed the Klug Death cceptance Scale(Klug Sinha 1987) A two-way analysis of variance of the CIDS scores indl- Personal death expenence was measured via a wntten cated that neither the death education treatments nor queshon, Included wth the CIDS, asking subjects to volun.f amon in death confrontaton or death Integraton nal experence Independently produced a signuhcant teer informahon concening any expenence wth death, be vana t wth a relative, a fend, a stranger, or a personal brush scores a signuhcant nteraction dd occur between expen- with death An evaluaton form wth open-ended questions ence and type of educational programme as indicated by

Effect of death education or anxiety are not exduded It is the construct used m this study METHO D Subjects The subjects were a first level dass (no clinical expenence) of 106 diploma nursmg students Self-selection mto the study was controlled by mcorporating the treatment pro￾grammes mto the adult development sedion of a required psychology course Informed that they were taking part m a study of teachmg approaches, subjects' consent was obtamed, and they were randomly assigned to one of three groups expenenhal, didactic and control Some subjects did not attend an enhre treatment session (for reasons such as medical and dental appomtments, an exammation m another course) and others did not complete the Confrontation￾Integrahon of Death Scale m full Their data were omitted The sample size then consisted of M = 23 m the expenential, « = 2 7 m the didadic group and « = 26 in the control group Measures Reconciliation with death was measured by the Confrontation-Integration of Death Scale (CIDS) Developed by Klug (1976) and adapted by Chandler (1980) for an investigation of the relationship of nursing students' personality type and their death athtude, the CIDS IS a Likert-type response option questionnaire It measures the two components of the reconcibahon with death construct, death confrontahon (the consaous con￾templahon of one' one death) and death integration (the posihve emotional assimilahon of the consequence of death confrontahon) The CIDS has 18 items with a total score range of 0-72 The score range for the death confron￾tation factor IS 0-32, for the death mtegrahon factor, 0-40 A high score indicates that the subject possesses a high degree of the factor measured There is evidence for the validity of the reconaliation with death construct and its measurement of the CIDS m its low negahve correlahon with Templar's Death Anxiety Scale (Templar 1970) Research mdicates that the CIDS is a reliable instrument (Klug 1976, Klug & Sinha 1987) It has recently evolved to a I6-it«n questionnaire renamed the Klug Death Acceptance Scale (Klug & Smha 1987) Personal death expenence was measured via a wntten queshon, induded with the CIDS, asking subjeds to volun￾teer infonnahon concsmmg any expenence with death, be it with a relahve, a fiiend, a stranger, or a perscMuJ brush withdejAh An ev^vahonfonn with open-ended queshons (e g 'What did you like best, least about the programme?') was used to gam descnphve data of subjeds' reachons to the programmes and their assessment of personal change m death awareness Programmes Dtdacttc a format of lectures, films and group discussion was used to present topics death m our society, a develop￾mental view of death, the dying process, tasks of the dymg and the value of death Expenential a personal focus was taken usmg death awareness exercises, music, drawmg and dyadic encounters between students Placebo a simulation game, 'Brookside Manor' (Coons & Bykowski 1980), dealmg with independence m the agmg adult and a lecture/discussion on adult development compnsed the control programme Programme leaders were chosen with the standards for death educators as proposed by Leviton (1977) as a guide He believes that such educators should have come to terms with their own death feelmgs and be aware of their mfluence on the total personality, be knowledgeable about the subject matter, be able to use the language of death naturally, be familiar with psycho-thantological develop￾mental events throughout life, and be cognisant of the impact of social changes on the athtudes, practices, laws and mshtuhons concemed with death Procedure To avoid the sensitization effect of a pre-test, a post-test only design with randomtzed subjects was used Subjects made a comntutment not to discuss the expenence with any student outside their group until notified The evaluation forms were completed by subjects, anonymously except for group membership, at the end of the programme's 7-hour dass day Seven days later, dunng a regularly scheduled psychology class, the CIDS was admmistered The instruments were coded with group and attendance information A death education programme was provided for the control subjects at the conclusion of the study RESULTS A two-way analysis of vanance of the CIDS scores indi￾cated that neither the death education treatments nor personal expenence mdependently produced a sigruficant vanation m death confrontahon or death mtegration scores A significant mteraction did occur between e^qien￾e n « and type of educahonal programme as indicated by

WA Hurt and L Stewour on the scores of experenced subjects Though a sumulan trend appeared in the death integration scores( Figure 2),t was not statistically signuhcant The F-ratio for these scores was 1 724 whth a probabilty of P=0186(e P>005) These results(a disordinal nteraction relatIve to treatm group)suggest a d fferent educational treatment is requred The students perceived both death education grammes as increasing theur awareness of death In dIdactic programme 688% stated that they were more aware of death wth comments such as i better understand what it is lke to be faced with the knowledge that you are going to die Students with increased awareness identified this awareness as helpful The majonty of the expenential group(61 3%)also beleved themselves to be more aware, but few commented on whether t was helpful A typical response was Reahzed I've been wormed about the death of others but haven t taken time, strength to consider my Expermental own In both treatment groups those who dd not beheve themselves to be more aware generally ated previous level agure 1 Profle of means death confrontation O=inexper- of awareness as the reason, eg I dIdnt enced■= experenced aware I've already had several expenences with death The evaluations indicated that both programmes were seen as postive, worthwhile expenences by the monty of students Some ndIcated that, whule they wanted expertise n cann for the terminally ll, they were uneasy addressing personal death concerns One commented 'As student nurses I think we should focus on other people's deaths some overtly acknowledged that self-awareness seems the first step in leaming to help patients. You must come to terms with lyour] own feelings before you can deal wnth patents and others' One student evaluated his/her pro gramme thus way 1 had hopes of getting a handle on sympathy--some "how tos"I guess I DISCUSSION Bref death educaton promote pers death awareness n nursing students and the erefore seem a Experiential worthwhile add tion to nursing curncula An expermental Figure 2 Profle of means death integraton O=mexpenenced programme was more effective than a didactIc ■= experienced helping students without a personal death expenence to confront their thoughts and feelings conceming death The music and death encounter exerases such as a guided hfe- the death confrontation scores(Figure I)AF-raho of 4 374 death fantasy may make death seem more real Student wth a probablity of P=0016(e P<005)was obtained. comments substantiate thus, e.g I knew death was always The expenental approach had a positive effect on the there, but i found out some of my feelings toward death death confrontaton of subjects wth no personal expen- tself Thus affective approach, however, had a negative ence wth death The same approach had a negative effect effect

WA Hurtig ar^L Stewtn 26 0 25 0 24 0 23 0 22 0 2 Didactic 3 Experiential Control Figure 1 Profile of means death confrontahon O = inexper￾ienced, • = expenenced 30 0 - o 2 29 0 28 0 2 Didactic 3 Experiential Cantrol Figure 2 Profile of means death mtegration O = lnexpenenced, • = expenenced the death confrontahon scores (Figure I) A f-raho 005) These results (a disorduial mteradion relative to freatment group) suggest a different educahonal freatment is required for expenentially dififerent students The students perceived both death education pro￾grammes as mcreasmg their awareness of death In the didactic programme 68 8% stated that they were more aware of death with comments such as 'I better understand what it IS like to be faced with the knowledge that you are going to die' Students with mcreased awareness ldenhfied this awareness as helpful The majonty of the expenential group (61 3%) also bebeved themselves to be more aware, but few commented on whether it was helpful A typical response was 'Reabzed I've been womed about the death of others but haven't taken time, strength to consider my own' In both treatment groups those who did not believe themselves to be more aware generally ated previous level of awareness as the reason, e g 'I didn't become more aware I've akeady had several expenences with death' The evaluations indicated that both programmes were seen as positive, worthwhile expenences by the majonty of students Some mdicated that, while they wanted experhse m canng for the termmally ill, they were uneasy addressmg personal death concems One commented 'As student nurses 1 think we should focus on other people's deaths' Some overtly acknowledged that self-awareness seems the first step m leammg to help patients- Tou must come to terms with [your] own feelmgs before you can deal with patients and others' One student evaluated his/her pro￾gramme this way 1 had hopes of gettmg a handle on sympathy — some "how tos" I guess I came lookmg for answers, but I'm leavmg with more queshons Personally very relevant' DISCUSSION Bnef death educahon programmes can promote personal death awareness m nursmg students and therefore seem a worthwhile addihon to nursmg cumaik An expenenhal programme was more dfechve than a didachc ^proach m helping students without a personal death expenence to coi^ont their thoughts and feelings concenung death The music and death enaninter exercises sudi as a guided li£e- (kath fantasy may make death seem more real Student comnaits substantiate this, e.g 1 blew death was always there, but I found out SCHIK of my ledu^s towiard dei^h itself' This diechve ^^roach, howevo*, had a negahve on expenen£»d students m tlwir wdlu^ness to 32

Efect of death educate confront their thoughts concening death It may be that Canadian baccalaureate nursing programme in the the gef and sadness remaining from past encounters was mplementation of a 1-day death education workshop for touched in too intense a manner The student may resist students a quantative study is beng planned to help confronting these strong feelings and reactions In an edu- Identfy essental leaming expenences n the preparaton of cational setting The be strong precept may be in place nurses to care for the dying It may also be that the emotions from a loss expenence surfaced during the death awareness exercses and Impacted the death confrontation scores One tem on the Acknowledgement CIDS reads 'After discussing the subject of death, I feel depressed' Agreeing with this statement would lower the Thus research was partially funded by the Alberta death confrontation score The didactic approach, not Foundation for Nursing Research addressing personal feelings, would be less lkely to arouse adness in an experienced subject Such a reaction is not necessanly negative Expenenced students dId fnd the references expenential programme valuable-as one put it, I have had past expenences wnth people close to me that have Bugen L(1979)Death education perspectives for schools and dued and this workshop brought up some feelings that I unties In Death and Dying Theory/Research/Prachce(Bugen L have put away I dont thInk this is bad-In fact, It made ed ) WC Brown, Dubuque, lowa, PP 236-249 me see the mportance of telling others how you feel Caty S&Downe-WamboldtB(1984)Alook at death educaton whether It's before they go away or before you die in Canada Dmensions of health Services 60, 37-39 These results have imphcations for nursing educaton Caty S Tamblyn D(1984)Postve effects of educaton on a productive teachng strategy may be to divide death nursing students attitudes towards death and dying Nursng ducation classes Into groups according to personal death Chandler C(1980) Personality type and reconcliation wth enced group could begin to lea death Unpublished masters thesIs, Universtty of Alberta about death through expenental methods, using death Edmonton awareness exercises to help them encounter the thought of Collett l Lester(1969) The fear of death and the fear of death a more cogntve, didactic aproach could be taken dying Journal of Psychology 72, 179-181 wIth the death expenenced students at least initially, Coons&Bykowsk](1980)Brookside Manor A gerontological could confront their death concerns in a less intensive Simulahon Institute of Gerontology, University of Michigan Students with unresolved thoughts and feelings about Wayne State, Ann Arbor death, ansing from past bereavements, may be Identhed Degner L (1985) The effect of an undergraduate nursing source and referred for individualized help, if necessary palliative care on death anxety and attitudes to care of the dying in nursing students Dssertahon Abstracts Intemahonal Using an expenence basts for programme assignment 46.3781B-3782-B allows for more effective use of teaching time A experen- Denton j& Wisenbaker v(1977) Death expenence and death tal approach which requres the higher student/teacher anxiety among nurses and nursing students Nursing Research rato could be used only for those students who would 26(1),61-64 derive the most beneft Such a division may also facahtate Dickstein L(1972)Death concem measurement and correlates the dynamucs withun the learning groups, as students may Psychological Reports 30, 563-571 more able and wllng to share reactions to death with Dickstein L Blatt S (1966)Death concen, futunty and anta others having sumlar expenence Though the majonty of paton Joumal of Consulting sychology 30, 11-17 students appreciated the opportunuty to discuss death and Drummond E Blumberg ](1962) Death and the curnculum their reactons to it, some were reluctant to become more Joumal of Nursing Educaton 1(2),21-28 aware of personal death concems Nurse educators wll Durlack J(1978)Companson between expenential and didache need to help some students recognize the mportance field d&KItson C(1986)Coping with death the practical self-awareness in fulfilling the caregiver role Measurement over time was not feasIble in thus study it realty Nursing Times 82(12),33-34 olck m& ne P(1959)Nursing students leam to face death could not be determined f the death confrontation scores Nursing Outlook 7(9), 510-513 of experienced subjects in the expermental group would Hardt D(1979)Death The Final Fronher Prentice-Hall Improve, and f the death mtegrahon scores would followEnglewood Clffs,New Jersey the trend undated to a statistically signuhcant level Hopping B(1977) Nursing students'attitudes toward death Currently, the results of this study are being used in a Nursing Research 26(6), 44

^ect of daith educatton confront their thoughts conceming death It may be that the gnef and sadness remammg from past encounters was touched m too intense a marmer The student may resist confronting these strong feelings and reactions m an edu￾cational setting The 'be sfrong' precept may be in place It may also be that the emohons from a loss expenence surfaced durmg the death awareness exerases and impacted the death confrontahon scores One item on the CIDS reads 'After disaissmg the subject of death, I feel depressed' Agreemg with this statement would lower the death confrontahon score The didactic approach, not addressing personal feelmgs, would be less likely to arouse sadness m an expenenced subjed Such a reaction is not necessanly negative Expenenced students did fmd the expenential programme valuable — as one put it, 1 have had past expenences with people dose to me that have died and this workshop brought up some feelings that I have put away I don't thmk this is bad — m fact, it made me see the importance of tellmg others how you feel whether it's before they go away or before you die' These results have implications for nursmg education A produchve teachmg strategy may be to divide death educahon classes into groups according to personal death expenence The mexpenenced group could begm to leam about death through expenenhal methods, using death awareness exerases to help them encounter the thought of death A more cognihve, didadic aproach could be taken with the death expenenced students at least mihally, they could confront their death concems m a less intensive way Students with imresolved thoughts and feelmgs about death, ansmg from past bereavements, may be ldenhfied and referred for individualized help, if necessary Usmg an expenence basis for programme assignment allows for more effechve use of teachmg tune A expenen￾hal approach which requires the higher student/teacher ratio could be used only for those students who would denve the most benefit Such a division may also facibtate the dynamics withm the leammg groups, as students may be more able and willmg to share reachons to death with others having similar expenence Though the majority of students appreaated the opporturuty to discuss death and their reachons to it, some were reluctant to become more aware of personal death concems Nurse educators will need to help some students recognize the importance of self-awareness m fulfilbng the caregiver role Measurement over time was not feasible m this study It could not be determmed if the death confrontahon scores of expenenced subjects m the expenenhal group would improve, and if the death mtegration scores would follow the frend inthcated to a st^shcally significant level Cun-ently, the results of this study are bemg used m a Canadian baccalaureate nursing programme m the implementation of a 1-day death education workshop for students A qualitative study is bemg planned to help identify essential leaming expenences in the preparation of nurses to care for the dying Acknowledgement This research was partially funded by the Alberta Foundation for Nursmg Research References Bugen L (1979) Death education perspechves for schools and unities In Death and Dymg Theory/Research/Practtce (Bixgenl ed), W C Brown, Dubuque, Iowa, pp 236-249 CatyS & Downe-Wamboldt B (1984) A look at death educahon in Canada Dimensions of Health Services 60, 37-39 Caty S & Tamblyn D (1984) Positive effects of educahon on nursmg students' attitudes towards death and dying Nurstng Papers 16(4), 41-53 Chandler C (1980) Personality type and reconaliation with death Unpublished master's thesis. University of Alberta, Edmonton Collett L & Lester D (1969) The fear of death and the fear of dying Journal of Psychology 72,179-181 Coons D &BykowsktJ (1980) Brookside Manor A Gerontologtcal Simulation Institute of Gerontology, University of Michigan￾Wayne State, Ann Arbor Degner L (1985) The efifect of an undergraduate nursmg source in palliative care on death anxiety and attitudes to care of the dying in nursmg students Dtssertatton Abstracts Intemattonal 46, 3781B-3782-B Denton J & Wtsenbaker V (1977) Death expenence and death anxiety among nurses and nursing students Nurstng Research 26(1), 61-64 Dickstein L (1972) Death concem measurement and correlates Psychological Reports 30, 563-571 Dickstein L & Blatt S (1966) Death concem, futunty and antia￾patton Joumal of Consulttng Psychobgy 30,11-17 Drummond E & Blumberg J (1962) Death and the cumculum Joumal of Nurstng Educatton 1(2), 21-28 Durlack J (1978) Companson between experiential and didactic methods of death education Omega 9(1), 57-68 Field D & Kitson C (1986) Copmg with death the practical reality Nurstng Ttmes 82(12), 33-34 Folck M & Nie P (1959) Nursmg students leam to face death Nursmg Outlook 7(9), 510-513 Hardt D (1979) Death The Final Frontier Prenhce-Hall, Englewood Cliffs, New Jersey Hoppmg B (1977) Nursmg students' attitudes toward death Nurstng Research 26(6), 443-447 33

A Hurtig and L Klug L(1976)An empincal nvestgabon of the relahonshup Ross C(1978)Nurses personal death concems and responses between self-actualuzation and reconcilation with death to dynng-Patent statements Nursing Research 27(1), Unpublished doctoral dissertation, UnIversty of Ottawa,64 Ottawa Schultz( 1978)The Psychology of Death, Dying and Bereavement Klug L Sinha A(1987)Death acceptance a two-component Addnson-Wesley, New York formulation and scale Omega 18(3), 229-235 Samoff I Corwin S(1959)Castration anxiety and the fear of KurlychekR(1978)Assessment of attitudes towards death and death Journal of personalty 27, 375-385 dying a antical review of some available methods Omega Stoller E( 1980) Impact of death-related fears on attitudes of 9(1),37-47 nurses in a hospital work setting Omega 11(1),85-95 Laube J( 1977)Death and dying workshop for nurses its effects Taylor $(1979)Realizaton of the death, dying and gneving on their death anxiety level Intemational Journal of Nursing processes in a selected group of student nurses(doct Studies14(3),10120 dissertation, East Texas State University)Dissertation Leviton D(1977) Death education In New Meanings of death, Abstracts Intemational 40, 1370 (FeIfel H ed ), McGraw-Hill, New York Templar D(1970) The construction and validation of Lester D(1967) Experimental and correlational studes of the death anxiety scale The Journal of General Psychology 82 fear of death Psychological Bulletin 67, 27-36 65-177 Lester D, Getty C& Kneisl C(1974)Atttudes of nursing Thrush J, PaulusG& Thrush P(1979) AvalabLty of education students and nursing faculty toward death Nursing Research on death and dying a survey of US nursing schools Death 23(1)50-53 Education 3. 131-142 murray P (1974) Death education and its effect on the death Wagner B(1964)Teaching students to work wth the dying anxiety of nurses Psychological Reports 35, 1250 Amercan Journal of Nursing 64(11), 128-131 Popoff D(1975)What are your feelings about death and dying Watson M(1968)Death-a necessary concern for nurses hursing Outlook 16(2),47-48 Quint J(1967) The Nurse and the Dying Patent Macmullan, New Wise D(1974)Leaming about dying Nursing Outlook 22(1 ), York Ray ]& Najam J(1974)Death anxety and death acceptance a Yeaworth R, Kapp F winget C (1974) Atttudes of nursing prelminary approach Omega 5, 311-315 students toward the dying patent Nursing Research 23(1), Robinson L (1974)We have no dying patents Nursing Outlook 20-24 22(10)651-653

WA HurttgartdL Stnom Klug L (1976) An empincal mveshgahon of the relationship between self-actualization and reconciliation with death Unpublished doctoral dissertation. University of Ottawa, Ottawa Klug L & Smha A (1987) Death acceptance a two-component formulation and scale Omega 18(3), 229-235 Kurlychek R (1978) Assessment of athtudes towards death and dymg a cntical review of some available methods Orrtega 9(1), 37-47 Laube J (1977) Death and dymg workshop for nurses its effects on their death anxiety level International Joumal of Nursing Studtes 14(3), 110-110 Leviton D (1977) Death education In New Meamngs of Death, (Feifel H ed), McGraw-Hill, New York Lester D (1967) Expenmental and correlational studies of the fear of death Psychologtcal Bulletin 67, 27-36 Lester D, Getty C & Kneisl C (1974) Athtudes of nursmg students and nursmg faculty toward death Nurstng Research 23(1), 50-53 Murray P (1974) Death educahon and its effect on the death anxiety of nurses Psychologtcal Reports 35,1250 Popoff D (1975) What are your feelmgs about death and dymg Nursing '75 5,16-24 Qumt J (1967) The Nurse and the Dying Pattent Macmillan, New York Ray J & Najam J (1974) Death anxiety and death acceptance a preliminary approach Ome^a 5, 311-315 Robmson L (1974) We have no dymg patients Nurstng Outlook 22(10), 651-653 Ross C (1978) Nurses' personal death concems and responses to dying-patient statements Nurstng Research 27(1), 64-68 Sdiultz R (1978) The Psychology of Death, Dying and Bereavement Addison-Wesley, New York Samoff I & Corwm S (1959) Castration anxiety and the fear of death Joumal of Personality 27,375-385 Stoller E (1980) Impact of death-related fears on attitudes of nurses m a hospital work settmg Omega 11(1), 85-95 Taylor S (1979) Realization of the death, dying and gneving processes m a selected group of student nurses (Doctoral dissertation. East Texas State University) Dtssertatton Abstracts Intemattonal 40,1370 Templar D (1970) The construction and validaticm of a death anxiety scale The Joumal of General Psychology 82, 165-177 ThnishJ,PaulusG &ThmshP (1979) Availability of education on death and dying a survey of US nursmg schools Death Educatton 3,131-142 Wagner B (1964) Teaching students to work with the dying Amencan Joumal of Nurstng 64(11), 128-131 Watson M (1968) Death — a necessary concem for nurses Nurstng Outlook 16(2), 47-48 Wise D (1974) Leaming about dymg Nurstng Outlook 22(1), 42-44 Yeaworth R, Kapp F & Wmget C (1974) Athtudes of nursmg students toward the djrmg pahent Nurstng Research 23(1), 20-24

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