Impact of End-of-Life Care Education on Knowledge, Confidence, and Attitudes Toward Care of the Dying in Entry-Level Nursing Students

Purpose: More  than 25% of Japanese population are age of 65 years or older. Given anticipation of many deaths, quality end-of-life (EOL) care by nurses becomes more important than ever. All entry-level nursing programs in Japan have been mandated to include EOL care education since the basic nursing education curriculum was revised in 2009. However, it is unclear how EOL care have been taught and how the EOL education has influenced on students. Therefore, the purpose of this study was to explore how many hours of EOL care education were taught, and investigate the impact of the hours of EOL care education on the student’s knowledge, confidence, and attitudes toward caring for dying people by comparing the freshmen and the seniors in Japanese entry-level nursing programs. 

Methods: The subjects of the study were the freshmen and seniors in all nursing programs, including diploma, associate, and baccalaureate programs in Japan (n=746 as of November 2013). First, we sent a letter to the administrators of the programs and asked to provide their syllabus andthe consent to participate in the student survey. Second, self-administered questionnaires including the Japanese version of the Frommelt Attitude Toward Care of the Dying (FATCOD), 10 questions to assess EOL care knowledge, and 1 item to ask percived confidence in caring for the dying, were distributed to the freshmen and seniors in the programs randomly selected from the programs whose administrator provided the syllabus and agreed to participate in the study. Descriptive and multiple regression analyses were performed.

Results: Sixty-five programs returned the syllabus, and of those, 42 programs (n = 19 for baccalaureate, n = 1 for associate, and n = 22 for diploma) agreed to participate in the student survey. According to the proportion of the original subject programs, 30 programs (n = 9 for baccalaureate, n = 1 for associate, and n = 20 for diploma) were randomly selected from the 42 programs for the student survey. A total of 3,638 questionnaires were distributed to the freshmen and seniors (3rd-year students for diploma and associate, and 4th-year students for baccalaureate). Seven hundred twenty-two students returned the completed questionnaire, but 26 were excluded because the year in the program was missing (valid response rate 19.1%; n = 391 for freshmen and n = 305 for seniors). The mean age was 20.5 (SD = 5.1) years for freshmen and 22.7 (SD = 4.9) years for seniors, and 7.9% were male. The attitude toward care of the dying (FATCOD) was significantly more positive in seniors (mean = 116.1, SD = 8.9) than in freshmen (mean = 112.8, SD = 8.9) (p < .001). The number of correct answers to the 10 questions to assess EOL care knowledge was also better in seniors (mean = 6.1, SD = 2.2) than in freshmen (mean = 4.9, SD = 2.1) (p < .001). A third of the total participants had previous experience of attending person’s death, and they had a higher mean FATCOD score than the counterpart (115.8 vs. 113.6, p < .01) and were more likely to be confident in caring for the dying (38.3% vs. 26.0%, p < .05). The students with confidence were less frequent among seniors (27.2%) than among freshmen (32.3%), though the difference was not statistically significant. After controlling for age, experience of hospitalization, and previous experience of attending person’s death, the seniors had better knowledge about EOL care (p < .001) and more positive attitude toward caring for dying people (p < .001) than freshmen. There was no difference in FATCOD or knowledge among types of program. Hours of EOL education indicated in either syllabus or student’s report were not associated with knowledge, confidence, or FATCOD scores. About a half of seniors perceived insufficiency of EOL care education. 

Conclusion: The low response rate is a limitation of this study, but the mean of FATCOD scores in this study was comparable to that in the previous Japanese studies of nurses and nursing students. The FATCOD scores in Japanese studies have found to be lower than that in the US studies. Hours of EOL care education did not have impact on students’ knowledge and attitude toward care for the dying, but students somewhat seemed to have gained knowledge and learned something about care for the dying persons by completing the program. However, better knowledge and positive attitude toward EOL seemed not to help students be confident in caring for the dying person. It is needed that the development of curriculum that can provide students with confidence and feeling of sufficiently educated about EOL care at their graduation.