Exploring Turkish Nurses’ Attitudes towards Death: A Prospective Study

The impact on the people and cultures vary according to the time of death showed a deep interest in the people living in all cultures and throughout history, have been the subject of experience and ideas. Seen from the outside is not the experience of death is an issue objectively perceived [2]. Life expectancy is increasing in Turkey and around the world. Turkey in 2005, which is 5.7% of the population over the age of 65 in 2009, was 7% in 2050, while 17.6% reported or are expected to reach [3]. In addition to the process of death, such as cancer, especially in chronic diseases that cause distress to pass increased. However, patients and their families to help them deal with the process of death and hospice palliative care in our country, and to support the process of dying patients and their families are not developed and remain alone. Nurses are the largest group of the treatment team who are responsible for taking care of the dying patients and these statistics suggest that nurses will be responsible for the care of a larger population of dying patients in the future. For all these reasons responsible for the care of the patient 24 hours a day and having a large share of the health care system to determine attitudes of nurses to death, and this is one of the current issues in regard to education.


Introduction
Death is an integral part of human existence; consequently it is inevitable that it is a subject of anguish and concern at some stage in our lives. Death, although inevitable, can be distressing to contemplate, and doing so may even be taboo in many cultures [1].
The impact on the people and cultures vary according to the time of death showed a deep interest in the people living in all cultures and throughout history, have been the subject of experience and ideas. Seen from the outside is not the experience of death is an issue objectively perceived [2]. Life expectancy is increasing in Turkey and around the world. Turkey in 2005, which is 5.7% of the population over the age of 65 in 2009, was 7% in 2050, while 17.6% reported or are expected to reach [3]. In addition to the process of death, such as cancer, especially in chronic diseases that cause distress to pass increased. However, patients and their families to help them deal with the process of death and hospice palliative care in our country, and to support the process of dying patients and their families are not developed and remain alone. Nurses are the largest group of the treatment team who are responsible for taking care of the dying patients and these statistics suggest that nurses will be responsible for the care of a larger population of dying patients in the future. For all these reasons responsible for the care of the patient 24 hours a day and having a large share of the health care system to determine attitudes of nurses to death, and this is one of the current issues in regard to education.

Literature Review
Literature, found many studies about the attitude of nurses on death. Studies of nurses working attitude, age, gender, level of education, level of education on palliative care [4], which has been running previously served or are currently running [1], loss of a loved one, before dying the patient care delivery [5] was affected by many factors, such as. In addition we are experiencing death, health personnel, based on their own experiences, thoughts and feelings about death significantly influenced the values and belief systems [6]. Also nurses are afraid to come face to face with death and the terminally ill, terminally ill prefer to work in departments that are not fatal, the responsibilities of caring for the patients when they are forced to defend themselves in the research carried out frequently seen [6].
In our country, studies have revealed generally negative attitude of nurses toward death. Öktem [7] in his study at a hospital in Ankara, fear of death and attitudes of nurses were there, albeit to varying degrees [7]. Agile and Cava (2012) study of nurses working in Ankara stated that fewer positive attitudes about death [1]. Nephrology nurses, nurses in the study had a fatal patients with moderate to exhibit avoidance behavior, is depressed feeling states of death, death anxiety experienced mid-level women nurses on death anxiety, depression, and avoidance of fatal attitude of patients more than male nurses determined [8,9]. However, as well as the cultural characteristics of our country like Iran, which is the boundary for the nurses working in a more positive attitude to death stated [10].
Dunn et al. [11] study, a positive attitude towards the nurses stated that the majority of patients dying and the other research Gama et al. [12]. Hematology and oncology nurse presented more negative attitudes towards death than palliative care nurses [12].
Scientific and medical advances, and thus delayed the terminal period of the death, end of life care, palliative care and hospice care has become important concepts such as. These concepts are different concepts that overlap with the concepts. Within a certain time period is finished the vital functions of the terminal is defined as the expected time. This time there is no definite separation and limitation. Loss of physical and mental abilities in the process of death in patients with pain due to psychogenic factors and can require more maintenance. The end of life care, death in the process of improving the quality of life of patients, to reduce or eliminate pain and other health problems, personal, cultural and religious values, beliefs, and habits to provide care while remaining sensitive to the individual as much as possible to maintain the independence of the honorable or reputable aims to provide the death [4]. Today, end of life care for the «good death» concept has been developed. Beck strand and co-workers in the process of death, the death of a person to provide a good person should be left alone reported [13]. Death is a psychological as well as a physical event that affects not only the person who is dying but also the people caring for that person, including health professionals. Fears, anxieties, distress, and grief may be activated or reactivated by this proximity to death and to the patient's suffering. Taking care of terminally ill patients can be an emotionally painful, stressful, and distressing experience. Bu nedenle bakımdan en fazla sorumlu olan hemşireler daha fazla etkilenmekte ve hasta ve hemşire arasındaki ilişki farklı bir sürece girmektedir. This nurse-patient relationship differs from all other care relations in at least four respects: the level of exposure to death, the inevitability of suffering versus the potential for personal growth, distorted experience of time, and involvement in the care giving relationship (emotional and corporal intimacy) [13].
Faced with this situation adversely affected the quality of care can be considered to offer the affected nurses. The care given by nurses or dying patients in the terminal stage of nurses' attitudes toward death may be affected. Death has entered a period of individual and family needs the support of a nurse. Patients at the end of his life, it is important to take care of a calm and reassuring environment, such an environment can be provided by nurses [14]. Encountered in the event of death more nurses working in clinics can experience more anxiety in the face of death can be estimated. End of life care when nurses meet patient care needs must recognize their own feelings and behavior. For all these reasons and the factors that affect nurses' attitudes about death, suitable undergraduate and postgraduate training programs, will be useful in terms of the measures to be taken. Nurses' attitudes towards religious belief affect patient death and dying?

Methods
The aim of this study was to examine Turkish nurses' attitudes toward and experiences with death and caring for dying patients. A descriptive and cross-sectional study was conducted at 3 state hospital located in different regions in Turkey.
Cosmopolitan hosts Turkey in mosaics and has a structure different from east to west. Therefore in this embodiment, this current socio-cultural differences in the individuals affected. In this study the three different regions (Easther Anatolia Region-Kars, Middle Anatolia Region-Yozgat, Aegean Region-Bandırma) nurses working in hospitals in the province were selected.
Kars is located Easthern Anatolia and located on the edge of Aizerbaijan. Bandırma is situated in the Aegean coastal city, Located in the heart of Central Anatolia Yozgat in addition to international immigration emigrant different ethnic origins live together due to temporary accommodation center city. Although the different sects of Islam, the dominant religion in Turkey and cosmopolitan cultures, structures are built. Turkey has a strong family structure, and therefore the terminal stage, especially the elderly and individuals in rural Turkey is usually cared for in their homes. The elderly or individuals with terminal stage want to spend the last month at home.
End-of-life care is still a new topic in Turkey, and palliative care education is neither included as specific clinical education for nurses who are involved with end-of-life care nor as a specific academic course in the nurse educational curriculum.

Sample and Settings
This study is a cross-sectional descriptive study. Its population consists of 372 nurses who work at the Internal Medicine and Surgery Clinics and the Intensive Care Units of the Yozgat Public Hospital, Bandırma Public Hospital and Kars Public Hospital. The study was conducted with 171 nurses from public hospitals within the provinces of Yozgat, Bandırma (Balıkesir) and Kars who provided care to dying patients within the last three months and accepted to take part in the study.

Materials
The study data were collected by using the Personal Information Form and the Frommelt Attitude toward Care of the Dying Scale. Personal Information Form: This form was developed by the researchers following a scan and review of the literature Frommelt [4]. The form is constituted of questions inquiring the nurses' age, gender, civil status, the clinic they work in, religious beliefs, demographic characteristics, knowledge about death and their views regarding care for dying patients.

From Melt Attitude Toward Care of The Dying Scale (FATCOD)
FATCOD is a 30-item scale developed by Katherine H. Murray Frommelt [4]. The scale identifies both positive and negative attitudes. The validity and reliability of this scale was investigated in Turkey by Çevik in 2010 [1,15]. FATCOD is a likert-type scale; a score of 1 represents "strongly disagree" and 5, "strongly agree." The total score in this scale is obtained by adding the inverse/negative value of the items on negative attitudes to the value of the items on positive attitudes. The total score of this scale varies between 30 and 150, with higher scores indicating a more positive attitude.

Ethical Approval
Prior to data collection, written approvals were obtained from the hospitals in which the study was conducted. The purpose of the study was explained to all participating nurses, and their verbal consents were obtained. The nurses were also informed that their decision to participate or not is entirely voluntary, that they could end their participation at any time, could refuse to provide information, have the right to be fully informed about the study and that their personal information would remain confidential.

Data Analysis
Data were evaluated with the SPSS 16.0 package program. P values less than 0.05 were considered as significant. Statistical analyses were performed by using mean, percentage, independent group t test and the One-Way Anova test.

Results
Of the nurses who participated in this study, 87.1% were women, 52.6% were between the ages of 31-40 and 80.7% were married. It was also determined that 48.0% were high school graduates and 51.5% worked in internal medicine clinics. The mean number of years in the profession was X=10.67.
( Table 1) provides the distribution of the mean scores from the melt attitude toward care of the dying scale (FATCOD) according to the demographic characteristics of the nurses. No statistically significant difference was identified between the mean FATCOD scores with respect to the nurses' gender and clinic (p>0.05). A comparison of mean FATCOD scores according to the age groups revealed that increasing age was associated with lower scores, and that the difference between lower and higher ages was significant (p<0.05). Single nurses had a more positive attitude towards death, and the difference with married nurses was statistically significant (p<0.05). A comparison of mean FATCOD scores according to the level of education revealed that higher levels of education were associated with a more positive difference in scores, and that the difference between nurses of higher and lower levels of education was significant (p<0.05). A comparison between nurses with respect to the number of years in the profession showed that nurses with less work experience had a more positive attitude towards death, and that the scores decreased as the number of years in the profession increased. In this respect, the difference between nurses with less and more years in the profession was found to be statistically significant (p<0.05). The nurses' characteristics with regard to end-of-care are provided in (  The distribution of the nurses' mean FATCOD scores according to certain variables is provided in (Table 3). Nurses who described themselves as having strong religious beliefs and considered that their beliefs affected their attitudes towards dying individuals had more positive attitudes; the difference with nurses who did not consider themselves as having strong religious beliefs was found to be significant (p<0.05). Nurses who provided care less frequently to dying patients had a more positive attitude score, and the difference with nurses who provided care to dying patients more frequently was significant (p<0.05). In addition to this, nurses who considered their level of knowledge regarding the needs of dying patients as adequate had a more positive attitude, and the difference with nurses who considered their level of knowledge as insufficient was significant. Nurses who encountered cases of death in their environment had lower attitude scores in comparison to nurses who did not encounter such cases; this difference was also found to be significant (p<0.05).

Discussion
In this research, Yozgat, Bandırma and nurses working in hospitals in Kars business life to death and dying on the knowledge and attitudes were assessed patient care. The information obtained from this study was discussed in the literature. The nurses, 87.1% female, mean age =32.01±6.22 X, with 52.6% of the 31-41 age range, the average score of FATCOD positive men than in women (74.45±14:14), 81% were married, 48% ININ bachelor's degree, more than half of the average length of the built-in clinics in the job is running, and was found to be 10.67±6.80 years (Table 1).
Rooda et al. [16] a study of acceptance of death is higher in males than females reported that the average score. However, the literature shows that gender does not affect care of dying patients [4,15]. Due to the small number of male nurses in this study by gender where FATCOD higher mean scores obtained from the scale considered.
In a study conducted with a high level of education of nurses stated that a better knowledge about the experience of dying and death [11]. In our study, together with the rise in the level of education has increased as a positive difference in the score. This difference was statistically significant (p=0.000) ( Table 1). This result was compatible with the knowledge of the literature.
More than half of the nurses (60.2%) stated that strong religious beliefs. More than half of the sample of nurses (54.4%) to be faithful to influence attitudes towards death and dying patients expressed (Table 2). Studies on the subject of religious faith and to be faithful to death and dying is stated that a major factor affecting the individual care [10,11].

Information on Death and Dying Patient Care Nurses' Experiences Conditions
Almost all of the nurses (84%) information on end of life care in the dying patient information specifying the other hand, almost half of nurses in end of life care to dying individuals the knowledge and skills of the partially adequate (43.9%) and one quarter (26.3%), insufficient stated that information (Table 2).
Bachelor's degree in literature during the preparation of the training are not enough nurses a dying patient care, daily life of professional in-service training/continuing education programs should be supported emphasized [16,17]. End of life care in intensive care units is necessary to improve the stated continuous in-service training programs [18]. Richardson [19] in his study of nurses working in a university hospital, nurses, 74.5% had found insufficient training for death during the training given to them, 58.6% of patients in the terminal stage of physical and psychological training in care giving stated requirements are expressed.
More than half of nurses being faithful attitude towards the dying patient end of life affect 30.4% would be less than one third the effect of 15.2% affect the reported position. The end of life of nurses in the care of dying patients was 84.2% PERCENT knowledge that 15.8% reported previously was not aware of. We also asked about the degree of knowledge of nurses in end of life care of patients in the period 29.8% while having enough information available 43.9% partially sufficient, and 26.3% stated that the information is insufficient ( Table 2).
Nurses stated that the death of a strong religious faith can be said to have accepted more easily. Studies, religious beliefs, god, belief in life after death and nurses, doctors and the general population is associated with death and dying on the more positive attitude. Flannelly [20] after a strong religious belief and the life world (Last Day) believing reduce anxiety, fear of death, and death have been reported. Fehring et al. [21] 100 In a study conducted with cancer patients, those with spiritual happiness and strong religious beliefs, religious beliefs and spiritual states exhibit a weaker compared to those who reported less negative attitudes [21]. This research is also very strong in the belief that nurses have more positive attitudes of those who indicated that the difference was statistically significant (p = 0.002) ( Table 3).
In another study, student nurses, nursing education in our country, with emphasis on end of life care affect patient care/ will not affect 60% of the students asked «rather affect the» end of life care, and shared the view that more attention must be given to the issue stated that the curriculum [14]. Cramer et al. [22] in his study, the majority of nurses reported not finding enough about death with their training. Scott et al. [23] in their study of nurses to improve the quality of end of life care and death, symptom control, communication with patients and their relatives stated that they want to increase the education issues. End of life care nurses provide to improve the control of pain and other symptoms, improving communication with patients and their relatives, to increase education about end of life care, the patient should be worth the wishes expressed at the end of life, ethics stated [24].
Nurses are evaluated according to the years of working experience in the profession at work are more positive about the work of the nurses to death scores decreased with increasing the difference was statistically significant (p=0.008, Table 1). Lange et al. [15] 403 nurses and over 11 years in the job work done on those «death avoidance» score were higher than those between 5-10 years of study indicated that [15]. Rooda et al. [16] made a similar study of nurses' professional experience in the fear of death and age and a significant negative relationship where indicated. As the dying years of professional experience and attitude scores of patient fall [16]. In our study, more than those who work in the same way was found to be more negative attitude scores. This is the result of a new graduate nurses, patient care, and after graduation they were more than willing to suggest that information may be reflected in the application.
Queried the skills needed to carry that end of life care nurses, 87.1% of patient care, to realize the process of death and death to know the symptoms, 67.8% per cent must have effective communication skills, 64.3% of the legal and ethical issues should be knowledgeable, 53.8% of pain management and 53.2% stated that there should be the ability to act according to cultural differences (Table 2). In their study of nurses to improve the quality of end of life care and death, symptom control, communication with patients and their relatives stated that they want to increase the education issues [23]. Becstrand et al. [24], end of life care nurses provide to improve the control of pain and other symptoms, improving communication with patients and their relatives, to increase education about end of life care, the patient should be worth the wishes expressed at the end of life, ethics stated.
FATCOD dying patient attitude scores compared to the frequency of care giving fewer nurses taking care of a dying individual to be more positive attitude scores 4 times a week and over a dying individual caregivers and the difference was found to be lower attitude scores were statistically significant (p= 0.002, (Table 3). Kumaş et al. [25] his study nurses working with patients in terminal stage, and 40% and above are almost always disappointing, 32.3% indicated that they experienced depression. Nurses working in the intensive care unit in order to determine the thoughts and feelings about death in another study, more than half of the nurses felt the inability to cope with the emotions expressed in the face of death (the Black, 2006). This result is consistent with the literature.
Attitude of those who faced death in the immediate vicinity of the nurses with the availability of the death in the immediate vicinity, while lower scores did not meet the state nurses' attitudes were more favorable. The difference was statistically not significant (p=0.046), (Table 3). Thoughts of death in our country, intensive care nurses and a study conducted in order to compare their anxiety, the first encounter with death, sadness and professional lives of the majority of nurses 21.2% stated they feel helplessness [26]. Tatar [27] in his study of coronary intensive care units (n=30), the first encounter with death half of the nurses experienced intense sadness, helplessness, and 13% and 20% indicated that they felt the failure. Faced with the phenomenon of death in our study fewer nurses had more positive attitudes because negative emotions are thought to be less deneyimlediğinden. More care nurses who had a dying patient emotional exhaustion, grief, negative emotions such as fear and helplessness scores more negative attitudes can be influenced lived [27]. This result was compatible with the knowledge of the literature.

Conclusion
These experiences are valuable sources of knowledge on death and end-of-life care for Turkish nursing. The valuable outcomes and descriptions of care from the nurses enrich the lives of those caring for dying persons and those caring for persons who have died including their family members. Similarly, this will also enrich the lives of future nurses who will learn from the experience of caring for persons who had a peaceful death.