Geriatric Nursing: Relationship Among Death Attitude, Meaning in Life, and Career Choice Motivation

ABSTRACT Background Aging populations require higher quality care. However, few undergraduate nursing students choose careers in aged care. Negative death attitudes and loss of meaning in life may reduce motivation to choose geriatric nursing (GN) as a career. The relationships among these variables have yet to be clarified in the literature. Purpose The purpose of this study was to investigate the relationships among death attitude, meaning in life, and motivation to choose a career in GN among undergraduate nursing students in China. Methods This cross-sectional study was conducted using an online survey. Five hundred ninety-five final-year undergraduate nursing students in four nursing schools completed the Career Choice Motivation Questionnaire for Geriatric Nursing, Death Attitude Profile-Revised, and Meaning in Life Questionnaire. A t test, analysis of variance, Pearson's correlation, and multiple linear regression model were used to analyze the data using SPSS Version 22.0. Results The mean Career Choice Motivation Questionnaire for Geriatric Nursing item score was 3.15 (SD = 0.49; 1–5 points), indicating the participants were moderately motivated to choose GN as a career. The multiple linear regression revealed statistically significant associations among death attitude, meaning in life, and motivation to care for older adults, explaining 14.5% of the total variance (R2 = .15, F = 9.01, p < .001). Perceiving meaning in life, having escape acceptance, and having approach acceptance were each shown to be positively associated with choosing a career in GN. Conversely, fear of death and death avoidance were found to be negatively associated with choosing this career path. Conclusions Death attitude and perceptions regarding the meaning of life are associated with the motivation of nursing students to care for older adults.


Introduction
With countries around the world experiencing population aging, declines in fertility, and increasing life expectancy, older adults may be expected to spend more years dealing with frailty and illness (Dixon, 2021).In China, the older adult population aged 60 years and above is growing at an unprecedented speed, rising from 222 million in 2015 to 264 million in 2020 (18.7% of the population), and the population over 65 years old was 191 million in 2020 (13.5% of the population; Tu et al., 2022).Because of China's threedecade-long one-child policy, a large number of single-child parents have entered old age, nearly half of whom are "empty nesters" (i.e., no longer living together with their children).With the acceleration of urbanization, significant numbers of younger workers in rural areas are leaving home to find work in higher-population-density areas, further increasing the care pressures on empty-nest older adult families (Wu, 2021).Families often face great difficulties in providing care for their older adult relatives.
Adults experience higher rates of various chronic diseases than the general population.Moreover, the rate of multimorbidity in older adults in China is 43.6% (R. Zhang et al., 2019).This faces older adults with complex health needs and greater challenges to care.China's traditional elderly care institutions focus primarily on meeting basic living needs.Medical institutions provide short-term hospitalization only when older adults are seriously ill, and medical care and basic older adult care are largely separate services.Since 2013, China has been working to combine medical care and elderly care to meet the medical needs of older adults with chronic diseases through hospitals for general care functions and pension institutions for specialized healthcare needs.However, the shortage of nurses providing care to older adults is a key factor limiting quality of care (Feng et al., 2020).
Similar to other countries (Dai et al., 2021), most undergraduate nursing students in China choose to work as nurses in large general hospitals, especially in the field of acute and severe nursing in wards treating adult patients.Although nursing students may have a moderate level of motivation or willingness to care for older adults, few eventually choose geriatric nursing (GN) as their career (Guo et al., 2021).This may be because general hospital positions have more advantages than GN positions in terms of, for example, salary and welfare, social recognition, and personal development (H.Zhang & Sun, 2019).Another reason may be that undergraduate nursing curricula are tailored to hospital nursing and lack the content necessary to encourage and stimulate students to choose a career in GN (Garbrah et al., 2017).Career motivation affects career commitment, satisfaction, and engagement (Somers et al., 2019).
Meaning in life (MIL) is the process by which individuals recognize and search for meaning of their own lives and includes the aspects of MIL-presence (MIL-P) and MIL-searching (MIL-S; S. S. Liu & Gan, 2010;Steger et al., 2006).MIL-P is the understanding of the purpose and mission of life, reflecting the degree to which one's life is perceived as meaningful, whereas MIL-S is the goal and mission of trying to find MIL.With economic development, the influence of diverse values, and the continuous reconstruction of MIL, young people in China experience existence anxiety that has accumulated over several generations, resulting in loss of individual MIL (Chen et al., 2021).Although young adults today desire to pursue a meaningful life, realize their self-worth, and gain recognition from the society, they are highly vulnerable to adopting a herd mentality and falling into blind compliance with social standards.When considering a career in older adult care, students in China may want to choose a job with more consideration for realizing the value of life.Alternatively, because of MILrelated uncertainty, nursing students may blindly and passively conform to family and social expectations with regard to pursuing working status and prestige and choose to work in a general hospital.Nursing students with higher levels of MIL are generally more motivated to provide better elderly care and to be more engaged at work (Tsai et al., 2018).
From the existential theoretical perspective (Cohen, 2003), career choice is motivated by the desire to find a meaningful job, which provides the opportunity to find career satisfaction and MIL.Some nursing students do not want to pursue a career that involves caring for older adults because they think it will involve suffering and waiting for death, which are depressing activities.Nursing students may also worry that GN may not allow them to effectively practice their nursing skills or become experts in their role, which can affect their pursuit of MIL (Garbrah et al., 2017).Meanwhile, other nurses believe work in GN can bring them closer to the souls of the older adults they care for and expose them to the living wisdom of care recipients.In this case, nurses can achieve MIL through listening to the older adults tell their life stories (Ferstad & Rykkje, 2023).Significant attention has been paid in previous quantitative studies to the influence of external factors such as working environment, family suggestions, social status/prestige, attitudes, and lived experiences.However, the intrinsic motivation factors affecting MIL have largely been ignored (Cheng et al., 2015;Dai et al., 2021).
According to terror management theory, defensive thinking emerges in response to awareness of and acute fear resulting from death to avoid facing the prospect of one's eventual death (Greenberg et al., 1997).Discussing death is not easy in Chinese families, with discussions about the death of parents considered unfilial and taboo because of fears over inviting bad luck.Especially in Shandong province, which is the home region of Confucius and still deeply influenced by Confucian moral thought, filial piety remains the most important of all virtues.This study was designed to examine the relationships among death attitude, MIL, and career motivation in GN (Hsieh et al., 2021), which is an issue inadequately investigated in the literature.

Study Design and Sample
In this cross-sectional study, an online survey was conducted to collect data.Informed consent was obtained from all of the participants, and the protection of their privacy was ensured.A convenience sampling approach was used to enroll participants from four universities with similar 4-year undergraduate nursing programs in Shandong Province, China.The undergraduate programs included 3 years of theoretical study and one final year in which a 1-year internship at a general hospital was offered.The inclusion criteria were as follows: (a) willingness to participate, (b) being a Chinese student, (c) being enrolled in a 4-year undergraduate program, (d) taking the last semester of their fourth year, and (e) being in an internship at the time of data collection.No exclusion criteria were used in this study.The students were provided a link to the online survey form (wjx.cn).The survey was conducted between April and May 2022.Of the 740 qualified participants, 595 completed the survey (response rate: 80.4%).

Measures
The researchers independently conducted a systematic literature review of studies related to death attitude, MIL, and motivation for choosing GN as a career path to determine the measurement tools with suitably high reliability and validity.After discussions with experts from nursing universities, the structured questionnaire was developed and revised.
The data were collected using an introductory information form, the Career Choice Motivation Questionnaire for Geriatric Nursing (CCMQ-GN), the Death Attitude Profile-Revised (DAP-R), and the Meaning in Life Questionnaire (MLQ).

Sociodemographic Variables
The introductory information form included the following six sociodemographic items: age, gender, place of residence, experience cohabiting with older adults (aged ≥ 60 years), experience caring for older adults (aged ≥ 60 years), and internship experience in GN institutions.In this study, "elderly" and "older adult" are defined as individuals ≥ 60 years old, in line with the standard practice in China.

The Career Choice Motivation Questionnaire for Geriatric Nursing
This questionnaire was used to gauge the motivation of participants to choose GN as a career path.The 20-item Chinese version of the CCMQ-GN was created by Cheng et al. (2015) based on the expectancy-value theory to measure the two dimensions of motivation, that is, value and expectancy.The value dimension includes the four subscales of interest (three items), utility (three items), attainment (five items), and cost (three items).Each item is scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).The cost subscale is reverse scored.The expectancy dimension includes six items, with no subscales.Higher total scores for this questionnaire indicate higher motivation for GN (Cheng et al., 2015).The CCMQ-GN has reported Cronbach's αs of .87(value motivation) and .91 (expectancy motivation; Dong et al., 2022).In this study, the Cronbach's α was .91.

The Death Attitude Profile-Revised
The DAP-R was developed and revised by Wong et al. (1994) as a 32-item scale with five subdimensions: fear of death (seven items), death avoidance (five items), neutral acceptance (five items), escape acceptance (five items), and approach acceptance (10 items).A 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) is used to score the items, with higher average subdimension scores indicating a greater tendency toward the related attitude.Validity and reliability have been established for the Chinese version of the DAP-R (L.Tang et al., 2014), and the Cronbach's α value in this research was .897.

Meaning in Life Questionnaire
The original version of the MLQ was developed by Steger et al. (2006), and the Chinese version was validated by S. S. Liu and Gan (2010).This questionnaire is composed of nine items in the two subscales of search for meaning (MLQ-S; four items) and presence of meaning (MLQ-P; five items).Each item is scored from 1 = strongly disagree to 7 = strongly agree, and one item, "I have no clear purpose in my life," is scored in reverse.Higher total scores are associated with a greater sense of MIL.The Cronbach's α values in this study were .754for MLQ-P, .842for MLQ-S, and .877for MLQ.

Data Collection
The researchers uploaded the online questionnaire to the "Question Star" platform (wjx.cn) and generated a shared link.Next, one researcher contacted the faculty in charge of managing fourth-year intern students and explained the purpose of this study.After the faculty member agreed to cooperate in this study, the researcher sent her the questionnaire link using WeChat, which she sent to the nursing intern students using WeChat.Faculty in China commonly use WeChat to release notices and news.By clicking on the link, the participants could answer the questions on either a computer or mobile phone.In the first part of the questionnaire, the purpose of the study was introduced, and a statement on anonymity and privacy protection was provided.The participants were required to click on the "Agree" button to begin the questionnaire.All of the questions required an answer, and missing data were not accepted.After completion, submission was automatic.Researchers were able to view the questionnaire results on the platform by logging in using their name and password.

Data Analysis
SPSS Statistics Version 22.0 (IBM Inc., Armonk, NY, USA) software was used to analyze the collected data.Descriptive statistics were analyzed for frequency, percentage, mean, and standard deviation.For normally distributed variables, between-group differences were tested using an independent t test for group pairs and one-way analysis of variance for multiple groups.Pearson's correlation and a multiple linear regression model were used to evaluate the effect on career choice motivation.A two-sided p value < .05 and 95% confidence interval were deemed statistically significant.

Ethical Considerations
Before data collection, this study was approved by the institutional review board of the teaching development department at Jining Medical University (IRB No. 2020-235).All of the procedures were carried out in line with informed consent and privacy protection principles.Before questionnaire distribution, the researcher selected the privacy protection options "forbid questionnaire copying" and "block search engine retrieval."In addition, the questionnaire link was designed as a one-time link that expired after data collection.Questionnaire responses were anonymized, and the participants were allowed to withdraw from this study at any time.All of the data collected for this study were stored in a password-protected file accessible only to the researchers using a private account.

Sample Characteristics
The 595 participants in this study had a mean age of 21.51 (SD = 1.08) years.As shown in

General Characteristic-Related Differences in Career Choice Motivation Questionnaire for Geriatric Nursing Scores
The results of the independent t test are shown in Table 1.The participants from rural areas earned a higher average score for motivation than their peers from urban areas ( p < .05),those who had not lived with older adult relatives at home scored lower on the CCMQ-GN than their peers who had ( p < .05),and those who had interned at GN institutions had significantly higher scores for motivation than their peers who had not ( p < .05).Furthermore, the analysis of variance results showed that, compared with their peers who had never cared for or had limited experience caring for an older adult, the participants with frequent experience caring for an older adult earned a higher average score for motivation ( p < .001).
Career Choice Motivation Questionnaire for Geriatric Nursing, Death Attitude Profile-Revised, and Meaning in Life Questionnaire Mean Scores and Their Intercorrelations The descriptive statistics for career choice motivation for GN (CCMQ-GN) are summarized in Table 2.The mean score for the CCMQ-GN was 3.15 (SD = 0.49), with subscale scores of 3.53 (SD = 0.62) for interest, 3.22 (SD = 0.65) for utility, 3.14 (SD = 0.73) for cost, 3.12 (SD = 0.63) for attainment, and 3.06 (SD = 0.60) for expectancy.
The correlations among death attitude, MIL, and career choice motivation for GN are presented in Table 3. Significant positive correlations were found between MIL, MIL-P, and MIL-S, respectively, and motivation for GN as a career choice (r = .24,p < .001;r = .21,p < .001;and r = .20,Qiushi LIU and Bongsook YIH p < .001,respectively).Fear of death and motivation for GN as a career choice shared a weak, significant, and negative correlation (r = −.13,p < .01).Although a significant and positive correlation was found between the death attitude subscale "approach acceptance" and motivation for GN as a career choice, their relationship was very weak (r = .08,p < .05).

Multiple Linear Regression Analysis on the Associations Between Death Attitude
Profile-Revised and Meaning in Life Questionnaire, Respectively, and Career Choice Motivation Questionnaire for Geriatric Nursing Multiple linear regression analysis was performed using the scores of the CCMQ-GN as dependent variables and the subscale scores of the DAP-R and MLQ as independent variables.The sociodemographic variables were also used as independent variables, and within-group statistical differences in career choice motivation scores were compared.All of the independent variables accounted for 14.5% of the variance in career choice motivation for GN (R 2 = .15,F = 9.01, p < .001).Presence of meaning ( p < .01),searching for meaning ( p < .05),and having a death attitude of escape acceptance ( p < .05)or approach acceptance ( p < .001)were found to be significantly and positively associated with motivation to choose a career in elderly care.Conversely, fear of death ( p < .001)and death avoidance ( p < .05)were found to be significantly and negatively associated with choosing GN as a career path (Table 4).

Discussion
The results of this study indicate MIL, MIL-P, and MIL-S to be positively associated with students choosing GN as their career path.The average scores for MIL, MIL-P, and MIL-S in this study were 4.99, 4.88, and 5.13, respectively.
These scores fall into the medium range and are slightly higher than those reported in a study on nursing students by Kim and Kim (2017).MIL reflects one's perspective on the intrinsic value of life and perception that life is worth living (Steger et al., 2006).Higher sense of MIL is associated with greater perceived subjective happiness.In addition, students with higher MIL are more likely to be more positively motivated to discover meaning from work (Jung & Yoon, 2016;Steger & Dik, 2009).
The participants in this study showed a medium level of motivation to choose a career in GN.The mean scores of the value subscales were slightly higher, and those for the expectancy subscales were lower than those reported in Cheng et al. (2015) and Guo et al. (2021).Similar to these studies, the interest motivation subscale earned the highest score of all CCMQ-GN subscales.However, compared with these studies, the cost, utility, and attainment subscale scores for GN career choice motivation were relatively low (Cheng et al., 2015;Guo et al., 2021).Although caring for older adults can increase the motivation of students to continue caring for older adults, this does not infer they view a GN career as meaningful.Conversely, these students, especially those from urban settings, may perceive a GN career as relatively disadvantageous in terms of offering fewer promotion opportunities, lower compensation, less prestige, and a relatively depressing working environment (Cooke et al., 2021;P. Liu et al., 2021).Moreover, contemporary nursing education, which focuses greater attention on emergency and critical care skills, makes it difficult for students to correctly perceive the value of elderly care as a career path (Fetherstonhaugh et al., 2022;Garbrah et al., 2017).As most GNs have a relatively low level of education, their opportunities for better jobs and career growth are more limited than better-educated peers in other nursing specialties (Li et al., 2021).
During the COVID-19 pandemic, most elderly care institutions in China were closed to internships.In this study, only 16.4% of the participants had nursing internship experience.However, those with this experience were more motivated to care for older adults than those without internship experience.Practical experience has been shown to improve motivation to choose GN as a career (Cheng et al., 2015;Hsieh et al., 2021).Conversely, negative feelings regarding the role of nursing in elderly care engendered during an internship or lack of confidence in the knowledge and skills needed to care for older adults may lead to misunderstandings in the nursing profession about the older adult population (Okuyan et al., 2020).Hu et al. (2021) found the competencies of registered nurses providing geriatric care to be limited, which may affect the confidence of interns caring for elderly patients.
Nursing education should focus greater attention on students' sense of MIL to help them experience positive meaning imparted by knowledgeable nurses caring for older adults and to cultivate intrinsic meaning from gratitude, empathy, and prosocial activities (Cooke et al., 2021;Lee & Park, 2019;Tsai et al., 2020).Helping students overcome the challenges involved in providing nursing care to older adults and improve opportunities for career development may improve the perceived meaning in nursing students' lives and promote career choice motivation.
The findings of this study suggest a significant association in students between death attitude and motivation to care for older adults.Holding negative attitudes toward death, for example, fear of death and death avoidance, was shown to relate negatively with motivation to choose GN as a career path, whereas higher scores for escape acceptance and approach acceptance were found to relate positively with motivation to choose GN as a career path.However, neutral acceptance was not associated with motivation to choose GN as a career path.W. Tang et al. (2022) reported passive death attitude to correlate negatively with willingness to care for older adults, and Barnett et al. (2021) found higher acceptance of death to correlate positively with attitudes toward end-of-life care.When death is accepted as a natural part of life, death and aging are more likely to be perceived as normal physiological changes.This may help promote the image of GN as simply "another nursing specialty" with no need of special concern or consideration (Upasen & Thanasilp, 2020).Death attitude is known to be correlated to professional identity (Xie et al., 2021) and may be correlated to professional identity among GNs.Because aging shortens time to death, death attitude may be associated with attitudes toward and pressures on end-of-life care for older adults, thus potentially impacting motivation to choose GN as a career.However, attitude toward end-of-life care also relates to whether nurses receive education on death.Traditionally, older adults die at home, where families can prepare for a loved one's death during the process of caring for them, which facilitates acceptance of death when it comes.However, the place of death today is more likely to be a hospital, where excessive expectations of treatment outcomes aggravate nonacceptance of and resistance to death because of factors such as urbanization and socioeconomic status (Cai et al., 2017).Nursing education on caring for older adults should integrate a series of courses on MIL and death attitude that include the participation of older In this study, the independent variables accounted for only 14.5% of the total variance, indicating that the factors associated with students' choice to pursue GN as a career are complex and diverse.Dai et al. (2021) showed that six aspects and 27 variables affect willingness to work in geriatric care, although educational interventions based on these factors were not found to significantly affect career preference.Today in China, existence anxiety and low perceived MIL are common (Chen et al., 2021).Thus, interventions that combine MIL with other factors of influence on older adult care education are needed.Volunteering in older adult communities, taking courses related to older adults, and participating in GN internships can cultivate future nursing professionals who pursue meaningful careers and embody the enthusiasm necessary to cope with negative perceptions and promote professional development.Achieving the necessary changes will require significant effort to design curricula that combine MIL and education in older adult care and to provide better training support to GN educators.

Limitations
This study was conducted only in the Shandong Province in Eastern China.Therefore, the results may not be generalizable to the entire country.In addition, the results are limited to data provided by fourth-year undergraduate nursing students.Thus, longitudinal changes in study variables could not be assessed.Finally, as a cross-sectional survey design was used in this study, causal relationships between the studied variables cannot be determined.

Conclusions
In this study, MIL was found to be positively associated with motivation to choose GN as a career path, whereas negative death attitudes, for example, fear of death and death avoidance, were found to be negatively associated with this motivation.Furthermore, escape acceptance and approach acceptance were positively associated with this motivation, whereas no correlation between natural acceptance and motivation to choose GN as a career path was found.Future studies may be developed to further confirm the observed effects as well as to develop elderly-care-related educational content and strategies to improve the MIL and death attitudes of nursing students.
During the COVID-19 pandemic, clinical practice environment restrictions, heavy workloads, higher-risk older adult care, and limited older adult care staff presented unique challenges and offered new insights into the development and meaning of geriatric care.To attract more qualified and passionate nursing students, in addition to improving nursing skills, it will be necessary to formulate clinical educational policies and guidelines that encourage openness, flexibility, friendliness, psychological support, and humanistic evaluation standards to provide GNs more professional development opportunities, autonomy, independence in decision making, and social prestige.Ultimately, these changes may help reverse discrimination and prejudice toward GN clinical practice and appropriately increase its meaning and value.

Implications for Nursing Practice
With rapid population aging and the related rise in the prevalence of chronic ailments, an increasing percentage of the population in China as well as in many other countries is over 60 years old and unable to care for themselves independently.These developments greatly challenge the practice of GN specialists.The shortage of geriatric care professionals is a key factor limiting the supply of services available to older adults.Thus, motivating more students to choose a career in GN will be critical to improving the availability and quality of care provided to our elderly population.In this study, both MIL and death attitude were found to be associated with the likelihood of students choosing GN as their career path.On the basis of this evidence, nursing educators should invest more effort in designing integrated courses, enhancing the positive impact of GN internships, boosting student motivation, and cultivating professionals in the field of GN.

Table 4
Multiple Linear Regression Analysis of DAP-R, MLQ, and CCMQ-GN (N = 595) Note.F = 9.01, R = .38,R 2 = .15,adjustedR 2 = .13,Durbin-Watson=2.03, p < .001.DAP-R = Death Attitude Profile-Revised; MLQ = Meaning in Life Questionnaire; CCMQ-GN = Career Choice Motivation Questionnaire for Geriatric Nursing; GN = geriatric nursing; MIL = meaning in life.The Journal of Nursing ResearchQiushi LIU and Bongsook YIH adults.Creating more opportunities for undergraduate students to be in contact with older adults in ways that facilitate cross-cultural life story narration, drama, and simulation for older adults can eliminate intergenerational estrangement and improve career choice motivation.