Components of an educational program should be included as a result of recognized need. Kubier- Ross (1969) identified the need of health professionals to deal with their own emotions and attitudes toward death in order to effectively care for dying patients and their families. College courses, seminars, and lectures have been incorporated into nursing education to fulfill this need. Efforts are now underway to evaluate educational programs for their effect in producing increased acceptance toward the concept of death (Crase, 1978). Literature reveals conflicting evidence. Studies evaluating single courses yielded no significant changes in attitude as a result of one course (Hopping, 1977; Pennington, 1979; Watt, 1977). When studies included longer time intervals, i.e., between undergraduates and graduate students (Golub & Reznikoff, 1971), students and nurses (Denton & Wisenbaker, 1977), or freshman and senior students (Yeasworth, et al., 1974), significant changes were revealed. In general, one could conclude that "fears of death and dying decreased with increased education" (Lester, Getty, & Kneisel, 1974).
Experience seems to be a key factor in peoples' attitudes. Studies indicate an inverse relationship between experience and attitudes, the more experience one has with death, the more negative one's attitude becomes (Denton & Wisenbaker, 1977; Stoller, 1980). One study tested registered nurses at completion of a death education unit and again four weeks later. Findings showed no change in attitude at first, but a significant change was revealed at the second testing (Murray, 1974). It may be that a combination of educational units and opportunity to apply one's knowledge produces the most positive attitudinal changes.
The University of Connecticut nursing curriculum offers segments of death education in the form of lectures, panel discussions by faculty, reading assignments of current literature on the subject, and small group seminars. Many students care for dying patients as part of their clinical assignments and members of the faculty are available for one-toone counseling as needed.
This study was conducted to evaluate the effectiveness of the school's program in producing more positive attitudes in its students toward death. A positive attitude was defined as a score greater than 51 on the Death Attitude Questionnaire (Figure 1). Such a score reflects a personal philosophy encompassing death, an ability to discuss death, understanding of dying patients, and ability to care for dying patients.
Personal exposure to death seemed to be an important factor that could not be controlled, hence was included as an independent variable to determine its effects on students' attitudes.
Hypotheses: Two independent variables, academic exposure and personal exposure, were tested for their effects on the dependent variable, attitude toward death. The specific null hypotheses were:
I. Personal exposure to death will not have a significant effect on attitude toward death.
II. Academic exposure to death will not have a significant effect on attitude toward death.
FIGURE 1 DEATH ATTITUDE QUESTIONNAIRE FIGURE 2
III. The interaction between personal and academic exposure to death will not have a significant effect on attitude toward death.
Definition of Terms: As used in this study, terms were given the following definitions:
ATTITUDE TOWARD DEATH is "the sum total of a person's inclinations and feelings, prejudice or bias, and convictions about death" (Hopping, 1977) as measured by a score on Part I of the questionnaire modeled after Hoppings Death Attitude Indicator (Ward, 1979).
PERSONAL EXPOSURE refers to a positive response on any of the items included in Part II of the questionnaire. These questions assess whether the subject has ever been with a dying person at or near the time of death and whether the subject has had any experience affecting his or her general attitude about death.
ACADEMIC EXPOSURE is defined as being an eighth semester student at the University of Connecticut School of Nursing in March of 1981.
Subjects: The sample used in this study was obtained from sophomore and senior nursing students at the University of Connecticut in March of 1981. One hundred-fifty questionnaires were distributed; of the 133 returned, 18 were discarded due to unanswered portions. Data from 43 sophomore and 72 senior nursing students were utilized for the study. Subjects were then classified into four groups according to the types of exposure to death they had experienced: no exposure, personal exposure only, academic exposure only, or both personal and academic exposure.
The sophomore students had no academic exposure to the concept of death included in the nursing program. Senior students, however, all had academic exposure to this concept through the nursing curriculum in the form of lectures, seminars, and in some cases through clinical experiences. Personal exposure was determined from responses to Part II of this study's questionnaire as outlined in the definitions.
Data Collection: Questionnaires were taken to a senior nursing class where they were distributed to students, completed, and collected. One day later, questionnaires were distributed to nursing students in a sophomore class where they were completed and returned. Questionnaires were then classified into the four groups according to exposure to death. After scoring each questionnaire, an analysis of variance was computed for this two -by-two unbalanced factorial design. The alpha level was set at 0.05.
As indicated by this study, personal exposure does not have a significant effect on attitude toward death. Null hypothesis I was accepted.
Academic exposure to death through the University of Connecticut School of Nursing was found to have a significant effect on attitude toward death. Null hypothesis II was rejected.
The interaction between personal and academic exposure to death did not have a significant effect on attitude toward death. Null hypothesis III was accepted. The presence of one factor was not shown to potentiate the influence of the other factor. Mean scores indicate that effects of personal and academic exposure are, however, additive (Figure 2).
This study indicates that the University of Connecticut School of Nursing provides a curriculum which enhances positive changes in attitude toward death. Although the means of each group indicate a positive attitude (greater than 51) this study shows an improvement in attitude as a result of academic exposure. This supports the Yeasworth, et al. (1974) finding that "important shifts in attitude result from nursing education."
Personal exposure accounted for some changes in attitude as shown by the increasing means. However, this difference was too small to be statistically significant. Only 23 of the 115 participating students comprised groups without personal exposure. A study utilizing a larger sample would be necessary to validate any assumptions.
The interaction of the two independent variables upon the dependent variable shows an additive effect as evidenced by the increased scores. The presence of one factor does not potentiate the influence of the other factor in this study.
Replication of this study would be necessary to increase internal validity. It may be advisable to conduct a longitudinal study utilizing repeated measures to eliminate the maturational effect over the two-year educational process.
Measuring attitudes of freshman rather than sophomores would produce a more balanced group by increasing the number of students with no personal exposure to death. Also, limiting the dimensions of personal exposure to include only the death of a close friend or relative, viewing a death, or a close encounter with one's own death would lessen the difference in cell size.
Hoppingfe Death Attitude Indicator was modified for use in this study. Time factors did not allow a pilot test of the instrument following changes. This resulted in difficulty scoring responses placed along a continuum. Use of a forced choice rating scale would eliminate this problem.
Results from this study concur with those of other time interval studies in testing for significant changes in attitude. This study does not support the finding that an inverse relationship exists between experience and attitudes as promulgated in the literature. The approach to death education at University of Connecticut School of Nursing is supported both by the literature and the results of this study.
In view of the findings of this study, other schools of nursing would do well to include similar programs of death education in their nursing curricula. Presently existing programs should be evaluated for their effectiveness in producing positive death attitudes.
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